April 2013

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Evolving Frontiers in Medical Specialties Primary Care: The Future Scope of Practice Controversies What Is Health Care Reform Doing for Substance Abuse Treatment?

Robotics in Cardiac Surgery Teledermatology Takes Hold Updates From Cardiology, Oncology, and Bariatric Medicine

VOL. 86 NO. 3 April 2013

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IN THIS ISSUE

SAN FRANCISCO MEDICINE April 2013 Volume 86, Number 3

Evolving Frontiers in Medical Specialties FEATURE ARTICLES

MONTHLY COLUMNS

12 The Doc Whisperer: “It’s Change I Don’t Like”

Jack Lewin, MD

4

Membership Matters

6

Ask the SFMS

7

New SFMS Members

9

President’s Message Shannon Udovic-Constant, MD

13 Primary Care: Current Challenges and the Future

Callie Langton, PhD 15 The Future of General Surgery: A 2013 Update

John Maa, MD

17 Substance Abuse: Health Care Reform Brings Changes

for Treatment

David Pating, MD 19 Cardiac Surgery: The Role of Robotics

Sachin Shah, MD

21 Teledermatology: Technology to Improve Access to Care

Lawrence Cheung, MD 23 Developments in Oncology: An Update on Progress

Caroline Behler, MD 25 Neurology: New Developments in the Field

Brian Andrews, MD, FAANS, FACS

26 Bariatric Medicine: Seven Exciting Developments

Sean Bourke, MD

11 Editorial

Gordon Fung, MD, PhD 32 In Memoriam

Nancy Thomson, MD 33 Hospital News

OF INTEREST 31 Choosing (Ever More) Wisely: An Update

from the “Moral Center of Care”

Steve Heilig, MPH

31 Medicare/Medi-Cal Dual Eligible Patients

Update: Some Good News 32 SFMS/CMA Joins Amicus Briefs Challenging

Proposition 8 and the Defense of Marriage Act

29 Nurse Practitioners: Implementing the Affordable Care Act

David Vlahov, RN, PhD 30 The Rules of Primary Care: Creating Safe, Smart Ways to

Serve the Growing Pool of Patients

Paul R. Phinney, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Blue Shield to Require Physicians to Notify Patients Before Referring Out of Network

Support SFMS Members at the 6/15 Prostate Cancer Run/Walk

On March 15, Blue Shield announced that it would soon begin requiring contracted physicians to notify patients in writing before making out-of-network referrals. Effective May 15, physicians will be required to notify patients in writing using a form provided by the payor when referring a patient to an out-of-network provider. The policy does not apply to emergencies. This change comes on the heels of a similar change recently implemented by Anthem Blue Cross.

While existing language in Blue Shield provider contracts had placed limitations on referrals to out-of-network providers for patients with HMOs, EPOs, and/or Medicare Advantage plans, those limitations did not apply to patients with PPOs. That will change effective May 15. According to Blue Shield, the completed form must be filed in the patient’s medical record and be made available to Blue Shield within five business days if requested.

Physicians with concerns are encouraged to contact the Blue Shield Provider Liaison Unit at (800) 258-3091.

Questions about managed care contracts and payor issues?

SFMS members receive one-on-one assistance from the Center for Economic Services via CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.

SFMS members Seck Chan, Edward Collins, Robert Kahn, Ira Sharlip, Rodman Rogers, Stuart Rosenberg, and Lawrence Werboff of Golden Gate Urology will be hosting the Zero Prostate Cancer Run/Walk at Crissy Field on June 15, 2013.

The goal of the event is to help educate and create awareness about prostate cancer. The Zero Prostate Cancer Run is a premier men’s health event in the country, having now been held in thirty-two cities throughout the U.S. This is the first time the race will be held in San Francisco. For more information about the event, please visit zeroprostatecancerrun.

Update Your Practice Information for the SFMS Online and Print Pictorial Directory

Spotlight your practice and expand your referral base with an updated member profile! With the SFMS online Physician Finder and the print directory, physician members have the opportunity to promote their practices on customizable individual Web profiles and connect with a larger patient and referral base.

SFMS has sent out e-mail and mail notifications to all physician members currently engaged in the practice of medicine to update contact information for the directory. If you did not have your picture in the 2012 directory, or if your information is outdated, we encourage you to update your directory entry by contacting SFMS at lestrada@sfms.org or (415) 561-0850 extension 200.

Promote Your Practice with the SFMS Directory

If you would like to reach 1,000 health care professionals in San Francisco, please consider placing an ad in the 2013 SFMS Member Directory. Members are eligible for an exclusive discount on quarter-page vertical ad placements. Advertising rates start at $395. To obtain the ad rate and contract agreement, contact Lauren Estrada at lestrada@sfms.org or (415) 561-0850 extension 200.

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org/sanfrancisco.

Update on Medicare MAC Contract Protest The Centers for Medicare and Medicaid Services (CMS) announced in September 2012 that Noridian has been named the new Medicare Administrative Contractor (MAC) for Medicare Parts A and B in Jurisdiction E (previously called Jurisdiction 1).

Two protests were filed challenging the award.

On January 18, 2013, the Government Accountability Office denied the two protests. As permitted by law, both protestors (Palmetto GBA and CGS) subsequently filed complaints with the U.S. Court of Federal Claims challenging the Jurisdiction E MAC contract award in February.

For at least the next several months, Medicare providers in Jurisdiction E (California, Hawaii, Nevada, and the Pacific territories) will continue to file their Medicare claims with the incumbent Palmetto GBA. CMS will notify affected Medicare doctors about the situation, including any implementation dates, following the Court of Federal Claims review.

Medi-Cal Extends 2012 EHR Attestation Deadline

Xerox, the vendor in charge of the Medi-Cal electronic health record (EHR) incentive payments, has resolved the technical difficulties that were complicating some doctors’ ability to complete their 2012 attestations. Specifically, the Medi-Cal State Level Registry was not properly allowing some doctors who have been designated as members of groups to inherit and use the group’s information. As of March 15, the system is fully functional. Because of the difficulties and resulting attestation delays, the California Department of Health Care Services (DHCS) has received federal authorization to extend the 2012 attestation deadline to April 30, 2013. This deadline extension applies to all eligible professionals, not just those affected by the group attestation problem. For more information, visit www.medi-cal.ehr.ca.gov or call Xerox’s EHR Program at (866) 879-0109. www.sfms.org

April 2013 Volume 86, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Physician Networking Event a Huge Success!

More than forty San Francisco physicians participated in SFMS’ Spring Networking Mixer at 83 Proof on March 14. Attendees were able to meet local physicians to expand their professional networks and share experiences.

With great attendance and positive feedback from all, SFMS plans to organize similar social networking events in the coming months. Please check the SFMS blog or follow SFMS on Twitter (@SFMedSociety) for event details. SFMS would like to thank MIEC for its support of the Spring Networking Mixer.

SFMS Seminar: Customer Service, Patient Relations, and Telephone Techniques, May 10, 9 a.m.–12 p.m.

Customer service in a medical setting has a unique set of challenges specific to providing first-rate health care and patient satisfaction.

Among these challenges are such issues as patient privacy, high volume, and management of people in crisis.

This half-day practice management seminar provides valuable training for both front- and back-office staff to handle patients and tasks both efficiently and professionally using superlative customer service skills.

This seminar will provide your staff with the tools necessary for positive patient relations.

Complimentary breakfast is included. With questions or to register, please contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260.

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

April 24: California’s Health Benefit Exchange: How It Will Impact Your Practice and Change Commercial Insurance • 12:15 p.m. to 1:45 p.m.

May 1: The Power of the Pen: The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients • 12:15 p.m. to 1:15 p.m.

May 8: Time Management: How to Quickly Make Decisions on What Matters Most • 12:15 p.m. to 1:15 p.m.

May 15: Enforcement Provisions of the Medical Practice Act • 12:15 p.m. to 1:15 p.m.

Sequestration FAQ for California Physicians

The $85.4 billion 2013 sequester includes a 2 percent cut (or $10 billion) in Medicare provider payments. SFMS has put together a guide to frequently asked questions about the sequestration cuts on our website at http://bit.ly/13PSoU4.

www.sfms.org

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Lauren Estrada BOARD OF DIRECTORS Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

april 2013 San Francisco Medicine

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ASK THE SFMS

Get answers to your important practice-related questions with the help of SFMS experts. SFMS’s Ask the SFMS feature connects members with SFMS physicians and partners who can answer questions on a wide variety of topics dealing with the practice of medicine, ranging from practice management, patient education, and EHR assistance to health policy, legal/ malpractice, financial management, and more!

If you would like to submit a question to our experts, please email info@sfms.org.

What Is the Meaningful Use Incentive Program?

The Electronic Health Record (EHR) Incentive Program was established by CMS to help health care organizations improve care delivery by using certified electronic health records (CEHR) and reporting on key clinical quality measures.

Incentive payments are available to physicians and other eligible professionals, hospitals, and critical access hospitals who demonstrate “meaningful use” of a CEHR. The meaningful use incentive program started in 2011. At that time, an eligible professional could receive $44,000 over a four-year period under Medicare with the final payment in 2014. Medicare payments are due to be reduced after April 1, 2013, by 2 percent as a result of sequestration.

