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Volume 57, Number 4

Fall 2011 $4.95

Marin Medicine The magazine of the Marin Medical Society

Levels of Care

Public Health Medical Homes Partnership HealthPlan Advance Care Planning

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Volume 57, Number 4

Fall 2011

Marin Medicine The magazine of the Marin Medical Society


Marin Medicine

Levels of Care

Editorial Board

5 7 11 14 16


Levels of Care

“Continuity of care is lost when transitioning between the various levels of care if there is not a well-organized method of communication, planning and delivery.” Georgianna Farren, MD


Public Health Officer Jason Eberhart-Phillips, MD, MPH

“In a sense, everyone in Marin County and no one in Marin County is a patient of the health officer, but the county itself and everything that comes with it is the focus of his or her attention.” Steve Osborn


An Idea Whose Time Has Finally Come?

“How can we rebuild American primary care capacity and attract physicians to primary care specialties? The answer may be the patient-centered medical home, a key element in the healthcare reform paradigm.” Irina deFischer, MD


Managed Medi-Cal Expands to Marin County

“On July 1, most of Marin County’s 20,000 Medi-Cal enrollees became members of Partnership HealthPlan of California (PHC), a six-county regional health plan that also serves Medi-Cal patients in Solano, Napa, Yolo, Sonoma and Mendocino counties.” Marshall Kubota, MD, and Lynn Scuri, MPH


Advance Care Planning

“Why do physicians shy away from planning in advance for the terminal aspects of care or disease? After all, mortality worldwide is 100%.” Lael Duncan, MD

Table of contents continues on page 2. Cover: “Toy Balloons,” by George Chernilevsky

Irina deFischer, MD, chair Peter Bretan, MD Georgianna Farren, MD


Steve Osborn


Cynthia Melody


Linda McLaughlin


Erika Goodwin Marin Medicine (ISSN 1941-1835) is the official quarterly magazine of the Marin Medical Society, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403. Periodicals postage paid at Santa Rosa, CA. POSTMASTER: Send address changes to Marin Medicine, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403. Opinions expressed by authors are their own, and not necessarily those of Marin Medicine or the medical society. The magazine reserves the right to edit or withhold advertisements. Publication of an advertisement does not represent endorsement by the medical association. E-mail: The subscription rate is $19.80 per year (four quarterly issues). For advertising rates and information, contact Erika Goodwin at 707-5486491 or visit marinmedicalsociety. org/magazine. © 2011 Marin Medical Society

Marin Medicine The magazine of the Marin Medical Society


20 23 25 27 28

“MMS enhances the health of the community by helping local

Our Mission: To support Marin County physicians and their efforts to enhance the health of the community.

residents gain the knowledge, motivations and opportunities needed to make informed decisions about their health.”



About the Marin Medical Society


Consultations at the Speed of Light

“In addition to my private practice in Novato, I am the sole urologist for a company specializing in telemedicine. By using robots to connect with patients at great distances, this technology solves the dilemma of remote specialty care.” Peter Bretan, MD


Novato Community Hospital

“I am pleased to report that 2011 marks the 50th year Novato Community Hospital has served the communities of northern Marin and southern Sonoma counties.” Kurt Kunzel, MD


Changing from Within

“Finding Balance in a Medical Life is a well-written, thoughtprovoking guide to understanding the dilemma we physicians are in, along with strategies for how to change.” Lori Selleck, MD


An Insightful Journey

“Enjoy Every Sandwich, the new book by Dr. Lee Lipsenthal, describes his journey during diagnosis and treatment for cancer.” Scott Levy, MD, MPH


President Peter Bretan, MD President-Elect Irina deFischer, MD Past President Lori Selleck, MD Secretary/Treasurer Georgianna Farren, MD Board of Directors Larry Bedard, MD Anne Cummings, MD Scott Levy, MD Barbara Nylund, MD

Staff Executive Director Cynthia Melody Communications Director Steve Osborn Executive Assistant Rachel Pandolfi

Membership Active: 310 Retired: 86


Marin Medical Society 2901 Cleveland Ave. #202 Santa Rosa, CA 95403 415-924-3891 Fax 415-924-2749 Printed on recycled paper

2 Fall 2011

Marin Medicine

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now accePting new PatientS Call 1-888-699-DOCS (3627) GREENBRAE 1350 S. Eliseo Drive #220 Steven Hao, MD, Cardiac Electrophysiology Richard Hongo, MD, Cardiac Electrophysiology Robert Rho, MD, Cardiac Electrophysiology Christine Jacobson, MD, Dermatology Kara Reinke, MD, Dermatology Hilarey Bhatt, MD, Internal Medicine Rebecca Li, MD, Internal Medicine Gyorgy Pataki, MD, Internal Medicine Ellen Rosenthal, MD, Internal Medicine Max Duncan, DO, Neurology Richard Mendius, MD, Neurology Smriti Wagle, DO, Neurology Mary Burke, MD, Psychiatry GREENBRAE 1350 S. Eliseo Drive #120 Ken Rosenberg, MS, LAc, Acupuncture Bruce Roberts, MD, Integrative Medicine Molly Roberts, MD, Integrative Medicine

NOVATO 101 Rowland Way #220 Tareq Elqousy, MD, Internal Medicine Steven Hao, MD, Cardiac Electrophysiology Richard Hongo, MD, Cardiac Electrophysiology Robert Rho, MD, Cardiac Electrophysiology Christine Jacobson, MD, Dermatology Timothy Davern, MD, Liver Disease Management and Transplant Smriti Wagle, DO, Neurology Tareq Elqousy, MD, Pediatrics Alison Reed, MD, Pediatric Endocrinology Jose Antonio Quiros, MD, Pediatric Gastroenterology Farhad Sahebkar-Moghaddam, MD, Pediatric Neurology Gregg Jossart, MD, Surgery: Bariatric/ Endocrine/Gastrointestinal CORTE MADERA 240 Tamal Vista Blvd. #190 James McCurdy, MD, Psychiatry Dongmei Yue, MD, Psychiatry

GREENBRAE 1100 S. Eliseo Drive #1 SAN RAFAEL Nikola Tede, MD, Pediatric Cardiology 750 Las Gallinas Ave. #210 Suruchi Bhatia, MD, Pediatric Endocrinology Katy Davis, MD, Pediatrics Alison Reed, MD, Pediatric Endocrinology Inessa Gofman, MD, Pediatrics Farhad Sahebkar-Moghaddam, MD, Pediatric Neurology Albert Goldberg, MD, Pediatrics Regina Arvon, MD, Prenatal Diagnosis, Genetics & Ultrasound Cindy Greenberg, MD, Pediatrics Denise Main, MD, Prenatal Diagnosis, Genetics & Ultrasound Sydney Sawyer, MD, Pediatrics Carl Otto, MD, Prenatal Diagnosis, Genetics & Ultrasound Kristin Pullen Williams, MD, Prenatal Diagnosis, Genetics & Ultrasound Kimberlee Sorem, MD, Prenatal Diagnosis, Genetics & Ultrasound


Levels of Care Georgianna Farren, MD


t Marin Community Clinics (MCC), a community health center, our clinicians daily experience the challenges of trying to provide quality healthcare to patients who have inadequate resources, just like millions of other patients throughout the United States. These patients may have inadequate medical coverage or no coverage, lack sufficient money for food, and have difficulty accessing preventive or specialist care. Transportation, language, cultural differences and a patchwork of insurance payment systems add further barriers to care. The health of these and other patients is influenced by environment, food, lifestyle, exercise, preventive measures, screening and genes—the list is extensive. Access to care and quality of care also influence health. I am reminded of a story about Dr. Jack Geiger, a founder of community health centers in the 1960s who treated malnourished patients with prescriptions for groceries and had the stores bill the health center. When questioned about this practice by federal officials, he argued that to the best of his medical knowledge the treatment for malnourishment was food. This issue of Marin Medicine focuses on the different levels of care available in Marin County and elsewhere. Probably the most broadly successful “level of care” involves the public health measures, policy reforms and educational interventions Dr. Farren, an internist, is chief medical officer for Marin Community Clinics.