An eligible doctor serving a significant population of Medi-Cal beneficiaries could instead receive a total of $63,475 over a six-year period with the final payment in 2016. Eligible Medi-Cal doctors can receive their first meaningful use incentive payment for adopting, implementing, or upgrading a CEHR. 6 7

San Francisco Medicine april 2013

There are three stages of measures and objectives for the meaningful use incentive program. Stage 1 covers 2010 through 2013 and includes fifteen core measures, five menu objectives including one population health measure, and six clinical quality measures. Stage 2 begins in 2014 and includes measures to improve patient care and safety as well as improved care coordination through the use of health information exchange. Stage 3 meaningful use requirements are still being defined.

Beginning in 2015, practitioners who do not demonstrate meaningful use will have their Medicare reimbursement reduced by 1 percent, with increasing penalties in subsequent years.

Kim Snyder is the vice president of Healthcare Informatics at Lumetra Healthcare Solutions, a nonprofit organization providing EHR and meaningful use assistance to primary care providers and specialists. Contact her at (415) 677-2162 or ksnyder@lumetrasolutions.com.

How Do I Prepare for a Meaningful Use Audit?

In 2012, CMS started auditing some doctors who have attested for meaningful use under the Medicare program. The audits are being conducted by an accounting firm, Figliozzi and Co., based in Garden City, New York.

Providers can be selected for an audit randomly or based on specific information and/or risk factors. In order to be prepared for an audit, a provider must be certain that measures and objectives used to attest for meaningful use incentive meet the CMS criteria. All reports and supporting documentation should be kept for six years. Equally important is proof www.sfms.org

that the CEHR a provider is using has a certification number provided by the Office of the National Coordinator for Health Information Technology.

If you are selected for an audit, you will be notified of audit requirements and questions via mail. You will have two weeks to respond with proof that the measure or objective in question is valid.

The auditor may determine your proof is acceptable, or the auditors may want to come to your site to see a demonstration of your CEHR. Again, make sure you have all documentation and reports to back up your attestation for meaningful use. If you fail the audit, you will have to return any incentive payments you have received from CMS. An appeal process is available if you are not satisfied with the auditor’s assessment.

Kim Snyder is the vice president of Healthcare Informatics at Lumetra Healthcare Solutions, a nonprofit organization providing EHR and meaningful use assistance to primary care providers and specialists. Contact her at (415) 677-2162 or ksnyder@lumetrasolutions.com.

Welcome New SFMS Members!

SFMS is pleased to welcome the following physicians and physicians-intraining to membership with the medical society. With your membership, you will join more than 1,600 members championing the cause of San Francisco physicians and their patients. SFMS would also like to extend a special thank-you to Barbara Garcia, director of health from the San Francisco Department of Public Health, and the San Francisco Public Health Foundation for underwriting membership dues for nine SFDPH physician leaders.

Physicians Hung-Ming Chu, MD | Psychiatry Lisa Alexandria Golden, MD | Family Medicine Steven Patrick Hamilton, MD | Psychiatry Shawna Karri Hedley, MD | Obstetrics and Gynecology Elizabeth Coleman Johnson, MD | Family Medicine Caroline Jean Lee, MD | Pediatrics Judith Ann Martin, MD | Family Medicine Dana Pruitt McGlothlin, MD | Cardiovascular Disease David Joseph Pine, MD | Psychiatry Yifang Qian, MD | Psychiatry Maria Fernanda Serrano-Correa, MD | Pathology Sachin Shah, MD | Cardiothoracic Surgery Irene Inhee Sung, MD | Psychiatry Albert Yingkeung Yu, MBA, MD, MPA | Family Medicine Residents Wen Jia Chen, MD | Pain Management (Anesthesiology)

16th Annual California Health Care Leadership Academy

May 31 - June 2, 2013 • Planet Hollywood, Las Vegas Welcome to the era of health reform. Increasing demand for services. Intensifying pressure for cost and quality accountability. Small practices joining larger groups seeking safe harbor. Undercapitalized medical groups sinking.

Hospitals and health plans acquiring practices in a “vertical integration” (consolidation?) of the health care market.

Can physicians control their own destiny – and the future of medical practice?

Hear from experts and leaders of change and attend a comprehensive slate of practice management seminars and workshops to position your practice for success.

Early-Bird and Multiple Registration Discounts Save up to $200 per person when you register before May 3!

Register at 800.795.2262 or caleadershipacademy.com

www.sfms.org

april 2013 San Francisco Medicine

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PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

FOR THE PUBLIC’S HEALTH: SOCIETAL GOOD VERSUS “NANNY STATE” Upon hearing the news of C. Everett Koop’s death, I thought fondly of “America’s doctor.”

C. Everett Koop, as surgeon general, was a champion of public health. He didn’t shy away from difficult issues. He fought big tobacco by successfully campaigning to ban tobacco ads, saying, “Tobacco is as dangerous as heroin.”

When the AIDS epidemic started, the White House didn’t want to support a public education campaign about safe sex and condom use, so he mailed the information directly to homes.

Eventually even President Reagan, who had been silent on AIDS, agreed about the importance of such an aggressive response.

Organized medicine has continued strong health advocacy. Efforts to curb tobacco use have been a great success.

Tobacco taxes have resulted in fewer young people initiating smoking. Legislation to prevent selling of tobacco in pharmacies has been enacted in San Francisco with SFMS support.

Legislation to limit exposure to secondhand smoke has been successful. A few weeks ago I was in Sacramento in the office of newly elected Assemblymember Mark Levine (Marin), speaking to his staff about AB 746—legislation he introduced to further eliminate secondhand smoke exposure by banning smoking in multifamily dwellings.

Now we turn to the taxation of sugar. Last fall a ballot initiative in Richmond to tax sugar-sweetened beverages lost due to enormous amounts of money spent by soda companies. CMA has policy to support such taxes due to the SFMS. SB 622, by Monning, will attempt a California statewide tax.

As physicians, we want to impact the health of our communities. We can counsel our patients about the harm of a diet high in sugar, but we can have larger impact by increasing the cost of sugar drinks to fund larger educational efforts.

Last year I coauthored a resolution to CMA asking for a ban on any cell phone use in cars. Initially when I was approached to consider writing this resolution, my response was, “But I have a hands-free phone.” Then I reviewed the data. I was very surprised. Having a conversation by phone produces the same delayed reaction time as alcohol. I have changed my behavior. I used to have regular advocacy-related calls during the legislative session while driving to work. I have stopped, but sometimes the temptation is so great that I put my phone in the back seat so that I can’t get to it. A young health care worker in the Stockton area just died from an accident while she was texting and driving. Is it enough to provide public service announcements regarding the fact that any phone use while driving is harmful? At what point is it a “nanny state” for a physician to recommend legislating change that will decrease harm to our patients? Last year the CMA House of Delegates was not ready for a full ban. www.sfms.org

How about mandating ski helmets for children younger than eighteen years of age? This legislation seemed like a nobrainer (sorry—I couldn’t resist). It passed the legislature twice, only to be vetoed by two different governors. In 2011, Governor Brown vetoed it, saying, “Not every human problem deserves a law.” Yet the prevention of a traumatic brain injury saves money to an already overburdened health care budget and keeps a future member of our workforce healthy. “Nanny state” or good public health policy?

Now we hear about caffeine and “energy drinks” and whether there should be some restrictions. There is increasing evidence that some of the energy drinks with large caffeine levels—and, yes, sugar—may be harmful. This needs to be balanced by the fact that there is some evidence that caffeine in small doses may have a positive health benefit. At this point, caffeine restrictions go too far even for me.

Back to the surgeon general: Try to name who is in the position now. Many probably don’t know it is Dr. Regina Benjamin. The surgeon general position has become so politicized that it isn’t a place for public health to be front and center anymore. Remember when Dr. Joycelyn Elders talked about safe sex and was removed from the position after only one year?

Dr. Richard Carmona has said he wanted to address the obesity epidemic while he held the position in from 2002 to 2006, but it was the start of the Gulf War, which was the only focus for the administration. He tried to link obesity to not having a healthy military but still had a hard time getting any traction.

I wish that Dr. Benjamin were speaking about gun violence as a public health problem now. But it seems that until we get another surgeon general willing to take a strong stand on important public health issues, it is up to the rest of us physicians to continue to work to improve the public’s health.

Rest in peace, Dr. Koop.

april 2013 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

The Only Constant is Change As I began my research on the theme for this month’s edition, I began to review many quotes about change. Why change? Because, as Heraclitus said, “There is nothing permanent except change.”

When I started my medical career, I envisioned becoming expert in my field. I dreamt that, by becoming expert, I would know the basic embryology, development, anatomy, and physiology of the cardiovascular system so that I could understand the pathophysiology and the adaptive and maladaptive responses of the body that created disease. This would allow me to further understand the treatment approaches and strategies and responses that the human body would go through. As I progressed through my career, I found that being an expert doesn’t really mean knowing it all but keeping abreast of all the changes in all fields of medicine, with particular knowledge in one field, so as to be able to integrate these advances in knowledge from the basic sciences with the highly technological advances in diagnosing and treating diseases. But equally important was being able to adapt to the working environment that was changing just as rapidly.

When it comes to change in the work environment, my first exposure to medicine was when I was growing up. I come from a medical family in which my father and his brother, Dr. Paul Fung and Dr. George Fung, were physicians in small group general practice. That was the model I learned to love for the opportunities it provided for people who felt that medicine was a calling to serve and heal their fellow humans in suffering. Although there are still many physicians and providers in solo and small group private practice, even at the California Medical Association—where all types of practices are respectfully treated as equals—there is a “Dinosaur’s Award” for the successful solo practitioner who is able to survive to make a living in this dying mode of practice. The current demands on solo and small group practice are taking a toll on this practice mode and shifting many physicians to become employees or contractors working for hospitals or foundations. This type of change has spawned a new specialty in medicine, as aptly described by Dr. Jack Lewin in his article “The Doc Whisperer: It’s Change I Don’t Like.”

With the new ACA (Obamacare) come many new challenges in providing primary care access to millions of newly insured. How will we, the current group of providers, physicians, and advanced practice nurses (APN) and physician assistants, cope or respond to this change? New approaches will need to be developed for the short, intermediate, and long terms. Some of these changes will definitely involve training physician team leaders of patient-centered medical homes. Some will look at training more and reworking the responsibilities of the APNs and PAs. These two topics are discussed in the articles by Callie Langton and David Vlahov. At this time, the changes will be a reality in nineteen months. The medical community as a whole needs to be involved in learning as much as possible about the law to help guide and advise the change to solve these issues. www.sfms.org

During my early years in medical school, we spent a whole year in classes learning anatomy, physiology, embryology, histology, and biochemistry. Then we spent a whole year learning the pathophysiology of diseases, from congenital malformations to traumatic accidents, infections, and chronic medical diseases. We learned about taking history and physicals, interviewing patients, and determining the most appropriate diagnostic tests to confirm a diagnosis or exclude diagnostic possibilities. In the third year, my classmates and I were split up into multiple small groups in clerkship rotations on different medical services: general medicine, general surgery, ob/ gyn, psychiatry/neurology, pediatrics, and anesthesia. This was our chance to practice with patients and learn how to formulate an assessment and diagnostic and treatment plan. When I was reviewing the articles for this month’s edition, I learned so much from Caroline Behler about the different pathways of oncologic diseases and the new targeted medications to treat them that it demonstrated how little we knew back then. In terms of diagnosis, Lawrence Cheung describes a new approach using available technology that can expand a physician’s practice and improve patient care—but in a way that challenges the doctor-patient relationship. Imagine what kind of relationship we can develop with our patients if we only interact with them through a telemonitor or we only see their pathology on a screen, and the patients don’t see the doctor at all. Sean Bourke describes a whole new emerging field of bariatric medicine to deal with the epidemic of obesity in the United States and worldwide. He explains the new science that’s responsible for the mechanisms of the disease and the latest approaches involving a nutritional and physical activity approach and what to expect from each component of management. David Pating pens an article on the advances in addiction medicine.

With treatment, technological advances are reshaping the practice of surgery to integrate minimally invasive techniques. Drs. John Maa and Sachin Shah give specific examples of how surgery is evolving with the latest use of technology. It’s also important for internists and other nonsurgical specialties to be aware of these to adequately present the options of treatment to their patients. Brian Andrews discuss the latest updates in neurology and neurological surgery.

With all these changes, we recognize that being a physician in the twenty-first century requires continuous lifelong learning. Every aspect of medicine, from medical school training to the basics of medical knowledge to advances in subspecialty medicine, is constantly changing. Even an expert can’t be expected to know it all regarding a field of medicine. This month’s theme highlights only a few of the many advances that are affecting the very livelihoods we have chosen to practice. april 2013 San Francisco Medicine

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Evolving Frontiers in Medical Specialties

THE DOC WHISPERER “It’s Change I Don’t Like” Jack Lewin, MD I didn’t realize that my career would move toward this special skill—of helping panicked, angry, confused,

sometimes loud-barking physicians of all specialties achieve greater life and career satisfaction in today’s rapidly transitioning environment. But this is something I am now apparently called to do. Hospital and medical group leaders increasingly are asking for assistance for large contingents of their doctor colleagues to help them better cope, survive, or—better—thrive in the world of change that is upon us.

More than half of American physicians are now employed, and many of them thus think they are insulated from the changes afoot. They’re not—and their employers (often hospitals) will be helping them understand reality as health reforms progress. Many of those in private practice—even in larger medical groups—are freaking out because of the uncertainties ahead. But at least 50 percent of U.S. physicians (and U.S. hospitals) are already engaged in payment reform and are moving away from fee-for-service (FFS) payment to bundles or capitation or salary in organizations that are themselves taking risk or capitation. I consult with an innovative home health company that is moving in this direction as well. I predict that half of those remaining doctors in FFS payment models will convert to something else within five years, because they will hear the whispers that their bottom line will be better if they move toward being rewarded for better outcomes, patient satisfaction, and efficiency. So I see a group of probably 25 percent of physician colleagues who will remain in FFS and just try to ride out the changes until they retire. A few doctors who provide discretionary or very episodic care, such as plastic surgeons, may be able to remain in FFS indefinitely.

But the world is changing, and doctors are experiencing stresses keeping up with it. The future is not grim. It will be better. Science is accelerating, and we can do more amazing things to help people than ever before. But not in the same old way we used to practice. . . .

So, as of right now, what should we expect to see coming from the “political” world?

More cuts are coming in health care! Doctors, hospitals, home health, drug and device companies: This means you.

We need to be ready very soon to propose how to seek additional savings in Medicare and Medicaid entitlements of (I’d suggest) $500 billion to $1 trillion over ten years to be sure these programs do not continue to rise faster than the GDP—and to prevent other blunt-edged cuts such as we have seen in sequestration. We can find ways to do that without hurting patient care by promoting payment reform, delivery system innovation, mobile and telehealth innovation, patient 12 13

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activation in shared decision making, and anything that ferrets out waste and/or promotes value (better outcomes at lower costs). The fact that health costs have recently slowed is likely to be temporary. But the nation can no longer afford to have health costs rise faster than the GDP (our ability to pay for them).

Sacred-cow tax deductions are likely to be reduced or capped in solutions to the budget, deficit, and debt ceiling issues. Don’t be surprised if this happens. But if these offset health care cuts, are they perhaps not worth it? I’d rather see deficit reduction with a carbon tax, and perhaps a value added tax (a VAT, or modified sales tax) that excludes food, health care, and energy; but fat chance of that happening.

The physician “doc fix,” or SGR formula (SGRrrr expressed as a growl), is not likely to be included in these deliberations, even though the Senate plan proposes that. It’s still a lot of money (less than $200 billion), even when the cost for eliminating it is less than it will ever be right now. But, unless a lot of hell is raised pretty fast around here, it could easily be dropped from the table and just kicked down the road again.

Patients should be aware that publicly funded care (Medicare and Medicaid) is significantly at risk of being transformed in ways that put beneficiaries at greater future financial risk through the deliberations ahead. Better pay attention.

In closing, as Mark Twain is alleged to have said, “I support progress and innovation; it’s change I don’t like.”

Jack Lewin, MD, is chairman, National Coalition on Health Care, and founder, Lewin and Associates LLC. He is former chief executive of the American College of Cardiology, the California Medical Association, and the State of Hawaii’s Department of Health and its public hospital systems.

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Evolving Frontiers in Medical Specialties

Primary Care Current Challenges and the Future Callie Langton, PhD Primary care was once the foundation of our health care system. However, a shortage of primary care

physicians now means nearly one in five Americans lacks sufficient access to primary care. This shortage results from many factors, including low payment rates for primary care services and challenges to physicians’ quality of life caused by overburdened patient panels. The trend contributes to major problems in our health care system, such as fragmented care, inappropriate use of subspecialists, and less emphasis on preventive care.

Numerous studies show that communities with a solid primary care foundation experience lower mortality rates, fewer hospitalizations, and lower health care costs, leaving a significant gap between the health care system we have and the health care system we need.

Demand for primary care services is expected to grow rapidly in coming years. The U.S. population is expected to increase by at least 18 percent between 2005 and 2025, with the population over age sixty-five growing by 73 percent.

Factoring in the increased primary care workload resulting from the aging population as well as current trends in medical specialty choice, we are left with an expected 27 percent shortage in adult primary care physicians by 2020, or an estimated shortage of more than 65,000 primary care physicians by 2025.

A secondary but no less important problem is the distribution of primary care providers across the state, with few willing to provide care in health professional shortage areas—whether in urban or rural locations. Research has shown that often the most effective strategy for attracting and retaining physicians is growing your own, yet it can be difficult for resource-poor areas of the state to start training programs in their communities.

A multipronged solution to the primary care physician shortage may be the best answer. It would include the increased use of efficient, team-based models; investment in recruitment, education, team-based training, and retention of all members of the primary care team; and valuing primary and preventive care more highly by changing the primary care physician pay structure.

No quick, easy, or one-size-fits-all solution to the primary care shortage exists. Long-term approaches such as loan forgiveness, higher payments for primary care, and graduate www.sfms.org

medical education reform should be paired with short-term ways to increase the productivity and efficiency of the currently deployed primary care workforce, such as practice redesign, implementation of the patient-centered medical home model of care, and increasing the number of residency training slots available in our state. A few of the most promising solutions are outlined below.

Short-Term Solutions

1. Increase residency training slots in primary care.

Many California legislators have focused recent efforts to expand the primary care workforce on opening new medical schools. While this is an important step toward creating an improved supply of physicians, the limited availability of residency positions in California means that new physicians may leave the state for training, increasing the likelihood that they won’t return to practice in California.