Marin Medicine

that the county’s new public health officer, Dr. Jason Eberhart-Phillips, discusses in his interview with our editor, Steve Osborn. As Eberhart-Phillips observes, “The great thing about coming to Marin County is that this place is miles ahead of almost anywhere in terms of appreciating the importance of having a community environment that supports good health.” Beyond public health measures, multiple levels of care are available to patients in Marin. Unfortunately, these levels are typically fragmented into specialties, hospital care, emergency room care, and primary care. This loosely connected variety of medical services is not structured with the patient’s best interest in mind. Continuity of care is lost when transitioning between the various levels of care if there is not a well-organized method of communication, planning and delivery. Fortunately, strategies for change are developing. One example is Partnership HealthPlan, a managed Medi-Cal provider that began operating in Marin County this summer. They are working to enhance access and coordinate care to most of the county’s 20,000 MediCal enrollees. As explained by their medical director, Dr. Marshall Kubota, the plan requires patients to select a primary care provider/medical home to manage their care and encourage preventive measures. The “medical home” aspect of that equation is explored in more detail by Dr. Irina deFischer, a family physician and geriatrician at Kaiser Petaluma who is a strong advocate for patient-centered medical homes, arguing that they “offer

a blueprint for transforming primary care in the 21st century.” A key aspect of medical homes is coordination of care across all levels. Another argument for coordinated care is presented by Dr. Lael Duncan, an internist who vividly describes the benefits of advance care planning for patients at the end of life. “Palliative care and advance care planning,” she writes, “work best when they are initiated early in the course of disease and are part of the ongoing care plan.” Other efforts to coordinate care are still in the pipeline. Medicare, for instance, is proposing financial incentives for coordinating and improving patient care through Accountable Care Organizations. Local hospitals are actively working on discharge transition planning with various community partners, and some steps are being taken toward developing a health information exchange that would allow easier access to needed patient records. Kaiser already models care coordination by using internally integrated electronic health records. Universal implementation of electronic records could ultimately serve the well-being of all patients. Ensuring that patients receive the right care whenever that care is needed should be a community goal regardless of the initial access point. Our community needs to coordinate quality healthcare efforts that use our many levels of care in a thoughtful and effective manner. Email:

Fall 2011 5


Three-Year Accreditation with Commendation. We received eight out of eight commendations and are the only North Bay hospital to earn accreditation.

Accredited Breast Imaging Center of Excellence

Society of Chest Pain Centers Accreditation

As your local community hospital, we strive to maintain and strengthen our high standards of patient care.

The Joint Commission’s Gold Seal of Approval™ for the hospital, behavioral health services, as well as advanced certification as a Primary Stroke Center.

We have just received a three-year accreditation with commendation from the Commission on Cancer (CoC) of the American College of Surgeons (ACS). And in the past year, we were recognized by several national organizations for our stroke care, chest pain, behavioral health, and breast imaging programs. We thank the dedicated staff and physicians who have made these achievements possible. We will continue raising the bar to deliver the health care the people of Marin County deserve.

The American Heart Association and American Stroke Association recognize this hospital for achieving 85% or higher adherence to all Get With The Guidelines® Stroke Performance Achievement indicators for consecutive 12 month intervals and 75% or higher compliance with 6 of 10 Get With The Guidelines Stroke Quality Measures to improve quality of patient care and outcomes.



Public Health Officer Jason Eberhart-Phillips, MD, MPH Steve Osborn

Marin County’s new public health officer, Dr. Jason Eberhart-Phillips, was born in Detroit in 1956 and raised in the suburbs of New York City. He majored in journalism at Northwestern University and started his career as a reporter in Tucson, Arizona. “I got out of the newspaper business when I began to realize that all my crusading work to build a better world had a very short half-life,” he wrote in an email prior to this interview. “Front page stories that created a huge buzz yesterday are wrapped around people’s garbage today.” Changing course, Eberhart-Phillips enrolled in the Pacific School of Religion in Berkeley, cross-registered in pre-med courses at UC Berkeley, and then attended medical school at UC San Francisco. After completing one year of internship in family medicine at the Santa Rosa Family Medicine Residency, he switched to public health and preventive medicine. “As I completed each rotation of my intern year,” he recalled, “I discovered that I was personally drawn much more to protecting people from disease and injury than from treating it after the fact.” Eberhart-Phillips eventually received an MPH from UC Berkeley to go along with his MD and his divinity degree. His jobs since then have included working in Los Angeles for the Epidemic Intelligence Service, serving as principal investigator in Mr. Osborn edits Marin Medicine.

Marin Medicine

his junior year of high school. This interview was conducted in Eberhart-Phillips’ office in San Rafael on July 29.

a large epidemiologic study in New Zealand, and working as Chronic Disease Director for the state of Alaska. He was the health officer for El Dorado County from 2006 to 2009, and for the state of Kansas from 2009 to 2011. In the latter job, he led successful efforts to pass indoor clean-air legislation and implement statewide policies restricting unhealthy foods from school vending machines. Eberhart-Phillips and his wife, Donna, have been married for 33 years. Their older son, Luke, is getting a master’s degree in wildlife studies at Humboldt State University, and their younger son, Paul, is entering

Q: Can you tell me a little bit more about the specialty of public health and preventive medicine? How does it differ from clinical medicine? A: The perspective is entirely different. Most clinical medicine specialties are patient centered, but preventive medicine, particularly in a public health department, takes a community centered focus. Public health looks at the whole community and asks whether that place—with its culture, economy and physical layout—is optimally supporting human health. In a sense, everyone in Marin County and no one in Marin County is a patient of the health officer, but the county itself and everything that comes with it is the focus of his or her attention. How can we create opportunities for people to have physically active lives, to avoid secondhand smoke, to get access to healthy foods and to have fewer unhealthy things in their diet? The great thing about coming to Marin County is that this place is miles ahead of almost anywhere in terms of appreciating the importance of having a community environment that supports good health. It is a treat for me to get to Fall 2011 7

come here and not be a lone wolf casting a flashlight into a dark room; the room is already well lit with the work that a lot of people have done before me and are continuing to do. Q: Has anyone ever tried to put a percentage on the amount of disease that is preventable? A: I have seen old papers on that, but I would really like to get a modern update. If you take away tobacco, sedentary lifestyle, unhealthy diets—if you take away all those known risks in the environment, where could we be? Where could we as a country be in terms of our healthcare expenditures, if we could reduce the demand for expensive medical treatment that is generated from all those preventable conditions? Well, we wouldn’t have the healthcare crisis we are having right now. Q: Physicians do spend an awful lot of time dealing with conditions that are essentially manmade. Is there some way they could be more proactive and more involved in prevention? A: To the degree that people’s behavior or their resolve to change their lifestyles and adopt more healthy behaviors are influenced by physicians, it is just so important for them to get that message from their doctor. More people tell you “I quit smoking because my doctor told me” or “I changed my diet” or “I’m engaged in much more physical activity because my doctor told me so.” We know that, however brief or however automatic that message is from the doctor, it has potential to have enormous impact. If we in public health can work to support the physicians’ message by creating a world where it is easier for people to follow their doctors’ advice, I think we will really get somewhere. Apart from what they can do right there in the exam room, doctors can get involved with us in trying to advocate for policies that will improve these conditions: polices around making the environment friendlier to healthy foods and physical activity, along with stronger ordinances on creating protection from secondhand smoke. For all the issues 8 Fall 2011

that are kind of bread-and-butter for us in public health, sometimes there might be a disconnect with the clinical community in terms of really being involved. I think that if community physicians who have a lot of gravitas with the public were seen to be supporting some of the policies that we want to achieve here in Marin County, it would carry enormous weight. Q: In May, you wrote a column in the local newspaper urging people to stop drinking soda pop during the summer. How does the campaign to restrict soda pop compare to the war on tobacco? A: Marin County has the best smoking rate in the state that has the best smoking rate in the world. How did we get to this point? We didn’t get to this point by telling people, “It’s bad for you, don’t do it.” We created a strong counter-marketing campaign that makes smoking look ridiculous if not absolutely horrible. We created clean indoor-air policies that really made it inconvenient for you as a smoker to have to always be going outside in the rain and cold. Now you can’t even smoke in many of our municipalities in your own apartment or condominium. We have drastically reduced the space where smoking is permissible, and the culture change that has gone with denormalizing smoking has had a huge impact on kids not taking it up. We have also reduced youth access to cigarettes. When you and I were kids, you could pretty much get them at any place you wanted. We have really clamped down on that now. You have to present an ID or stores can face a huge fine. And, of course, we have taxed the hell out of tobacco so some of the actual cost that the product is inflicting on society is being borne by the user. So, in all those ways, we have finally now gotten on top of smoking. We are going to have to do the same kind of thing for the main drivers of the obesity epidemic, such as soda pop. Counter-market the hell out of it. Change the culture around what is normal about filling up your kids with

soda pop. We are going to have to think about ways to limit access—we have certainly done that already in California in our schools—but where else does there need to be consideration about the vulnerability of the population? And then we have to think about taxes. We have to see the industry bear some of the cost. They are externalizing their costs onto all of us to the tune of billions of dollars a year. If they are creating a diabetes epidemic and we want to discourage people from going down that track, the industry has to be prepared to help cover some of that cost. Q: What is the reach of your job in terms of prevention? A: I am just sorting that out as I become familiar with the way public health is practiced in Marin County. Traditionally the health officer’s role is about public health preparedness, in terms of making sure that in an emergency, disaster, or an outbreak of communicable disease, the best possible response is orchestrated at the local level. When decisions have to be made and when authority needs to be exercised, state law vests certain powers with the health officer to exercise expert judgment, in consultation with the board of supervisors. But the job has grown beyond that to provide medical and epidemiologic expertise and consultation to all the policy development at the county level, even at the city level, that could have a bearing on human health. The challenge in our day and age is to help people in other fields—whether they are city planners, transportation engineers or people in business—to understand that what they do actually has health consequences. For example, the fact that we live in such an auto-dependent place is the result of a lack of public-health understanding and input into decisions made 30, 40, 50 years ago about how we were going to transport ourselves around this landscape. Those decisions have had enormous consequences in terms of the obesity epidemic, in terms of depriving people of the opportunity to have physical activity be an intrinsic part Marin Medicine