The federal Balanced Budget Act of 1997 capped Medicare-funded graduate medical education (GME) at 1996 levels for almost all teaching hospitals and continues to limit teaching hospital efforts to expand or create new programs. As a result, the California Academy of Family Physicians (CAFP) and others are focusing efforts on finding additional private funding for GME from those who benefit from an adequate network of physicians in California.

CAFP’s sponsored bill, Assembly Bill 1176 (Bocanegra), creates a funding source for underfunded medical residency training programs, asking private insurance companies to share in the cost of training their future workforce. These funds will be used to stabilize and expand medical residency training in California, helping to ensure that every Californian has access to a physician when and where they need one. Physicians enrolled in residency programs provide regular care to panels of patients, often in underserved communities, both during and after their training. The result is improved access to primary care services both now and for years to come.

2. Establish patient-centered medical homes (PCMHs).

Each provider must be used more efficiently and to the full extent of his or her training. This can be achieved through the adoption and transformation of practices into the patientcentered medical home (PCMH) model of care. The medical home uses every member of the health care team to the fullest capacity of his or her training and skills, increasing efficien-

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Primary Care Continued from the previous page . . . cies in our current system while lowering costs, improving quality, and expanding access.

The PCMH also has the potential for positive, long-term effects on the workforce. Valuing primary care services through the PCMH will continue to attract the best and brightest to primary care, leading to more innovation and creation of the type of satisfying practice environment in which family physicians and other primary care providers can practice the kind of medicine they envisioned when they decided to become physicians.

3. Redesign the system.

In addition to the potential for cost savings and increased patient satisfaction, the increased use of technology, greater use of nonphysician providers, and streamlining patient communications may allow existing providers to deliver more needed care to more patients than the current system allows.

Payment strategies that encourage providers to provide the best care, rather than the most care, may entice needed practice redesign and more efficient delivery of care.

Changing the way primary care providers are paid can have an immediate effect on the amount and type of care they deliver as well, and it can potentially augment primary care capacity. Payment methods that are nonvolume-based (for example, per-beneficiary per-month) allow the primary care practice to “staff up” with care managers and other important support staff. Additional payments for care management may incentivize the development of teams that share care responsibilities. These teams potentially can deliver more primary care to a greater number of patients than a physician working alone could provide.

Long-Term Solutions

1. Reform medical school processes.

Medical school has been consistently identified as a place ripe for workforce reform, beginning with the admissions process. At many schools, subspecialists dominate admissions committees and screen students based on test scores and performance in undergraduate science classes. Both of these metrics may eliminate students drawn to primary care.

Students who grew up in underserved areas, women, older medical students, and minorities are more likely to choose primary care, yet their admissions packets may lack high test scores or research experiences.

Once enrolled in medical school, student interest in primary care must be nurtured by increasing involvement of primary care physicians in medical training, supporting student primary care interest groups, recruiting community physicians as faculty members, and offering students more opportunities to participate in community-based experiences.

Finally, publicly-funded medical schools in California have an obligation to use public funds to educate needed physicians. Incentives to attract, admit, and graduate students 14 15

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interested in primary care careers should be available. Production of primary care providers should be measured by providers practicing primary care four years post-medical school to ensure accurate reporting.

2. Increase support for scholarships and loan repayment.

In 2010, more than half of graduating medical students in the United States owed more than $150,000 in student loans, according to the Association of American Medical Colleges.

High debt levels, coupled with low payment for primary care physicians, make lucrative subspecialties more attractive for cash-strapped medical students. Primary care doctors are among the lowest paid on the physician scale, earning less than half of a radiologist’s salary.

Substantially increasing funding for scholarships, loan repayment, and tuition waiver programs has been shown to be an effective strategy for attracting students to primary care. Federally subsidized student loan interest rates are fixed at 6.8 percent. A $150,000 debt at medical student graduation can easily double over the course of the repayment period.

Wide-Reaching Graduate Medical Education Reforms

Current GME payment rules do not require training facilities to determine the types of physicians they train based on what their community or the state needs. This often leaves primary care residencies with large budget shortfalls as more lucrative subspecialty programs are favored. Targeting of funding for new residency positions should be planned with attention to population growth, regional workforce needs, and evolving changes in delivery systems.

Introducing accountability for GME funds and providing incentives for hospitals funds that train needed providers could reverse the pattern of growth of hospital-based subspecialty residency programs at expense of primary care and help achieve a better subspecialty-primary care balance.

These short- and long-term solutions have in common the need for innovation and investment throughout the practice cycle of the primary care physician.

From medical school to residency to practice, such innovations will improve interest in primary care because they will result in more satisfying primary care careers.

CAFP believes that it’s primary care’s turn in the spotlight. Primary care enjoyed fifteen minutes of fame in the late 1990s, and we hope that its time in the spotlight will last a lot longer this time.

Callie Langton, PhD, is director of workforce policy for the California Academy of Family Physicians.

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Evolving Frontiers in Medical Specialties

The future of general surgery A 2013 Update John Maa, MD For the field of general surgery, the decade leading to 2010 was extraordinarily challenging. A

confluence of powerful forces, including declining reimbursement, increased professional liability, an unfavorable work environment, and a change in resident work hours were all cited as factors contributing to the “impending disappearance of the general surgeon.”

Yet in 2013, optimism has returned, as several encouraging trends suggest that the future of general surgery is strong, vibrant, and resilient. The field is undergoing a transformation, catalyzed by technology and the revolution of minimally invasive surgery, with important consequences and feedback loops that extend into widely divergent yet connected domains—surgical innovation, emergency care, education, journalism, government, and health policy.

I believe that general surgery is now entering a renaissance in which the general surgeon can pursue several rewarding career paths that can potentially move the field of medicine far forward.

The Rise of Minimally Invasive Surgery—da Vinci, NOTES, and SILS

Beginning with laparoscopic surgery in the late 1980s, surgical innovation has driven many advances in general surgery. Nearly every general surgical procedure has been transformed by minimally invasive technology, resulting in shorter hospital stays, quicker patient recovery, decreased postoperative pain, and better cosmetic results. However, these benefits must be weighed against higher health care costs and a potential increase in complications, such as common bile duct injury or vascular injuries. The first FDA-approved use of the robotic da Vinci Surgical System was for the general surgical treatment of gallbladder and gastroesophageal disease in 2000. For much of the past decade, relevant applications for the da Vinci robot in general surgery have been difficult to clearly identify. In 2013, the technically challenging Whipple resection has emerged as the leading application in general surgery, with complex pancreatic and liver resections emerging on the horizon. As reported in The New York Times recently, important concerns regarding safety and marketing strategies related to the da Vinci have been raised and merit further investigation.

The continuous drive to perform more procedures through smaller incisions has ushered in the fields of natural orifice transluminal surgery (NOTES) and single-incision www.sfms.org

laparoscopic surgery (SILS) as further refinements of conventional laparoscopy. NOTES is a novel surgical approach whereby “scarless” abdominal operations can be performed with an endoscope passed through a natural orifice such as the mouth, genitalia, or anus. The subsequent incision in the stomach, vagina, bladder, or colon thus avoids any external incisions and scars. Some of the earliest descriptions were to remove the appendix or gallbladder transvaginally; in 2007, the first human transgastric cholecystectomy was reported, followed by the first transgastric appendectomy. In 2008, surgeons from Johns Hopkins used NOTES to remove a patient’s kidney. More recently, transvesical and transcolonic approaches have been advocated instead of the transgastric approach to access the upper abdomen.

SILS, a minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s navel, has been more widely adopted than NOTES. Unlike a traditional laparoscopic approach that uses multiple ports, SILS leaves only a single small scar in the umbilicus. The challenge is to manipulate multiple instruments through this single port, and the slightly larger fascial incision that must be made in the umbilicus to accommodate the SILS port, with an increased risk of incisional hernia. Ongoing clinical studies will determine the comparative merits of SILS and NOTES surgery to conventional laparoscopy, and whether the improved cosmetic outcomes justify the additional time, costs, and risk of complications.

Medical Education and Training

To master this wide array of new, minimally invasive techniques, increasing numbers of general surgery residents are pursuing advanced specialty fellowship training in endocrine, minimally invasive, colorectal, foregut, bariatric, oncology, and breast care surgery, among other fields. Historically, additional fellowship training in these disciplines was not considered necessary, but some postulate that the ACGME 80hour workweek restrictions have catalyzed this trend toward increased specialization. The field of general surgery has responded with a blossoming of research and fellowships in surgical education to determine how best to train residents within the 80-hour framework, promoting a competencybased curriculum and efficiency in education. The resurgence of medical school applicants to general surgery residency in 2013 reflects optimism about the future’s improved prospects for careers in general surgery. Moreover, the increased need for a general surgical workforce was recognized in the Affordable Care Act, through which an increase in residency slots for

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The Future of General Surgery Continued from the previous page . . . general surgery were allocated over previous years.

Workforce and Emergency Surgical Care Over the past decade, trauma surgery has been reinvigorated, and the concept of a dedicated emergency surgeon has evolved. Both were catalyzed by the shortage of surgeons to provide emergency-call coverage, because fewer general surgery residents entered the workforce annually, pursuing advanced fellowship training instead. Two dominant models that emerged in the early 2000s are shaping the emergency surgical workforce nationally: the acute care surgeon and the surgical hospitalist. Integral to both models is the dedicated onsite availability of a surgeon for either trauma or emergency general surgery care. An estimated 400 programs are now in place across the country, each representing a unique variation on the original themes. In my opinion, these two fields are now merging, with a focus on timely and high-quality delivery of care to the emergency surgical patient.

General Surgeons as Medical Journalists: The Power of Communicating to the Lay Public

Two of the nation’s leading medical journalists are Atul Gawande, MD, FACS, of The New Yorker magazine, and Pauline Chen, MD, FACS, of The New York Times. I believe the clarity of their writing and their extraordinary ability to communicate to the public is a result of the breadth, volume, and quality of their experiences as general surgery residents. Perhaps another reason for the rising popularity of general surgery over the past years has been the success of the hit television show Grey’s Anatomy, which features the daily lives of general surgery interns and residents. The show was inspired by Dr. Gawande’s first book, Complications, which was also the original title of the television pilot, and every chapter of his book became a TV episode. Through their writing, Drs. Gawande and Chen have also influenced the political debate about health reform and humanized society’s view of the practice of surgery.

(AHRQ), which have recently been drawn to the attention of the ACS. AHRQ inpatient quality indicator #23 will track the number of laparoscopic cholecystectomies per 100 cholecystectomies at the hospital level. The federal government has identified laparoscopic cholecystectomy as an underused procedure and concluded that higher rates of laparoscopic cholecystectomy represent better hospital quality.

Beyond the efforts of the ACS are those of individual surgeons. Recognizing the urgent need for physician leadership in Congress, Congressman Dan Benishek (R, MI) left his clinical practice and in 2010 became an advocate and champion for patients and surgeons on Capitol Hill. His path partly traces that of a young general surgeon who arrived in Tucson twenty-five years ago to solve the challenges of Arizona’s emergency care system. That surgeon, Dr. Richard Carmona, would dedicate his career to implementing a trauma system in Arizona grounded in the concept of regionalization, which would be key to the successful outcome for Congresswoman Gabrielle Giffords. Dr. Carmona, a graduate of the UCSF School of Medicine and the UCSF General Surgery Residency program, would later become the seventeenth surgeon general of the United States of America. I believe that future answers to the challenges of health reform will come from other surgeons like Dr. Benishek, who will follow Dr. Carmona’s inspirational path and become public servants.

As president-elect of the Northern California Chapter of the ACS, I would like to extend a personal invitation to readers of San Francisco Medicine to attend the Northern California chapter meeting on June 8, 2013, at the Marines’ Memorial Club, where you can learn more about these topics and the increasingly bright future of the field of general surgery.

John Maa, MD, FACS, is an assistant professor in the UCSF division of general surgery. He is also a member of the SFMS and serves on the board of directors and he is also president-elect of the Northern California Chapter of the American College of Surgeons.

Surgeons Engaging in Health Policy and Government

In 2010, the American College of Surgeons (ACS) opened its new headquarters in Washington, D.C., just steps from Union Station, as a forward base to advocate for both the future of surgery and the entire profession of medicine on Capitol Hill. Led by accomplished trauma surgeons Drs. David Hoyt and L.D. Britt, the ACS in January of 2013 took a strong proactive position regarding firearm safety to promote the best interests of public health and safety. The College has continued its important efforts toward a novel and permanent solution to the Sustained Growth Rate Formula. The ACS also recently joined the Choosing Wisely effort by submitting an initial series of overutilized procedures associated with surgery. The societal push toward minimally invasive surgery is further reflected in the new patient safety and quality indicators from the Agency for Healthcare Research and Quality 16 17

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www.sfms.org

Evolving Frontiers in Medical Specialties

Substance abuse Health Care Reform Brings Changes for Treatment David Pating, MD Health care reform is around the corner. On Janu-

ary 1, 2014, 5 million previously uninsured Californians will become newly eligible for enrollment in expanded Medi-Cal or subsidized health insurance coverage under the Affordable Care Act (ACA, 2010). The health status of the newly insured is expected to be subpar—suffering higher rates of chronic disease, mental disorders, and substance abuse. While substance abuse and dependence affect about 15 percent of the general public, rates among the newly insured are anticipated to be two to three times higher. This poses potential concerns, since nationally, only 10.4 percent of those needing substance abuse treatment receive necessary services. By conservative estimates, if substance abuse remained untreated in this newly enrolled population, the impact of untreated substance abuse could cost California 2.5M days of lost employment and $2.6B in total health care costs. Obviously, things must change.

Fortunately, health care reform provides opportunities to improve treatment for substance abuse and dependence.

First, the Affordable Care Act assures parity in mental health and addiction treatment benefits. Parity in coverage means that co-pays, deductibles, and day or dollar limits for substance abuse treatment must be on par with those for medical disorders. Currently, persons with substance use disorders suffer systemic discrimination on the basis of their health condition—being an addict or alcoholic. In California, many health insurance plans, including Medi-Cal, currently not only limit care, require higher co-pays, or mandate “carved out” services for substance abuse treatment but they also preclude reenrollment based upon this status. Under the ACA, equity in access and health benefits will be the law. This is good.

In addition, the Affordable Care Act includes provisions to promote higher-quality and cost-effective care through integrated medical and behavioral services. Integrated care for substance abuse is essential, since as many as 40 percent of hospital admissions and the majority of chronic conditions— diabetes, hypertension, asthma—are all negatively impacted by substance abuse. In primary care practices, 20 percent of patients drink at levels that exacerbate their chronic medical disorders. National guidelines provide simple and clear instruction on how to identify at-risk drinking and provide advice for both adults and youth. What is undiscovered are optimal ways to integrate these clinical solutions into comprehensive systems of care.

Recently, new care delivery models colocate (or reversecolocate) substance abuse treatment in primary care clinics www.sfms.org

(and vice versa). These models have been piloted statewide in federally qualified health centers (FQHCs) and many county medical and behavioral health clinics. In these clinics, substance abuse and/or mental health counselors are embedded alongside internists, family medicine physicians, nurse practitioners, and health care case managers. When substance abuse issues arise, as in the context of managing opioids for chronic pain conditions, or in managing hypertension in patients who drink excessively, the medical care team has all the counseling resources needed to address the problem quickly and efficiently.

The proximity of substance abuse (and behavioral health) services is essential to good outcomes.

Research indicates that the warmer the handoff between primary care clinicians and the substance abuse specialist, the greater the likelihood of engagement. Similarly, the quicker the referral to a specialist, the higher the treatment initiation rate. If referrals take longer than forty-eight hours, motivation to enter treatment plummets, resulting in less than 25 percent actively enrolling in treatment. While some of us jokingly assume these patients stopped off at a bar because the wait (for treatment) was too long, we all know we can do better than this.

One of the promising areas of colocation that results in “no wait” includes the inclusion of medical services in methadone clinics, or the relicensing of methadone clinics as FQHCs. Methadone clinics serve patients who carry high medical burden—not only including hepatitis C, HIV, and STDs but also disorders exacerbated by poor self-care, chronic stress, and poverty. In these situations, the methadone-dispensing window presents an opportunity to attend to the daily health needs of the marginally insured. Along with their methadone dose, patients in clinics with embedded medical services can receive daily observed therapy for diabetes, tuberculosis, and other conditions, including blood pressure monitoring and glucose checks. This is a public health triple-play!

Beyond this, some far-thinking clinics are looking for ways to leverage electronic health records (EHRs) as a means to promote greater integration of services.

Researchers in academic hospitals are experimenting with leveraging EHR systems to cue clinicians to screen and

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Substance Abuse Continued from the previous page . . . provide effective substance abuse care management. One new and exciting area is the creation of patient registries for tobacco smokers and substance abusers. The ability to track compliance with treatment for these disorders has many positive implications, as has been already demonstrated for cancer, asthma, and diabetes registries. In addition, tracking appropriate stepped-based usage of medications—such as acamprosate, topiramate, naltrexone, or Antabuse for alcohol; naltrexone or Suboxone for opioids; nicotine patch, varenicline or bupropion for nicotine dependence; and other medications—leverages the skills of the primary care provider and increases compliance. In short, the days of managing tobacco and substance abuse with a cold shoulder and hard glare, “Just quit!” are over.

David Pating, MD, is chief of addiction medicine at Kaiser San Francisco. He is former president of the California Society of Addiction Medicine and is a member of the SFMS.

Reference 1. Pating DR Miller MM, Goplerud E, Martin J, Ziedonis DM, New systems of care for substance use disorders: Treatment, finance, and technology under health care reform. Psychiatric Clinics N Am. 35(2102); 327-356.

Last, while not specifically funded by ACA dollars, the leading fringe of substance abuse treatment is venturing into the world of online and video care.

Perhaps we could say these are preventive or health-maintenance services when promoted under the rubric of health reform. Online, medically sponsored peer-support communities for substance abuse provide a safe, creative, and effective means to leverage Internet technology.

Multiple vendors who have discovered this treatment niche are vying for this potentially unlimited market, spurred by a youth-oriented, online culture for INC. whom virtual Facebook friends may A REGISTRY & PLACEMENT FIRM offer just as much support as the real friends of Bill W. in Alcoholics Anonymous. This is the future of medicine for a new generation.

Concluding this short tour of new Nurse Practitioners ~ Physician Assistants systems of care for substance use disorders in the era of health care reform, I must mention the impact of new cycles of drug epidemics, which last on average four to six years. Currently we are in the middle of a prescription opioid epidemic of the “Oxys” et al. Prior to this was the methamphetamine epidemic, now waning. Next may be new synthetics, or even an old drug newly reborn: high-potency cannabis. Whatever the Locum Tenens ~ Permanent Placement drug of abuse du jour, no amount of health reform will be effective without V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 physicians being willing reform their bias and stigma about alcohol and drug FA X : 8 0 5 - 6 4 1 - 9 1 4 3 abusers. Substance use disorders are common, treatable, and manageable— tzweig@tracyzweig.com the real reform is our own willingness w w w. t r a c y z w e i g . c o m to tackle this public health menace, one patient at a time.