Typical automobile-dependent Marin suburb from the 1970s. Photo by Thomas Sennett, 1972.

of their daily lives, the way it was in prior generations, the way it still is in most European countries. When you have to spend so much time in your car and when every destination is a car trip away instead of a walk or bike trip away, the design of your community is setting you up for obesity. We humans were not designed for this amount of sedentary activity. Q: So, in other words, if a developer were to come with a project for a subdivision, say here in San Rafael, is that something that you would be asked to consult on? Would that have to pass your review? A: Ideally that is where we would see this going. Government now does an environmental impact assessment— that goes back to the 1970s. By doing this development project, are we going to threaten any wildlife or any endangered species? Maybe we humans are the endangered species now in terms of what this kind of dispersed urban development has done to our opportunities to get the exercise that our Marin Medicine

parents and grandparents once took for granted when cities were laid out more like San Francisco and less like Marin and Sonoma. I think that only our wealth and our huge amount of healthcare spending is helping us be so healthy when the built environment is working against us in the other direction. We shouldn’t have to join a gym or be forced to remember to discipline ourselves to get out and do that jogging or ride that bike. Ideally, exercise should not be a chore done in addition to all the other things we do in our lives; it should just be a natural part of our everyday lives. My parents’ and grandparents’ generations didn’t have to join a gym to be fit and healthy and enjoy in most cases, with the advances in medicine, a longer lifespan than many middle-aged people are going to have today. Q: How do doctors participate in that kind of review? A: They join with us in connecting these dots. When public health is at the table advocating for more mixed-use devel-

opment, more pedestrian- and bicyclefriendly development, more accessible parkland and accessible healthy foods, they need to be there alongside us saying, “You know what, I have taken care of people in this community for the last 20 years. I’ve taken care of you and your family. I think this proposed development is a good thing. This is going to make it easier for my patients to be healthier and to follow my advice about how to lead a healthy lifestyle.” Ultimately redesign is going to take a while. It will take longer than the time to the next election for sure. But it is going to lower our healthcare costs and make us healthier and more fit to compete in a global economy, where we as a nation are losing right now. Q: What is your vision of an effective public health department? A: It’s an idea that I think is in evolution as we speak now. It is perhaps less about performing traditional roles of being a safety net or filling the gaps in the larger, mostly private, healthcare system. It is less about direct patient Fall 2011 9

services. It is less about mimicking what occurs in the community clinics, Kaiser, and all the other private clinics. Instead, it is more about focusing on these upstream risk factors that cause morbidity and mortality in the community. So it’s more about working with schools, local government, faith communities, business, and other interested parties who have a stake in keeping the population at optimal health and reducing their costs from disease and injury. So our role in public health goes from treating the downstream effects where prevention didn’t happen to getting at the root underlying causes and trying to use the best practices, the best policy know-how that we have, to help decision-makers implement the kinds of policies that prevent disease and injury in the first place. The beauty of this is that it will ultimately be a win-win, in that society will benefit from lower costs and the health department won’t present the taxpayer with the same high cost burden of running its own clinics and paying its own physicians and doing all this treatment, even if that treatment were more prevention-focused. It costs very little to develop and advocate for a new policy that will save even more money. In a time of dwindling county resources, we in public health can exert greater positive influence if our focus is on being transformative in the larger society—being an advocate who is bringing forward the case for human health wherever policies and culture and people’s lifestyle decisions are coming into play. Q: Do you think the community clinics and the federally qualified health centers have truly supplanted public health? Are they doing as good of a job as public health was doing before? A: Yes, I think they are much better positioned. It is less fragmented care. They are giving a medical home to people who were just getting part of their care as a stopgap and a safety net from a county clinic. Ultimately I think it is better from the patient-centered perspective and it frees up public health to do what only it can do well, which 10 Fall 2011

is a population- and policy-focused approach. That’s a change. It’s not something that goes down easy with everybody, and we have to make sure it’s a smooth handoff that doesn’t let anybody fall through the cracks. Q: Has public health effectively gotten out of the clinic business at this point? A: No, there still are county clinics that are providing services that no one has yet stepped up to provide. But overall, the paradigm is shifting. Public health is not the same thing as publicly funded healthcare. As we said way back in the beginning of this conversation, public health must be about how to transform this place, Marin County, into a place where you have every opportunity to make the kind of default choices that are good for your health. I mean transforming Marin County into a place where the easy choices about what you eat or how you get around turn out to be the healthy choices; where you actually have to work hard to lead an unhealthy life, instead of the way it can be now of having to work so darn hard to find healthy food or to find the time and ability to exercise. How can we transform this special environment, this beautiful place we call Marin County, into a community where it is easy to be healthy? Right now, for many people, it is very hard. Q: Do you have any interests outside of medicine? A: For me, the big attraction to living here, besides coming back to be with people I know and love, is the outdoor recreational activities. I now have great opportunities with my free time to be physically active, to hike and bike and do the things I like to do outdoors year round in a way I could not do in Kansas. Q: So you are a big hiker? A: Yes! The first thing I did was buy that book of hiking in Marin, 141 trails. I hope to do them all in the next year or two. Email:

Marin Medicine


An Idea Whose Time Has Finally Come? Irina deFischer, MD


wa s browsi ng on Facebook the other day when a post from Marissa caught my eye. Mar issa is a medical st udent at Tula ne who happens to be the daughter of two close friends of mine from medical school, both internists in New England. Her post was a link to a Medscape article titled “Significant discrepancies in physician hourly wages exist across specialties.”1 According to the article, physicians’ hourly wages range from a high of $132 for neurosurgeons to less than $50 for certain primary care physicians. I asked Marissa what her thoughts were on choosing a specialty. She responded first by quoting the statistics on medical student debt (average $160,000 on graduation) and the need to make a living, but continued to say that financial considerations were only part of the decision-making process. Other things she cited as important were respect from peers, lifeDr. deFischer, a Petaluma family physician and geriatrician, is presidentelect of MMS.

Marin Medicine

style and actual daily work. How much paperwork and busywork would she have to deal with each day, especially uncompensated paperwork and busywork? Compared with other medical specialists, primary care physicians are seen as overworked and underpaid, so it’s not surprising that fewer than 10% of today’s medical students say they plan a career in primary care. Yet abundant evidence shows that nations with strong primary care systems have better health outcomes and lower costs. These nations are able to deliver healthcare services at an average of half the per-capita costs of the American system at the same or higher levels of quality. In contrast, the specialist-dominated American system produces care of uneven quality, with excessive use of costly services that have few health benefits.2 American physicians are unable to deliver comprehensive primary care

because of the way pay ment is st r uctured. Primary care i s t he on ly ent it y c h a rged w it h t he longitudinal care of the whole patient, and the primary care relationship has the most profound effect on healthcare outcomes. Nonetheless, payment to primary care physicians has traditionally been based on face-to-face office visits, without taking into account the time spent in coordinating care with subspecialists and ancillary providers, or in communicating with patients and their families by phone or email. The existing primary care system is bursting at the seams, and it will be strained even more in 2014, when millions of additional patients are added to the rolls of the insured because of healthcare reform. How can we rebuild American primary care capacity and attract physicians to primary care specialties? The answer may be the patientcentered medical home, a key element in the healthcare reform paradigm.


he term patient-centered medical home was coined by the American Academy of Pediatrics in 1967 to describe a central location for archiving a child’s medical record. The concept was later Fall 2011 11

expanded to include APP functions as aaccessible, molecularcontinuswitch, ous, its comprehensive, family-centered, and switching appears to be govcoordinated, compassionate culerned by its interaction with and ligands. turallyAPP effective care.with Medical homes When interacts netrin-1, an gained momentum in 2006, when axonal guidance ligand, it mediatesa number of large employers primary process extension. Whenand APP intercarewith physician formed acts Abeta,organizations however, it mediates the Patient-Centered Primary loss, Care and Colprocess retraction, synaptic laborative to facilitate improvements in programmed cell death. During this patient-physician and Abeta create interaction, Abetarelations begets more a more efficientby model of (one of effective the Four and Horsemen) favorhealthcare delivery.of3 APP to the Four ing the processing Out of this collaborative came seven Horsemen. In other words, Alzheimer’s principles patient-centered medical disease is aofmolecular cancer. Positive homes, which summarized as selection occurscan notbe at the cellular level follows: but at the molecular level. Furthermore, Personal Each patient Abeta itself is aphysician. new kind of prion, since ongoing ithas is aan peptide that relationship begets more ofwith itself.a personal physician. We believe that all of the major neuroPhysician-directed medical pracdegenerative diseases may operate in tice. The personal physician leads a an analogous fashion. team that responsibility for the One of takes the interesting ramificaongoing carenew of patients. tions of our model of AD is that The we Whole-person should be able toorientation. screen for a new personal physician is responsible for kind of drug: “switching drugs” that providing arranging care for all the the switch theor APP processing from patient’s health care Four Horsemen to theneeds. Wholly Trinity,