Tracy Zweig Associates Physicians

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Evolving Frontiers in Medical Specialties

Cardiac surgery The Role of Robotics Sachin Shah, MD

Robots occupy a prominent role in industrialized society. Derived from the Czech word for forced labor, ro-

bota, robots evolved from rudimentary machines performing menial and repetitive tasks to instruments capable of highly complex maneuvers. They are frequently used in manufacturing, space and deep sea exploration, and other environments dangerous to human beings. Within the past decade, robots gradually entered the field of medicine, most noticeably in the delivery of high-quality and precise surgical procedures.

The use of minimally invasive surgery is increasingly popular among surgeons, patients, hospital administrators, and third-party payers. This is primarily due to the advantages of minimally invasive surgery, such as less pain, faster recovery, less blood loss, and shorter hospital length of stay. Cardiac surgery has been among the last of the surgical specialties to embrace minimally invasive surgery due to the complex nature of the operations and the outstanding results currently achieved with traditional full-sternotomy operations.

Thoracoscopic approaches to the heart have been used to decrease chest-wall trauma during heart surgery but have several drawbacks. These include suboptimal optics, long distance from point of action, fulcrum effect of long-shafted www.sfms.org

instruments, poor ergonomics, and inability of assistants to visualize the operative field. Robotics has been envisioned as a tool to enhance minimally invasive surgery by overcoming the disadvantages of traditional endoscopic techniques.

Early development of robotic technology began at the Stanford Research Institute and had support from NASA and the U.S. Army, who were interested in developing a platform for remote surgery.

Subsequently, companies such as Computer Motion and Intuitive Surgical pursued the commercial development of a surgical robot, resulting in the AESOP (automated endoscopic system for optimal positioning), da Vinci, and Zeus systems.

Consolidation within the field has left the da Vinci system the only currently available surgical robot with FDA approval for cardiac use.

Mitral valve repair with robotic assistance was first performed in 1998 by Carpentier. That same year, Loulmet performed the world’s first totally endoscopic coronary artery

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Evolving Frontiers in Medical Specialties

Teledermatology Technology to Improve Access to Care Lawrence Cheung, MD It is a fairly routine dermatological consultation. I am looking at a patient’s nevus on the abdomen, and

the referring physician’s concern is the presence of suspicious features in the nevus. After a thorough examination, I conclude that the presence of suspicious features warrants an excisional biopsy with a three-millimeter margin. The twist here is that I am examining a digital photograph of the nevus sent via secure e-mail from a government research station in Antarctica. The excisional biopsy is performed by a technician at the station, and the tissue sample is then flown back to U.S. six months later for processing.

The concept of teledermatology, in which a dermatologist formulates a diagnosis without being physically present with a patient, has been practiced for decades. However, the availability of high-resolution digital cameras and the increasing ease of transmitting encrypted digital photographs have dramatically changed this discipline. There are currently two standard methods of performing teledermatology: The most common practice is store-and-forward, in which digital photos are transmitted to the consultant dermatologist and an assessment and plan are transmitted back to the referring physician. A second method (which is much less frequently employed) is live-interactive, in which a patient encounter occurs in real time via video cameras.

The advantages of the store-and-forward method include the low cost and near universal availability of high-resolution digital cameras, as well as increased efficiency for the consultant dermatologist to be able to examine cases from multiple geographic locations. The disadvantages include camera and technician variability, as well as pictures of nonrepresentative lesions that render diagnosis impossible. In comparison, the advantages of live-interactive include the availability of real-time discussion between the referring physician, patient, and consulting dermatologist. The disadvantage is primarily a more rigid schedule for the dermatologist, the referral physician, and the patient.

A survey in 2011 documented thirty-seven active teledermatology programs in the U.S. The majority of the programs are based in academic institutions, with fewer programs established by the VA and military organizations and a handful of programs based at private practice settings and health maintenance organizations (HMOs). The same survey also showed that the storeand-forward method was used at a majority of the programs, but a small number of programs practiced live-interactive teledermatology, and some programs employed both techniques.

California is at the forefront of teledermatology with the nation’s largest program based at Kaiser Southern California, in which 6,500 consultations were performed in 2011 (J Am Acad Dermatol, 2012; 67:939-44).

A majority of my teledermatology consultations are done www.sfms.org

for Asian Health Services, a federally funded clinic located in Oakland’s Chinatown that provides culturally and linguistically appropriate medical care to approximately 24,000 patients in the community, many of whom would otherwise have no other access to health care. I staff a physical clinic once a month but, due to the limited access, I developed a teledermatology program in which I provide urgent consults and triaging decisions for patients who may require procedures and who are then scheduled at my physical clinic. Since the implementation of the teledermatology program, the patients’ wait time for accessing dermatology care has dropped from three months to within one week (and often within forty-eight hours). Because a majority of these cases are inflammatory skin disorders, the decreased wait time has resulted in significantly earlier diagnosis and treatment.

Teledermatology can be employed in the inpatient setting, and I also provide teledermatology consultations for residents at several teaching hospitals for inpatient cases in which they have difficulty obtaining physical consults. A majority of these cases involve the confirmation of drug exanthem and the identification of the offending drug. Because I can review the images at my computer or on my phone much faster than by physically visiting the hospital, the inpatient team is often able to discontinue the offending drug much earlier (in some cases, one to two days earlier).

At the present moment, the software programs used for teledermatology are still rather rudimentary. I use Second Opinion (on my PC) for outpatient consults and DocbookMD (on my iPhone) to transmit HIPAA-compliant messages and photos for inpatient consults. As we approach greater adoption of electronic health records, the implementation of teledermatology (and telemedicine overall) will undoubtedly evolve.

In its current form, teledermatology can be a powerful tool that complements traditional physical patient encounters. The need to perform specialized dermatologic procedures still necessitates a physical encounter with a dermatologist. Telerobotics, in which a robot can be controlled remotely to perform procedures, will be a natural evolution in teledermatology. This technology is still in its infant stages and the cost relatively high, but it will most likely become more relevant in the future.

Overall, teledermatology does not represent any new scientific advances in dermatologic care, but it addresses an important issue that continually plagues the specialty: poor access.

Lawrence Cheung, MD, practices general dermatology with a focus on eczema and psoriasis and has a solo practice located in the Lakeside district. An active member of the SFMS and CMA, he is currently the SFMS president-elect.

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Cardiac Surgery Continued from page 19 . . . bypass using robotic assistance. FDA approval for the use of the da Vinci system in mitral repair was achieved in 2002, following a multicenter trial demonstrating safety and efficacy.

Since then, reports from the groups at East Carolina University, St. Joseph’s Hospital in Atlanta, Cleveland Clinic, and Mayo Clinic have validated the safety, efficacy, and durability of mitral repair with robotic assistance. Additionally, these groups have noted improvement in postoperative pain, length of hospital stay, return to work, transfusion requirement, and early quality of life in patients undergoing mitral repair with robotic assistance.

The da Vinci Si surgical telemanipulation system consists of three components: the bedside cart, with three operational arms and an arm for camera mounting; the surgical console, where the surgeon manipulates the robotic arms; and the vision cart, which serves as the interface between the console and the bedside cart and allows the assistants to view the procedure being performed. The binocular camera, which is available in 8mm and 12mm sizes, allows 3-D vision as well as 10x magnification. The wristed instruments provide seven degrees of freedom and mimic the human wrist and hand (see image on page 19). Additionally, there is tremor filtering and scaled motion. These technological advances afford excellent visualization and enable the surgeon to perform precise, delicate movements within a confined space.

Over the past decade, robotic assistance in cardiac surgery has gained acceptance and proven to be a safe, effective way to avoid sternotomy.

Initial robotic applications focused on mitral surgery, particularly mitral repair. By employing the same repair techniques outlined by Carpentier, robotic assisted mitral repair has been shown to be durable and effective. More recently, robotic use in cardiac surgery has expanded to treatment of septal defects, coronary artery disease, atrial fibrillation, intracardiac tumors and masses, and tricuspid valvular abnormalities.

Compared with surgery performed through sternotomy, robotic-assisted cardiac surgery offers many clinical benefits. Patients experience less pain, recover faster, and have a shorter length of hospital stay and less blood loss. In addition, return to work is quicker, and patient satisfaction is high. The cosmetic result is favorable, and women may expect the incision to be concealed in their inframammary crease.

Robotic-assisted heart surgery, however, increases operational complexity and is associated with a steep learning curve for the surgeon and operative team. The learning curve appears to be approximately fifty cases. There is also a high level of resource commitment required by institutions developing such a program, and the creation of a skilled team of anesthesiologists, perfusionists, bedside assistants, nurses, and surgeons is critical to success of any cardiac robotic program.

Clinically, procedures done with robotic assistance tend to require longer time on cardiopulmonary bypass, and some 22 23

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patients will be better served with a sternotomy approach.

This would include patients with severe peripheral vascular disease, poor ventricular function, and those who need multiple concomitant procedures.