is coordinated and/or thusCare preventing the synaptic loss, inteneugrated across all elements of the rite retraction, and neuronal cellhealthdeath carecharacterize system. that AD. Indeed, we have Quality and safety are hallmarks identifi ed candidate switching drugs of the medical home. and are now testing these in transgenic Enhanced care is also available mouse modelsaccess of AD.toWe are testthrough openofscheduling, expanded ing the effects netrin-1 on this system, hours and other options. and finding similar effects. Payment recognizes the added prinvalue A corollary of the switching provided to we patients who have mediciple is that should now beaable to cal home. screen existing drugs, nutrients, and The medical home uses other compounds not just fornew theirways carof organizing and delivering care to cinogenicity (as is done using the Ames improve quality andAlzheimerogenicsafety as well as test) but also for their to improve inwe reimity. We rarelyaccess. stop toChanges think that are bursement to support the acquisition of likely exposed to many compounds health information technology and to that have positive or negative effects compensate for time coordinaton the likelihood thatspent we will develop ing care essential for supporting AD, and are it would be helpful to have the medical home. such information. We hope that our new Theof success of medical hinges model AD may providehomes new insight on two issues: whether payers will into thekey pathogenesis of this common recognize theoffer value of medical homes disease and new approaches to and agree h to pay more for them, and therapy. whether physician practices can deliver what the medical home promises. Many E-mail: physicians feel their practice already

offers most features of a medical home. I even know who PA Remergency K P Lphysicians ACE feel the ER is the ideal medical home HEARING CENTER as it is open 24/7 and takes all comers.


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projects underway across the coun& Hearing Aid Dispenser try seem to show promising results, as reflectedCoMPlete by the title of a study of the Group Health Cooperative medical HeAring ServiCeS homeDiagnostic in Seattle:Hearing “The Group TestingHealth Emissions medicalOtoacoustic home at year two: cost savNewborn Screening ings, higher patient satisfaction, and less burnout for providers.”4 Closer to CoMPreHenSive home, Sonoma County Health Action HeAring Aid has launched a joint medical-home evAluAtionS learning collaborative at nine practices Conventional, Programmable in the county, including & Digital HearingKaiser, Aids Sutter and community clinics, as Service & Repair well as the Santa RosaLatest FamilyTechnology Medicine Residency.5 The goal of the learning collaborative 707-763-3161 is to support the practices as they be47 Maria Drive, Suite 812 into gin a long-term transformation Petaluma, CA 94954 patient-centered medical homes. Marin FAX#: 707-763-9829 Community Clinics is also applying for two grants to begin a medical-home pilot project.

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Marin Medicine Summer 2010 23

Beginning in October, the CMS CenAPP functions as a molecular switch, ter funding to “advanced andfor itsInnovation switchingisappears be govprimary practice” demonstration erned bycare its interaction with ligands. projects for interacts 195,000 Medicare patients When APP with netrin-1, an who use federally qualified health cenaxonal guidance ligand, it mediates ters. The extension. projects areWhen intended tointershow process APP how medical homes can improve qualacts with Abeta, however, it mediates ity of care, promote better health, and process retraction, synaptic loss, and lower costs. The goal is to achieve recprogrammed cell death. During this ognition from the National Committee interaction, Abeta begets more Abeta 6 for Assurance, helpby manage (oneQuality of the Four Horsemen) favorchronic conditions, and actively coordiing the processing of APP to the Four nate care forIn patients. Medicare will pay Horsemen. other words, Alzheimer’s the health a “care management disease is centers a molecular cancer. Positive fee” of $6occurs per month eligible selection not at for the each cellular level patient who enrolls in a medical home. but at the molecular level. Furthermore, Medical homes for Abeta itself is a newoffer kindaofblueprint prion, since transforming primary care in of theitself. 21st it is a peptide that begets more century. They the foundation We believe thatbuild all ofon the major neuroof the patient-physician relationship degenerative diseases may operate in with elements such as registries and an analogous fashion. other quality health inforOne of themeasures, interesting ramificamation improved tions oftechnology, our new model of ADpatient is that experience, practice and we should be able toorganization, screen for a new equitable payment. Offering medical kind of drug: “switching drugs” that students such asprocessing Marissa training in switch the APP from the medical-home practices should increase Four Horsemen to the Wholly Trinity,

their interest in the careers in pediatrics, thus preventing synaptic loss, neufamily medicine, internal medicine and rite retraction, and neuronal cell death geriatrics. that characterize AD. Indeed, we have identified candidate switching drugs Email: and are now testing these in transgenic

mouse models of AD. We are also testReferences ing the effects of netrin-1 on this system, 1. NF,similar “Significant discrepancies in andLarson finding effects. physician hourly wages exist across speA corollary of the switching princialties,” (25 Oct 2010). ciple is that we should now be able to 2. McGlynn EA, et al, “Quality of health screen existing drugs, nutrients, and care delivered to adults in the United other compounds not just for their carStates,” NEJM, 348:2635-45 (2003). cinogenicity using the Ames 3. For details(as on is thedone Patient-Centered Pritest)mary but also for their AlzheimerogenicCare Collaborative, visit www. We rarely stop to think that we are likely to Group manyHealth compounds 4. Reidexposed RJ, et al, “The medical year two:or cost savings,effects higher thathome haveatpositive negative satisfaction, less develop burnout on patient the likelihood that and we will providers,” Health Affairs, 29:835-843 AD,forand it would be helpful to have (2010). such information. We hope that our new 5. Greaves B, may “The provide PCMH Learning Colmodel of AD new insight laborative,” Sonoma Medicine (Summer into the pathogenesis of this common 2010). disease and offer new approaches to 6. For details on NCQA assessments of h therapy. medical homes, visit and select the Programs link. E-mail:


PA R K PL ACE HEARING CENTER Phyllis Burt, MA, CCC-A Licensed Audiologist & Hearing Aid Dispenser

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Managed Medi-Cal Expands to Marin County Marshall Kubota, MD, and Lynn Scuri, MPH Tehama


n July 1, most of Marin County’s 20,000 MediCal enrollees became members of Partnership HealthPlan of California (PHC), a sixcounty regional health plan that also serves Medi-Cal patients in Solano, Napa, Yolo, Sonoma and Mendocino counties. PHC is one of six not-forprof it Cou nt y O rga n i z e d Health Systems operating in California. The plan originated in Solano County in 1994 and was successful in improving both access and quality of care for Solano’s Medi-Cal enrollees. Over the past 17 years, PHC has continued to expand into nearby counties, with the support and approval of each county’s board of supervisors. In Marin County, a planning group comprised of local physicians, hospitals, clinics, county officials and other stakeholders met with PHC over the past year to plan and implement PHC’s expansion into the county. Their support and guidance was key to the project’s ultimate success. “Partnership HealthPlan has an excellent reputation and staff with years of exDr. Kubota is the regional medical director for Partnership HealthPlan. Ms. Scuri (not pictured) is the regional office manager.

14 Fall 2011

Expansion of Glenn Partnership HealthPlan, 1994–2011

crease payments to providers to help improve access to care,” Mendocino explained Dr. Marshall Kubota, 2011 PHC’s regional medical direcColusa tor. “PHC’s administrative costs Sutter Lake are less than 4%, so almost all the dollars PHC receives from the state go to providing care Yolo to our members.” 2001 Sonoma Napa PHC’s primary care pro2009 1998 Sacramento vider panel for Marin County includes all the community Solano 1994 clinics and most organized Marin 2011 medical groups, such as Prima Medical Group, Tamalpais PediContra Costa San Joaquin atrics and Sutter Pacific Medical San Francisco Foundation. All the community perience providing care to low-income clinics and some private practices are populations,” said planning group open to new PHC members, though a member Dr. Georgianna Farren, chief number of practices are accepting curmedical officer for Marin Community rent patients only. Clinics. “We know the program will Kaiser Permanente (KP) San Rabe a benefit to local physicians and our fael serves as the medical home for patients with Medi-Cal coverage.” approximately 1,000 PHC members, Each PHC member is required to who receive all their care within the KP select a primary care provider/medisystem. As one of the original founders cal home to manage their care and of the Partnership program in Solano encourage use of preventive care. BeCounty, KP has been a valuable partner cause patients are linked to a medifor many years. “We are pleased that cal home, care is more timely and less PHC has expanded into Marin County fragmented, with fewer emergency and look forward to continuing our room visits and avoidable hospitalizalong relationship and collaboration tions. PHC has also established their with them,” said Judy Coffey, RN, seown formulary that promotes use of nior vice president and area manager generic medications over brand-name for KP Marin-Sonoma. drugs. “Any savings incurred through Many local specialists have conbetter management of care is used to tracted with PHC and are paid an enenhance services to members and inhanced rate to encourage access. PHC Butte

Marin Medicine

ized by our modest trial proposals. But as our clinical sophistication grows, the vision of a fully integrated mental and works closely with contracted providers physical health center with rapid and to help reduce administrative burden, seamless communication and consulensure quick claims payment and be tation between treating professionals responsive to provider needs. The plan is becoming not only desirable, but also contracts with specialty centers in inevitable. □ the Bay Area, such as UCSF, CPMC and Oakland Children’s Hospital. PHC is E-mail: looking at creative opportunities to improve access to specialty care through References telemedicine and expanded specialty 1. Unützer J, et al, “Collaborative-care manclinics. agement of late-life depression in the PHC’s executive officer, Jack primarychief care setting,” JAMA, 288:2836-45 Horn, noted that the expansion to (2002). Marin County hasetbeen the smoothest 2. Hunkeler EM, al, “Long term outin the plan’s history, but thatrandomized many chalcomes from the IMPACT lenges ahead. One of those chaltrialstill for lie depressed elderly patients in primary care,” Med J, 332:259-263 lenges is the newBrit state budget, which (2006). may affect payments to physicians and 3. Callahan CM, etand al, “Treatment depresother providers require aofvariety sion improves physical functioning in of member copays. older adults,” J Am Ger Soc, 53:367-373 Despite the challenges, Dr. Larry (2005). Meredith, director of Marin County 4. Areán PA, et al, “Improving depresHealth and Human Services, emphasion care for older, minority patients in sized that care,” PHC’sMedical expansion into the primary Care, 43:381-390 county is a big step forward, noting (2005). that, “Partnership HealthPlan creates an organized system of care that is better forMedicine members and better for our local Marin providers.” PHC’s services to members and providers include: • Care coordination. Services for PHC members with complex or specialized medical conditions. Phone: 707-8634276. • Member services. PHC offers phone support to members from 8 a.m. to 5 p.m. Monday through Friday. Staff can provide information or assist with any problems members encounter. Phone: 800-863-4155. • Provider support. PHC can help train office staff, answer questions on a timely basis, and be responsive to provider needs and issues. The PHC representative for Marin County is Daniel Santos at 415-259-4055, or call the main Provider Relations Line at 707-863-4100. For more information about PHC in Marin County, contact Lynn Scuri at 707-863-4146 or visit Emails:,

Marin Medicine

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Advance Care Planning Lael Duncan, MD


magine a patient, let’s call her Anne, is diagnosed with her first episode of congestive heart failure and atrial fibrillation after a brief hospitalization. At the time of discharge, her hospitalist recommends she see her cardiologist and her family physician and also suggests she consult with a palliative care specialist for management and planning. Anne does all this and is surprised to find the palliative specialist is especially concerned with how she wants to live her life (not how sick she is), which symptoms she is most concerned about, and what her family and social life are like. At their next visit one year later, Anne and her palliative specialist again discuss these matters and also talk about end-of-life scenarios. Anne is at first reluctant to “go there,” but later in the talk admits to him that she saw her father die in an ICU after weeks on the ventilator. She stares off as she quietly states, “He also had this heart condition. . . . My mom could not let him go. . . . It was all very difficult and painful.”


hen I was in medical school, “comfort care” generally meant that a patient was only receiving medication that would provide comfort, that the patient was Dr. Duncan, an internist and infectious-disease specialist, is medical director of Good Medicine Consult & Advocacy in San Francisco.

16 Fall 2011

expected to die within days, that they were “on hospice.” Our focus was overwhelmingly to detect, diagnose and treat disease first and foremost. Only when pain or discomfort were on top of the problem list, when we had run out of diagnostic and treatment options, did we address pain and suffering with any degree of fervor and strategic planning. We are now entering the era of patient-centered care, and we are engaging with increasingly empowered patients. Their voices are ringing ever more clearly as the financial crisis in healthcare looms and their individual needs remain unmet. Perhaps the provision of comfort (palliation of suffering, in all its forms) and care (treatment for disease) will be common in this new era. If we are fortunate, this combined approach will be a more cost-effective and will result in higher patient satisfaction, both early and late in illness. Palliative physicians are those who care for patients with serious, life-limiting and often chronic illness. The focus of their care is the quality of life, but not to the exclusion of providing treatments aimed at increasing the quantity of life. Palliative care, mistakenly called by some “symptom management,” is a specialty with breadth and depth unto itself, just like any other medical specialty. In the same way that our ability to diagnose, intervene and manage disease has advanced dramatically in the last few decades, so too has the focus, ability and armamentarium of the palliative specialist. The palliative specialist is trained to see the patient as a whole person,

in their own individual context and logistical setting, and to tease out what matters most to them as their life and disease simultaneously progress. Palliative specialists are trained to think “outside the box” when unraveling complex or multifactorial symptoms that often affect multiple organ systems. The palliative model is based on a team approach that provides the patient with medical care while also addressing family, psychological and spiritual needs. Unfortunately, the term palliative care is often used interchangeably with hospice care, which by definition is care given at or near the end of life. Palliative care is not hospice care. Much of hospice care, however, is the palliation of discomfort. In hospice care, diagnostic and curative treatments are not offered. In contrast, palliative care should be considered and administered at any time during a course of treatment.


uring her second visit, Anne and the palliative specialist determine that she would not want to go through the same experience that her father had in the ICU. She doesn’t mind the short hospitalizations, she says, but when things get “bad,” she doesn’t want to “hang around.” The specialist asks if she has talked to anyone about her wishes. She answers, “No, but I have a living will which states if things are terminal, I should be let go.” The specialist points out how ambiguous that statement might seem in certain contexts and asks if Anne has talked to the person who will have her durable power of attorney. “Not Marin Medicine

specifically,” she answers. “My daughter knows she will be the one, but we haven’t spoken about this.” The specialist again suggests how this might be a problem and recommends that Anne bring her daughter next time or arrange for a telephone conference for the three of them. He offers to write out her thoughts and wishes to ensure that her family is aware of what she values most. Advance care planning has begun.


hy do physicians shy away from planning in advance for the terminal aspects of care or disease? After all, mortality worldwide is 100%. For patients with organ failure, cancer or dementia, data on life expectancy do exist. Unfortunately, data also show that even in the weeks and days before death, prognosis on any given day remains statistically uncertain. Physicians are therefore hesitant to prognosticate or forecast for individual patients. This hesitation may be a sound approach based on epidemiology, but we all must bring our own clinical judgment to bear. The most useful question is, “Would I be surprised if this person died in six months to a year?” If the answer is no, advance care planning should begin immediately. Ideally, advance care planning begins at the time of diagnosis and is an ongoing process of discussion with regular re-evaluation. One problem we face is the lack of reimbursement for such detailed, difficult and often lengthy discussions. These dicey emotional interchanges have been called “surgical conversations,” indicating that it takes a surgeon’s skill to cut to the heart of the matter and lay bare what makes the most sense for each individual. One recent study found that advance planning conversations with heart failure patients focused largely on disease management, not preparation for end of life.1 The authors conclude: “End of Life Care (EOLC) is rarely discussed. Some patients would welcome such conversations, but many do not realize the seriousness of their condition or do Marin Medicine

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Clinicians are unsure how to discuss COLLECTION of Mary Silverwood the uncertain prognosis and risk of original pastels, framed. All Sonoma sudden death; fearing causing premaCounty scenes. Call 707-539-4576. ture alarm and destruction of hope, they wait for cues from patients before HOWEOLC TOissues. PLACE AN AD raising Consequently, the conversations rarely take place.” Buy, Sell, Rent The patient is Trade, likely often waiting – all for 1 dollar a word. for us to bring up the topic of advance To place a classified ad, contact Nan Perrott planning. One option to get past this at reluctance (on both sides) is to have, at or 707-525-4226. minimum, a conversation with the pa-


207-0053 Fax 524-8130, Texas Tech Univ 1999 tient or family centered on the concept * board certifi ed of “hoping for the best but preparing for the worst.”


nne’s advance care planning is time-consuming. She and the palliative specialist discuss prognosis and resuscitation, along with time-limited trials on the ventilator for more serious episodes of heart failure. Her daughter and other family members also have questions for the palliative specialist. Anne’s opinions change over time, and Fawn pug (see page 33)



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her family physician and cardiologist are all made aware of her plans and preferences. There is paperwork associated with each phase of advance care planning. It is a detailed and everunfolding process. Standard approaches to advance care planning have failed. Most often no plan is made, or the plan is not useful or specific enough to the clinical situation. Other shortcomings include failure of family members to accept or understand the plan, and then to strongly oppose its implementation. Or, the plan is not available to the treating physician at the time of need. Sometimes a plan may be in place but will be overridden by the treating physician or facility because they are not comfortable with the plan or with withholding care. The role of advance care planning is to really know and truly honor a patient’s wishes and informed plans regarding their health and healthcare. As formulated by Dr. Bernard Hammes of the Gunderson Lutheran Medical Foundation, the essential elements of effective planning are these: Plans must be created, and they must be specific and accurate. The plans must be understood and available and then incorporated into the decision-making process when necessary.