Moving forward, technological improvements in the robotic platform continue to expand the scope of robotic-assisted cardiac surgery. These refinements may include a lowerprofile device, improved intracardiac instrumentation, and single-port technology. Sutureless bioprosthetic valves will facilitate aortic valve replacement, and simulator-based training will promote widespread adoption of the skill set necessary to perform these complex operations. Further, entry into the field by another manufacturer will lead to cost efficiencies.

While robotically assisted cardiac surgery is currently in its development phase, it will likely grow into the standard approach for many cardiac procedures in the future.

Sachin Shah is an SFMS member and is the director of robotic and minimally invasive cardiothoracic surgery at California Pacific Medical Center. He obtained his skills in robotics at the Cleveland Clinic and has developed the Bay Area’s only program in robotic cardiac surgery.

References 1. Bonatti J, Schachner T, Bonaros N, et al. Robotically assisted totally endoscopic coronary bypass surgery. Circulation.

2011; 124:236-244.

2. Suri R, Antiel R, Burkhart H, et al. Quality of life after early mitral valve repair using conventional and robotic approaches. Annals of Thoracic Surgery. 2012; 93:761-9.

3. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: Potential realized. Journal of Thoracic and Cardiovascular Surgery. 2011; 141:72-80.

4. Lehr E, Rodriguez E, Chitwood WR. Robotic cardiac surgery. Current Opinion in Anesthesiology. 2011; 24:77-85.

www.sfms.org

Evolving Frontiers in Medical Specialties

Developments in oncology An Update on Progress Caroline Behler, MD The rate of progress in oncology over the past decade has far exceeded that of previous decades and continues to accelerate. Since 2010 there have

been twenty-eight new drug approvals in oncology, mostly targeted therapies that expand treatment options for patients with cancer, offer the hope of improved quality of life and survival, and often inform us of the fascinating biology of these tumors. The use of predictive markers limits these treatments to those patients with a high likelihood of responding. Rational selection of targeted treatments based on specific molecular features of a tumor is finally replacing a “one-size-fits-all� approach for treatment of malignancies.

Chronic lymphocytic leukemia (CLL): First-line therapy for symptomatic CLL with chemotherapy and the anti-CD20 monoclonal antibody rituximab induces response in up to 90 percent of patients. However, many patients will ultimately become chemotherapy-refractory, especially those with adverse genetic features (such as abnormalities in p53). Tyrosine kinase inhibition of B-cell receptor signaling leads to antiproliferative activity as well as mobilization of malignant cells from the lymph node compartment, further sensitizing them to cytotoxic therapy. The initial surge in lymphocytosis is thus an indication of efficacy. Recent results from a phase 1b/II study of the oral BTK inhibitor ibrutinib in CLL or small lymphocytic lymphoma (SLL), both front-line or in relapse, revealed a 71 percent overall response rate (ORR). Notably, ORR was similarly high for patients with 17p deletion, purine analog-refractory, and those with multiple prior therapies.1 Combining these agents with rituximab may yield even higher response rates. ORR for ibrutinib with rituximab was 83 percent,2 and idelalisib (an oral PI3 kinase inhibitor) with rituximab yielded an ORR of 79 percent.3 These responses typically indicate clinically meaningful reductions in lymph node size and improvement of anemia and thrombocytopenia, without the immune- or myelosuppression seen with cytotoxic chemotherapy.

Hodgkin lymphoma (HL): While cure is typically >90 percent in patients with low-risk HL, relapse remains a problem for a subset of patients, especially for those who do not achieve a complete remission (CR) with salvage chemotherapy and are thus much less likely to benefit from a potentially curative autologous stem cell transplant (ASCT). Brentuximab vedotin (BV) is an antibody-drug conjugate comprised of the monoclonal antibody to CD30 (expressed on the ReedSternberg cell) covalently bound to monomethyl auristatin E (MMAE), an antitubulin agent, allowing direct, intracellular www.sfms.org

delivery of a highly cytotoxic agent to the malignant cell. For patients with relapsed HL after ASCT treated with BV, ORR was 74 percent, with 34 percent CR.4 Recently updated results revealed that 59 percent of these patients remained alive with a median follow-up time of about 2.5 years, and prolonged overall survival (OS) was seen even in the very high-risk patients with short progression-free interval after ASCT.5 Use of this agent earlier in treatment of HL is also an area of interest.

A phase I study investigated BV combined with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) or AVD. CR was about 95 percent in both arms; however, excessive pulmonary toxicity was seen in the BV-ABVD arm.6 In the future, BV-AVD may be a useful option for patients for whom bleomycin is contraindicated. A multicenter phase I/II study (currently open at California Pacific Medical Center) investigates the combination of BV with bendamustine in patients with HL in first relapse, including those who will proceed to ASCT and ASCT-ineligible patients.

Breast cancer: Amplification of human epidermal growth factor receptor 2 (HER2) is well known to predict response to trastuzumab, a monoclonal antibody targeting HER2. Trastuzumab has activity as monotherapy and works synergistically with chemotherapy in metastatic breast cancer (MBC) and increases OS in the adjuvant setting. Lapatinib is an oral small-molecule inhibitor of HER2 that also improves OS in combination with chemotherapy for HER2-positive MBC. Pertuzumab, another anti-HER2 monoclonal antibody, is active in combination with chemotherapy for MBC. A phase III study comparing trastuzumab plus docetaxel with or without pertuzumab demonstrated a significant improvement in ORR (80 versus 69 percent), progression-free survival (PFS) (nineteen versus twelve months), and a trend toward improvement in OS with the pertuzumab combination.7 Despite the availability of numerous anti-HER2/chemotherapy combinations for second-line treatment and beyond, chemotherapy resistance increases with each relapse. An exciting new treatment, trastuzumab emtansine (T-DM1), is an antibody-drug conjugate with trastuzumab covalently bound to the microtubule inhibitor DM1. T-DM1 was approved by the FDA in February 2013, based on the results of a randomized study comparing T-DM1 or lapitinib plus capecitabine for patients with HER2-positive advanced breast cancer previously treated with trastuzumab and a taxane. PFS for TDM-1 was superior (9.6 months versus 6.4 months) with less toxicity.8 For patients with HER2-amplified MBC who have progressed through multiple lines of therapy, this is a promising option.

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Oncology Continued from previous page . . .

Non-small cell lung cancer (NSCLC): We have come a long way from the time when all NSCLCs were treated alike, now tailoring chemotherapy regimens to specific histologic subtypes and using molecular subtyping to identify optimal first-line therapy for advanced NSCLC. EGFR mutation is present in about 15 percent of NSCLC, particularly in nonsmokers.

ORR to EGFR inhibitors (erlotinib, gefitinib) in EGFR-mutated NSCLC range from 62 to 85 percent, and PFS appears superior in studies comparing EGFR inhibitors versus chemotherapy.9 EML4-ALK rearrangement is rare (4 to 7 percent of lung cancers) but more common in younger nonsmokers who do not have the EGFR mutation. Crizotinib, an oral ALK inhibitor, induces responses in 60 percent of ALK-positive, advanced NSCLC. Preliminary results of a phase III first-line study comparing crizotinib to chemotherapy for ALK-translocated NSCLC showed improved PFS in the crizotinib-treated patients (7.7 versus 3.0 months). ROS1 translocations are found in only 1.7 percent of NSCLC, also younger nonsmokers, but also predict response to crizotinib based on in vitro and early clinical data.

These examples highlight some exciting developments in oncology therapeutics over the past few years; similar strategies are being employed in a wide range of malignancies. As the activity of newer biologic or targeted therapies is typically first identified in advanced malignancy, initial studies and FDA approvals typically center on metastatic or relapsed/re-

fractory disease. But as we have seen with many other such agents, it is likely that many of the above-mentioned therapies will be useful in earlier treatment stages as well.

Caroline Behler, MD, joined Pacific Hematology Oncology Associates and California Pacific Medical Center in April 2012; she practices medical oncology and hematology. She was formerly an attending physician in the division of hematology/oncology at UCSF and the San Francisco VA Medical Center. She is an assistant clinical professor of medicine at UCSF.

References

1. Byrd JC et al. The Bruton’s Tyrosine Kinase (BTK) inhibitor ibrutinib (PCI-32765) promotes high response rate, durable remissions, and is tolerable in treatment naïve (TN) and relapsed or refractory (RR) chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) patients including patients with high-risk (HR) disease: New and updated results of 116 patients in a phase Ib/II study. Blood (ASH annual meeting abstracts). Nov 2012; 120:189.

2. Burger JA et al. The BTK inhibitor ibrutinib (PCI-32765) in combination with rituximab is well tolerated and displays profound activity in high-risk chronic lymphocytic leukemia (CLL) patients. Blood (ASH annual meeting abstracts). Nov 2012; 120:187.

3. Coutre SE et al. Combinations of the selective phosphatidylinositol 3-kinase-delta (PI3Kdelta) inhibitor GS–1101 (CAL101) with rituximab and/or bendamustine are tolerable and highly active in patients with relapsed or refractory chronic lymphocytic leukemia (CLL): Results from a phase I study. Blood (ASH annual meeting abstracts). Nov 2012; 120:191.

4. Younes A et al. Results of a pivotal phase II study of brentuximab vedotin for patients with relapsed or refractory Come learn the technical, legal and business procedures and Hodgkin’s lymphoma. J Clin Oncol. 2012; guidance to act as a Medical Review Officer. This valuable certification 30(18):2183. and occupational medicine credential is required by some state drug 5. Chen RW et al. Long-term survival analyses of an ongoing phase 2 study testing laws and the U.S. Department of Transportation. of brentuximab vedotin in patients with relapsed or refractory hodgkin lymComprehensive MRO Training Including Hair, phoma. Blood (ASH annual meeting abstracts). Nov 2012; 120:3689.