welve years after her first meeting with the palliative specialist, Anne has been hospitalized many times, at first infrequently, but now three or more times per year. She doesn’t get out much and tells her physicians she is starting to feel worn out and dreading the hospital, dreading the feeling as she slips into failure and gets more short of breath and begins to panic. Anne goes back to the palliative specialist, who suggests a transition to home-based care. Anne continues on her cardiac medicine but also gets sedatives, pain relievers and anxiolytics as needed. She agrees not to return to the hospital, and she signs her POLST form for “No Resuscitation.” Anne continues with home care and symptom management for eight months. Then, when weakness makes Marin Medicine

swallowing difficult, herfunctions pills are disemphasizing separate and continued is made comfortable. expertise,and the she entire department had She quietly with family nine to bedies restructured. Theher providers were days All along the way, she and askedlater. to choose an area of expertise, her family feltthat thatarea her wishes were and the practice only of expertise, driving force for her care and follow the inmate/patients to goals. wherNow her family she was careda ever they were feels housed. Thiswell denotes significant departure fromtogether the typical for. Her physicians worked as treatment model where a ainstitutional team. The physician who pronounced clinician assigned to a unit. In San her death is knew her well. Quentin’s restructured the care mulPalliative care andmodel, advance tidisciplinary team is are not planning worktreatment best when they assignedearly to a location, but to ininitiated in the course oftheir disease mate/patients. We now have individual and are part of the ongoing care plan. clinicians practicing in their areasapof The patients most suited to these strength,are rather than trying to provide proaches those with life-threatening every service. chronic or terminal disease. Plan early Working an institution, and provide within palliation often. Yourlocal pacustody administration tients will thank you. is an invaluable ally in the delivery of mental health services. Each peace officer—including Email: the warden, chief deputy warden, associate wardens, captains, lieutenants, References 1. Barclay S, et al, “End-of-life care sergeants and officers—plays a convercritical heart failure patients,â€? Br J rolesations in ourwith success. Local San Quentin Gen Prac, 61:49-62 (2011). custody ensures a safe working environment while serving as our access to Resources providing care. Absent this safety or American Academy of Hospice and Palliathis access, our working environment tive Medicine: would be much less efficient and efHallenbeck JL, Palliative Care Perspectives, fective. In part, our success is derived Oxford Univ Press (2003). from our ability to provide services, National Hospice and Palliative Care Orand this function is uniquely tied to ganization: custody operations. Finally, our professional relationship with C L various A S S I Fadministrative IEDS bodies has led to our success via their unwavering support, including workShred-It ing relationships withservice. the Secretary’s On-site guaranteed Office Office, the Office Stay of the Receiver,Free and console provided. compliant. the DivisionContact of Correctional Health consultation. Marie Anderson Care Services. â–Ą at 415-721-7278 or marie.anderson@

How to submit a classified ad

To submit a classified ad for Marin Medicine or MMS News Briefs, contact Erika Goodwin at or 707-548-6491. The cost is one dollar per word.

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ABOUT MM S The Marin Medical Society, a component medical society of the California Medical Association, supports local physicians and their efforts to enhance the health of the community. MMS and CMA offer a wide array of legal, collegial and advocacy benefits to their members, and they are involved with several community health initiatives.

Founded in 1898, MMS is a 501(c)(6) nonprofit organization governed by a board of directors composed of local physicians. MMS welcomes all physicians, respects diverse interests and acts as a unifying force in the community. Interested physicians with MD or DO degrees can join both MMS and CMA by completing a simple, one-page application form.


MMS enhances the health of the community by helping local residents gain the knowledge, motivations and opportunities needed to make informed decisions about their health. The medical society supports local, state and national efforts to promote healthy behaviors, create healthy environments and increase access to high-quality health care. Current MMS health initiatives include:

Disaster preparedness. In collaboration with the Marin County Public Health Department, MMS coordinates National Incident Management System (NIMS) disaster preparedness (DP) training for local physicians. The training helps physicians respond appropriately to earthquakes, communicable disease outbreaks and other types of disasters. Physicians in the DP group also volunteer at Marin Community Clinics.

Marin Specialty Access. This initiative seeks to improve access to specialty care for uninsured and underinsured patients in Marin County. Working in collaboration with physicians, safety net providers, community organizations and regional hospital systems, the goal is to encourage participation in the Marin Community Clinics specialty referral system.

Community leadership. MMS members serve in leadership positions for many local health organizations, including Heberden Telemedicine Foundation, LifePlant International, Marin Community Clinics, Marin HIV/ AIDS Care Council, Marin Medical Reserve Corps, Operation Access, Partnership HealthPlan, Rotacare, and Marin Women’s Study breast cancer research.

20 Fall 2011


Marin Medicine


Benefits and activities for MMS/CMA members include legal and financial services, collegial events, and legislative advocacy.

to interact with their colleagues in a relaxed and convivial atmosphere. MMS also sponsors an annual potluck dinner for women physicians.

Free medical-legal information. MMS/CMA members can contact the CMA Member Help Center at 800-786-4262 for assistance with general, legal and reimbursement issues, including contracts and agreements, subpoenas, employer/ employee relations, collections, confidentiality, and records retention. In addition, members can access the CMA Medical-Legal Library at, an online resource containing over 3,000 pages of medical-legal, regulatory and reimbursement information. These documents are free to members; nonmembers pay $2 per page.

CMA Meetings. MMS/CMA members regularly participate in meetings sponsored by the California Medical Association. Each fall, delegates from MMS attend the House of Delegates, which establishes the policies that guide CMA. During the spring, MMS/CMA members enroll in the CMA Leadership Academy, which helps physicians develop leadership skills and understand the latest trends in health care.

Collegial Events. MMS encourages physician collegiality in Marin County by sponsoring several annual events. The seasonal dinners, held at local restaurants two or three times per year, feature well-known speakers and lively social hours. Informal receptions throughout the year allow physicians

Legislative Advocacy. Physicians consistently indicate that influencing public policy is a top priority. MMS/ CMA members regularly meet with local representatives and with candidates for public office. Members are also invited to participate in the annual Legislative Day, when physicians from around the state convene in Sacramento to meet with legislators and other government officials.


One of key functions of MMS and CMA is to help physicians stay current with medical news and trends. Members receive free subscriptions to several publications, including: MMS News Briefs. This monthly electronic newsletter covers the latest local, state and national medical news.

Marin County Physician Directory. This annual publication features detailed listings for MMS members, including their specialties, board certifications, special medical interest and medical training. CMA Publications. MMS/CMA members can receive one or more free newsletters from CMA, including CMA Alert and CMA Practice Resources. In addition, the CMA On-Line Bookstore at offers a wide array of legal handbooks and practice management guides.


Marin Medicine. Each issue of this peer-reviewed quarterly magazine focuses on a particular medical topic, with articles by local physicians and other experts.


Members who are interested in influencing public policy, reviewing publications or assisting with disaster preparedness can sign up for MMS committees, including: Disaster Preparedness Physician Volunteer Group. Members of this group receive disaster preparedness training and volunteer their time at Marin Community

HOW TO JOIN MMS AND CMA Any medical doctor (MD) or doctor of osteopathy (DO) is eligible to join the Marin Medical Society and the California Medical Association. You can apply online at or request an application from Rachel Pandolfi at or 415-924-3891.

Clinics. For more information, contact Dr. Peter Bretan at Editorial Board. Approves editorial content for Marin Medicine magazine. Legislative. Organizes meetings with local legislators and candidates for public office.

CONTACT MMS Marin Medical Society PO Box 246 Corte Madera, CA 94976 415-924-3891 Fax 415-924-2749

Blue Door Conference Center presented by


Please join us for Our Presentations

ASSET PROTECTION FOR DOCTORS Wednesday, October 5, 2011 at 6:30 p.m. • Light dinner to be provided • –or– Saturday, October 8, 2011 at 11:00 a.m. • Lunch to be provided • Presentations by J.R. Hastings Accredited Estate Planner with the National Association of Estate Planners and Councils Member Wealth Counsel, Advisor’s Forum, California Bar Association, Colorado Bar, Nevada Bar and Washington, D.C. Bar

Blue Door Entrance 1003 Third Street, San Rafael (corner of Brooks Street, between A Street and Lindaro)

RSVP to: | 415.459.6635 Seating is limited, so RSVP early

There is no charge for attendance at these presentations


Consultations at the Speed of Light Peter Bretan, MD


t a recent speakers’ The ability to follow and see training program, I my patients instantaneously was sitting with a colanywhere, even on the other league discussing how difficult side of the world, cannot be it is to get specialist consultaoverstated as a technological tions at community clinics or feat. When I conducted a recent in rural hospitals because such medical mission in the Philipconsults are not cost-effective pines, for example, I was able for either the facility or the speto follow up on patients still in cialist. I showed him a possible the hospital back in the USA by solution to this problem by ususing my laptop and the local ing a joystick on my laptop to hospital telemedicine robot. AdDr. Bretan conducting rounds via laptop and robot. control a mobile robot at a rural ditionally, by leaving an Apple hospital 2,000 miles away. He peered I activate and control remotely from my iPod 4.0 (which costs less than $300) in into my computer screen and saw a laptop with the help of a joystick. The the Philippines, I was able to follow the hospital ward as I made “rounds” via robot comes equipped with a computer, patients I recently transplanted, as well the mobile robot. He was amazed to camera, microphone and motorized as converse with the local physicians learn that this type of medical practice wheels, along with a probe for both austhere via Face Time when I returned is now possible via the advancements cultation and sonography. The robot can to California. These communications of technology and robotic telemedicine. move between hospital and emergency are transmitted via the Internet and In addition to my private practice rooms and view X-rays in the radiology cost nothing. in Novato, I am the sole urologist for department. With the help of the robot a company specializing in telemediand a hospitalist or nurse practitioner, s part of my work for OffSite Care, I cine. By using robots to connect with I can perform physical exams and bladalso can electively visit patients in patients at great distances, this techder scans, and the patient and I can person if needed (as for urgent surgeries) nology solves the dilemma of remote see each other in real time. The image at 12 Northern California hospitals and specialty care. The system offers an imresolution—both of the patient and of three office clinics. Most of these facilimediate off-site urologic consultation, my face on the robot’s screen—is excepties are more than one or two hours away essentially available all the time. The tional, and it enables a true “in person” by car. As OffSite Care’s reach expands, company I work for, OffSite Care (lotype of communication. In fact, I find we hope to add several other urologists cated in Sebastopol), is part of a growno difference between a face-to-face and increase our range to more than 20 ing field of telemedicine services and consultation and a robotic one. hospitals and clinics, within less than products. Others include Vgo CommuIn hospitals where there are no uroltwo hours of air travel time. nications (Nashua, NH), RoboDynamogists available, telemedicine reduces This extended geographic coverics (Santa Monica) and InTouch Health or eliminates the need to transport paage has enabled me to significantly (Santa Barbara). tients to larger medical centers where a increase my practice and to care for OffSite Care uses a urologist is physically available and/or highly complex patients close to their telemedicine robot that on call. Patients and local support staff homes. I perform surgeries in the local are grateful that I am available via the hospitals with the full support of their Dr. Bretan, a Novato robot and are often relieved to see me. physicians and nurses. Then I follow urologist in private My sense is that the robot has glamthe patients via telemedicine without practice, is president of our status that I could never achieve having to delegate their follow-up care MMS. in person. to another surgeon.


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Fall 2011 23




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Telemedicine keeps patients close to their families and to their primary care physicians. Patients and their families want high quality specialty care, and they have little or no resistance to establishing a doctor-patient relationship via telemedicine. When I meet them in person, it’s a seamless continuation of our relationship. They often say, “You look just like you do in the robot!” Frequent contact via telemedicine provides a strong foundation to the doctor-patient relationship. The sound of my voice gives comfort as I discuss their case, and the family can also offer support because they are often right there with the patient.


ompared to other surgical specialties, urology is well suited for telemedicine because there are few emergencies and patients are relatively easy to evaluate via robotic means. In the rare instances when more complex patients require an in-person urologic evaluation, they can be transferred (after an initial telemedicine evaluation) to centers where 24-hour urologic onsite coverage is available. The benefit to both the local facility and patients is that this determination can be made with confidence immediately. For most of my telemedicine evaluations, the patient is stable, enabling me to schedule them for elective surgery if indicated. These types of straightforward cases are beneficial to the economics and operations of the local rural hospital. Most of my surgeries can usually wait days or weeks, which gives me a chance to put patients on antibiotics and do a cardiac workup if required. Telemedicine fosters a different relationship between consulting physicians and support staff in a remote hospital. The nurses understand that I’m working remotely, and they’re willing to work with me on the patient’s behalf with much more urgency than when I am there in person. By working closely with nurse practitioners, I have found that that there is absolutely no loss in assessment. They perform the physical exams on-site, and I am able to evaluate

the results via telemedicine. Once these relationships have been established, they are workable, durable, efficient and effective. Sometimes I’m more comprehensive with the care of telemedicine patients because I can easily visit them many times in the same day. I can order a sonogram or blood test, get the results, and then come back in a couple of hours to see the patient again. The evaluations take only a few minutes, and I can conveniently work these robotic communications in between seeing patients during my regular office schedule. Telemedicine visits are much quicker than seeing patients at a local hospital, and they help me provide a high standard of care. Telemedicine also makes it more convenient to have a conversation with patients and their families. This close contact helps the patient and family be more confident in me because they know what is happening during every stage of the hospitalization, and that the patient is safely under my direct supervision. My experience is that robotic telemedicine makes patient care more personal, not less personal. Telemedicine delivers face-to-face interaction, which lets patients see my concern for their health. There’s almost no difference in our interaction whether I’m with them in person or in my robotic persona. These regular visits strengthen the foundation of medical practice: the doctor-patient relationship. Technology can’t make more specialists, but telemedicine can now bring together patients and specialists in a timely manner, effectively ending a shortage of specialty care for many rural communities and community clinics. With telemedicine, robots can be used to care for patients who previously lacked access to specialists, with great quality of care and patient satisfaction. Email: For a CMA video presentation about telemedicine, visit watch?v=L20a4fhOn-s.

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Novato Community Hospital Kurt Kunzel, MD


am pleased to report that 2011 marks the 50th year Novato Community Hospital has served the communities of northern Marin and southern Sonoma counties. It is also our 26th year as a Sutter Health aff il iate a nd our 10th year in a likenew facility on Rowland Way in Novato. While we are on the subject of milestones, this is a good time to review some of the hospital’s changes during the last decade. In 2004, we expanded our outpatient services to central Marin by opening the Sutter Terra Linda Health Plaza in San Rafael. This facility, located on Civic Center Drive, includes a seven-day urgent care clinic, a physical therapy and sports fitness center, and lab, X-ray and EKG services. We opened another physical therapy and sports fitness center on the Novato campus in 2008 to complement Sutter’s new North Bay Regional Surgery Center, a joint venture with Sutter Health and local physicians. Late last year, we opened a branch of the Kalmanovitz Child Development Center at ou r Terra Linda facility. The center tailors services Dr. Kunzel, an emergency physician, is chief of medical staff at Novato Community Hospital.

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by using the iTriage app. iTriage can be downloaded from a link on our website ( or at the App Store.


to the individual needs of preschoolers, school-age children and adolescents. Therapists specialize in evaluating, diagnosing and treating learning disabilities, school-related learning problems, speech and language difficulties, and social-skill deficits. Treatment is coordinated with physicians, schools and community resources. The center accepts most insurance plans and sees patients on a sliding-fee scale. In January, we joined California Pacific Medical Center, Sutter Medical Center of Santa Rosa, and Sutter Lakeside Hospital under a single governing board as Sutter West Bay Hospitals. This new corporate structure enables us to respond more readily to our patients’ needs and helps us make better use of our resources. This summer, our Terra Linda urgent-care clinic went mobile, thanks to Sutter Health’s agreement with the mobile application iTriage. Now patients can determine wait times at the urgent care center on their smartphone

ver the last few years, several third-party organizations have recognized our clinical accomplishments. For exa mple, we received Cert if icates of Excellence from the California Hospital Assessment and Reporting Taskforce, and HealthGrades gave us its highest rating of five stars for joint and knee replacement, and for hip fracture repair. Meanwhile, our emergency department has consistently performed at the 99th percentile in the Press Ganey patient satisfaction survey. One of our most significant honors came during April, when the Beacon Collaborative awarded the hospital and emergency physician Dr. David Thompson its Power of Peers Award for successfully implementing an initiative to reduce severe sepsis mortality. During 2010, the initiative more than doubled our emergency department sepsis screenings (from 40% to 93%) and reduced sepsis mortality by 50%. The initiative began as a Partners Advancing Clinic Excellence project in 2009. (PACE Councils are staff-led groups using evidence and best practices to improve outcomes, care and patient safety.) During that first year, Fall 2011 25

the PACE Council had only limited success with the sepsis-screening tool, but processes and outcomes improved dramatically when Thompson championed the NCH initiative in 2010. Along with inpatient pharmacy manager Dr. Michael Buffum, Thompson created and expedited a new version of the sepsis-screening tool and conducted small tests of change with emergency department physicians and nurses. Thompson also developed a Sepsis

Critical Action Checklist that enabled nurses to meet timelines for effective early goal-directed therapy. In addition to guiding nurses’ actions and priorities when managing severe-sepsis and septic-shock patients, the checklist gathers important information for doctors and nurses to hand off to the next care provider. Along with the checklist, Thompson implemented chart audits and case study reviews, and he provided individual feedback to physicians and

All local physicians and their spouse or guest are invited to the Marin Medical Society’s fall 2011 dinner:

Enjoy Every Sandwich: Living each day as if it were your last Lee Lipsenthal, MD f

Wednesday, Oct. 12 6 p.m. — Social Hour 7 p.m. — Dinner & Program Jason’s Restaurant 300 Drakes Landing Rd., Greenbrae

Dr. Lipsenthal, author of Finding Balance in a Medical Life and Enjoy Every Sandwich, will show you how to grow the sense of meaning and purpose in your life while enhancing the quality of your work.

• Tickets $45 per person • f To RSVP and identify your dinner choice, contact Rachel at 415-924-3891 or You can also fax the form below to 415-924-2749 or mail to MMS, PO Box 246, Corte Madera, CA 94976.

nurses. As a result, we improved compliance with all elements of early goaldirected therapy. The results speak for themselves.


hanks to a successful community fundraising campaign and a matching grant from Sutter Health, we installed Alaris Care Infusion “smart pumps” throughout the hospital this summer. This technology improves patient safety, helps us avoid high-risk medication errors, and provides us with data that we can use to monitor best practices. Our community fundraisers are hard at work this year on a $100,000 matching grant project to upgrade our orthopedic surgery equipment. So far, the group has about half the amount needed to obtain the full match from Sutter Health by the end of the year. We will also be replacing our 10-year-old MRI with the latest technology this fall. This acquisition enhances our ability to serve the community with high quality inpatient and outpatient diagnostic imaging services. Like most healthcare organizations, we are engaging in new ways of thinking and learning to meet the challenges of healthcare reform, rapidly changing technology and an aging population. Strong community and staff partnerships have never been as important as they are now. While we celebrate our 50-year past, we maintain our focus on providing high quality affordable care to meet the needs of the communities we serve. Email:

NEW MEMBERS Name _________________________________________________________________________________________________________________________ # Tickets ________________________ Phone _______________________________________________________________________ Email ______________________________________________________________________________ Circle payment option Check enclosed /Visa or MasterCard #________________________________________________________________________________________________________________ Exp. date ____________________________________________ Signature _______________________________________________________________________________________________ Indicate your dinner choice(s) _____ Baked salmon with asparagus and potatoes

_____ Brandy chicken with rice and asparagus

_____ Blackened ribeye steak with spinach and potatoes _____ Triple mushroom gnocchi (vegetarian)

Fax to 415-924-2749

26 Fall 2011

David Goodman, MD Public Health & General Preventive Medicine Occupational Medicine 6 Parkside Way Greenbrae 94904 672-4427 Fax 464-0250 Harvard Med Sch 1993 Marin Medicine


Changing from Within Lori Selleck, MD Finding Balance in a Medical Life, Lee Lipsenthal, MD, 208 pages, $20.


ur medical communit y in Marin is fortunate to have several notable physicians engaged in wellness programs, such as Drs. Rachel Naomi Remen, Dean Ornish and Lee Lipsenthal. They have all written books about their work. One of the best is Lipsenthal’s Finding Balance in a Medical Life, originally published in 2007. The subtitle is, “A guided program to help you reclaim a sense of balance in your busy life in medicine.” While much has been written on the subject of wellness and life balance, Lipsenthal’s book is a fascinating read from a physician’s perspective. The discussion ranges from the types of personalities that go into medicine to the current stressors of trying to manage a busy practice as well as a personal life. The same abilities we used to excel and persevere in our training now often get in the way of finding a sustainable balance between the two. Lipsenthal shares his own journey from being a busy internist with a mainstream practice in Philadelphia, through his experiences with “meditation, spirituality, neurophysiology, shamanism, integrative or holistic medicine, organizational development and psychology.” He describes the process of self-analysis and self-awareness so that his colleagues may learn “not how to be a great doctor, but how to have a great life while using our medical skills and knowledge.” Finding Balance in a Medical Life is a well-written, thought-provoking Dr. Selleck, an internist at Kaiser Novato, is past president of MMS.

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guide to understanding the dilemma we physicians are in, along with strategies for how to change. The book gives an overview of the subject with many anecdotes from Lipsenthal’s life and the lives of his colleagues. For readers who are interested in real behavior change, the book also includes exercises to enable that process. For those who may be skeptical of this potentially “soft” subject, Lipsenthal supports his conclusions with more than 140 scientific references.


ne section of the book discusses the personality traits of physicians. Lipsenthal observes that while physicians are intelligent, caring and inquisitive, they are also competitive, obsessive, perfectionist and compulsive—all traits of Type A personalities. While those traits are essential to our medical training, they can get in our way now. “We rise to the occasion of our training,” Lipsenthal writes. “[We]

work longer hours for little money and see more and more patients. Because we do this for so long it becomes our way of being.” One highlight of the book is the simple question, “Are we happy?” Multiple surveys have shown that physicians are increasingly dissatisfied with their practices and have trouble finding work-life balance. Some of the reasons for this dissatisfaction were tallied by a 2001 Kaiser Family Foundation survey of 2,608 physicians. Of that group, 74% cited excessive administrative duties, 56% said they did not have enough time for family, hobbies and friends, and 54% were dissatisfied with a lack of autonomy. In almost all studies of physician satisfaction, roughly one-third of the respondents state that they would not choose medicine as a career again. Lipsenthal, while acknowledging that external factors are partly responsible for our unhappiness, points out that some of our unhappiness comes from our own attitudes, which we have the ability to change. In addition to discussing happiness, or lack thereof, Lipsenthal presents a lot of information on physician health. Studies from the 1990s, for example, found that “we smoked less, exercised more and ate healthier than our patients, yet our overall mortality was higher than any other professional group. Our per capita rates of heart disease, depression and stroke were higher than any other working group and the lifespan of a physician was shorter than comparable socioeconomic groups. Most disturbing is that women physicians had a life expectancy 10 years lower than the general population in the same socioeconomic category.” Lipsenthal does point out that this Fall 2011 27

An Insightful Journey Scott Levy, MD, MPH Enjoy Every Sandwich, by Lee Lipsenthal, MD, 224 pages, Crown Archetype, $22. As physicians, we’re taught to be grateful for the good things in life. We know the “evil eye” is lurking above, just wanting to seduce our 5-year-old son to jump out of that old tree. We hope we escape devastating events that often get labeled by intelligent colleagues as “bad luck.” We hug our kids, call home, and wish no one we know will have to endure the same agonizing treatment as the 3 p.m. appointment who was just diagnosed with pancreatic cancer. Enjoy Every Sandwich, the new book by Dr. Lee Lipsenthal, describes his journey during diagnosis and treatment for cancer. His very personal story delves into his struggle to make peace with his own mortality, even as it highlights the conflict between his medical brain and his emotional one. As physicians, we can recite and interpret statistics and expected outcomes, but our knowledge of the spiritual realm is usually limited. At some points in the book, suspension of disbelief is required. After all, what do I know about outof-body experiences and prediction of future events? I do know, however, that amazing and unexplainable things happen every day in the hospital. For this reason, I wanted to continue reading. I wanted to find out what Lipsenthal knew and what he saw. I was impressed by Lipsenthal’s use of meditation and how that focused his life into a healthier perspective. He takes us to that

desperate, hopeless place where life doesn’t seem worthwhile and then shows how he worked back to living a full life by using beautiful aspects of his experiences as stepping stones. While reading, I found myself thinking of the positive aspects of my own life and how better to integrate humility and gratitude. Lipsenthal’s story does not end with him being cured, but it did leave me with a feeling of continued growth, both physically and spiritually. Life moves on, and whether you choose to embrace and celebrate it is up to you. This is the ultimate message of hope. Although we’re not always given a say in what our future holds, we can surely change our perspective of it. Enjoy Every Sandwich is an uplifting read not just for physicians but for health care providers in general. Unlike many other stories that describe the course of treatment through the patient’s perspective, this book does not lecture the reader on how to deliver better care. Instead, Lipsenthal’s book teaches us how terrifying the process truly is. No matter how deep your resources and support system are, the journey from diagnosis to therapy is traumatic. Although most of us have witnessed a devastating terminal illness in our patients, few have had to experience such a diagnosis in our own immediate families, let alone in ourselves. Insight into this process is important for us to grasp and will ultimately lead to a better care experience for our patients. Email:

data reflects women who went to medical school in the 1940s and 50s and had trouble being accepted into a maledominated profession. Yet the problems persist. “Even now,” he writes, “while the majority of medical school enrollees are women, it is not always an easy place for women. In addition, women are still expected to perform most of the housework and parenting roles. Add to this the fact that most women physicians are perfectionists who are trying to do two jobs that are impossible to do perfectly (work and home) and it is still a recipe for disaster.”


fter describing “The Road to Burnout,” Lipsenthal moves to “The Road Within.” He devotes the second half of his book to self-evaluation, stress management, and how to shift our perspectives, finally putting everything together in a chapter titled “Psychosynthesis.” The last page, “What is Balance?” offers several possible answers. Among them: • Balance is being realistic about what you can control and what you can’t. • Balance is learning to accept and appreciate your own limitations. • Balance is remembering to love those people in your life who give you meaning and purpose. • Balance is learning to understand, love and embrace the part of your personality with which you struggle. • Balance is taking care of yourself first, so that you can take care of your family. Then, coming from a stable and loving home, you can serve your patients. • Balance is taking care of the body you’ve been given. • Balance is being open to new ways of thinking. I recommend Lipsenthal’s book to physicians who are finding themselves in need of some type of change. By reading it, they can get a clearer picture of what that change may be, and they can learn the tools to get started. Email:

28 Fall 2011

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Marin Medicine Fall 2011  

Quarterly publication of the Marin Medical Society

Marin Medicine Fall 2011  

Quarterly publication of the Marin Medical Society