Sweat, Oral Fluid, Alcohol Testing, and AAMRO 6. Ansell S et al. Frontline therapy Certification Exam with brentuximab vedotin combined with ABVD or AVD in patients with newSan Francisco, CA ly diagnosed advanced stage Hodgkin June 21–23, 2013 lymphoma. Blood (ASH annual meeting (Friday–Sunday) abstracts). Nov 2012; 120:798.

7. Baselga J et al. Pertuzumab plus Las Vegas trastuzumab plus docetaxel for metaDecember 6–8, 2013 static breast cancer. N Engl J Med. Jan (Friday–Sunday) 2012; 366(2):109-19.

8. Verma S et al. N Engl J Med. Nov 8, 2012; 367(19):1783-91.

9. J Clin Oncol. 2011 29(15):21212127.

Medical Review Officer Training (Special CME Programs)

800-489-1839 www.aamro.com

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www.sfms.org

Evolving Frontiers in Medical Specialties

Neurology New Developments in the Field Brian T. Andrews, MD, FAANS, FACS There are a number of recent developments in the practical applications of clinical neurology and neurosurgery. First, there are a growing number of neu-

rologists working full time within a hospital as so-called neurohospitalists. Such neurologists provide consultations, manage patients admitted with primary neurological disorders and those suffering from neurological complications from other diseases or treatments, and coordinate neurological followup once the patient leaves acute care. The advantages of such a service include immediate availability for urgent admissions and referrals, development of evidence-based protocols of care, and the prevention of complications from neurological disease.

Usually such neurologists do not focus on stroke care if there is also a dedicated stroke service at a hospital or medical center; however, in a smaller hospital setting, they may provide stroke management. It is expected that a neurohospitalist’s service can decrease costs, a patient’s length of stay, and mortality and readmission rates, while also improving core measures of care, just as a hospitalist service provides these advantages for hospitalized patients with general medical conditions.¹ In the case of ischemic stroke management, there has been a steady expansion of the window of time for attempted treatment to return blood flow to the brain. Modern stroke care involves careful evaluation of brain blood flow using perfusioncomputed tomography. This defines the areas of ischemia and potential areas of the brain that are salvageable. Whereas previous criteria limited the time frame of reperfusion to about four hours, today—using the latest advanced imaging criteria—thrombolytic therapy (with infusions of intravenous or intra-arterial TPA) or mechanical embolectomy can be attempted up to eight hours after the onset of an ischemic deficit without excessively increasing the risk of hemorrhagic transformation of the infarction.²,3 The field of neurointerventional care is rapidly expanding capabilities with evolving techniques and devices such as coils for aneurysm treatment, as well as stents and embolectomy devices for reopening the blood vessels of the brain occluded by atherosclerosis and thromboembolic disease. Often interventional procedures are combined with neurosurgical procedures or stereotactic radiosurgery to achieve desired results for complex disorders such as arteriovenous malformations of the brain. Preoperative embolism of the feeding blood vessels to tumors can render subsequent tumor removal more safe and efficient. Fellowship training in this field is now being pursued by radiologists, neurologists, and neurosurgeons.

Pediatric concussion management has become a recent focus of attention, particularly as it relates to sports. There are up to 3.8 million concussions annually in the U.S. Identifying and www.sfms.org

managing such children falls to providers in emergency departments and the pediatrician’s office, and to pediatric neurologists. A recent trend is to pretest entire populations of children with computer-based neuropsychological assessment technology such as ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), so that return to play can be guided by return to baseline performance of these tests. Practice parameters for the management of sports concussion and guidelines for return to play have currently been developed.⁴ Furthermore, the consequences of repetitive concussion are now being recognized in children, teens, and adults, with cognitive effects among college athletes and chronic traumatic encephalopathy among professional athletes now an increasing concern.5 Among the challenges facing neurologists is the epidemic of Alzheimer’s disease and other dementias in the expanding aged population. There is active research into the genetic and biological mechanisms that play into the development of dementia. Furthermore, novel treatments with amyloid vaccines, tau modulation, and passive immunotherapy are also currently being investigated.⁶ The concept of a brain health center for individualized care, caregiver training, and community education is now being established at CPMC. Another challenge facing the neurological community is the more than 45 million individuals in the U.S. who suffer from headache disorders, including tension-type headache and migraine. Research into the mechanisms of headache have identified that the so-called trigeminovascular system is involved in the development of migraines.⁷ There is now a subspecialty certification for headache specialists established by the United Council for Neurological Subspecialties. Treatment options include preventive therapy and abortive therapy and are becoming more evidence-based, which is of importance in that some common headache treatments have recently been shown to actually worsen headache.⁸ Epilepsy can afflict patients of all age groups and can be associated with structural lesions or a normal-appearing brain.

Recent trends are for the care of such patients to be provided in multidisciplinary epilepsy treatment programs involving neurologists, neuropsychologists, and neurosurgeons specializing in the care of such patients. Medical management remains the first line of treatment, except in the case of a structural lesion such as a brain tumor or vascular malformation, where surgical resection of the lesions is often advocated. In the case of epilepsy that is refractory to medical management, an attempt to identify the seizure focus is undertaken, often involving the placement of external EEG electrodes for extended duration monitoring, or involving the placement of subdural grids or

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Evolving Frontiers in Medical Specialties

Bariatric Medicine Seven Exciting Developments

After fourteen years in emergency medicine, I headed down an uncharted path. Sick of treating the

symptoms of overweight and obesity, I wanted to fight the cause. With a buddy from Stanford Residency, Dr. Conrad Lai, I founded JumpstartMD to combat the biggest health care crises of the twenty-first century: adiposity and its evil twin adisopathy, or “sick fat.” Looking back, I had no idea how gratifying this journey would be, and what a positive impact we would have on peoples’ lives.

I was also surprised to see how misguided the information we’d received in medical school had been on this topic, and how many “luminary” thought leaders would emerge from right here in the San Francisco Bay Area to help lead our field out of the darkness of old thinking and flawed science.

In honor of those luminaries and the marvelous journey that has transpired since we founded JumpstartMD seven years ago, these are the seven topics I find most exciting in bariatric medicine right now:

1. The growing recognition that all calories are not created equal Scientific evidence and the collective knowledge of bariatric clinicians on the frontlines of care paint an increasingly clear picture: Individuals vary greatly in their level of carbohydrate tolerance. Carbohydrate intake that exceeds an individual’s tolerance may cause adiposity, adisopathy, or both.

Thus carbohydrates, not fat, may well represent our greatest metabolic and cardiovascular health risk contributing to obesity.

Increased consumption of carbohydrates over the past forty years, both in relative total and as a percentage of all calories consumed, has been the major macronutrient change, in lockstep with the rise in obesity and diabetes. Treatment informed by this perspective enables bariatric physicians to tailor diets matched to an individual’s level of carbohydrate sensitivity. It also allows patients to wisely embrace behavioral change in line with optimal, individualized dietary guidance.

That path simply won’t be the carbohydrate-heavy, lowfat food “pyramid” we all learned in school. As humans cannot consume more than 30 to 40 percent of their calories from protein without untoward consequence, the most carbohydrate-sensitive group (such as those with insulin resistance, type 2 diabetes, or metabolic syndrome), in particular, cannot consume a diet that is low in both carbohydrate and fat.

For that carbohydrate-intolerant group (and, to varied degrees, the majority of the two-thirds of Americans who are overweight or obese), it is increasingly clear that a well-formulated, low-carbohydrate diet complemented by a good mix 26 27

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Sean Bourke, MD

of fats is healthier. Additionally, that mix of fats should focus on consumption of heart-healthy monounsaturated fats such as those in avocadoes, nuts, and olive and canola oil; temper fears of cardiovascular risk-neutral saturated fats; ensure adequate intake of omega 3s via fish or good-quality supplements; and minimize intake of industrialized oils (like corn and soy oil).

2. The potential use of two new and potentially influential laboratory assays to assess health risk, monitor efficacy of treatment, and educate and motivate individual patients The first assay mentioned, which I am not yet at liberty to discuss, is currently under development and going through academic validation. It promises to accurately predict individual carbohydrate tolerance at the point of care.

The second, lipid fractionation using Ion Mobility testing (the only assay that directly measures low-density lipoprotein particle size), can more accurately assess metabolic and cardiovascular health risk and pre- and post-weight-loss intervention efficacy of treatment.

Measuring LDL particle size is beneficial because it is carbohydrates, particularly white flours and sugars (again, not fat), that shape LDL particles into the various medium, small, and very small sizes that disproportionately drive cardiovascular risk. Further, smaller LDL particles flag an early proclivity to metabolic syndrome even prior to actual rises in insulin. Because carbohydrate restriction and weight loss are the principle treatments for metabolic syndrome patients, lipid fractionation can help tailor diets for insulin-resistant higherrisk patients. Additionally, measuring lipid fractionation particles pre- and post-weight loss intervention in those patients represents new value in terms of helping patients understand why their macronutrient composition matters, and to further motivate optimal dietary compliance.

3. The recent discovery at the Gladstone Institute that the ketone body Beta-hydroxybutyrate served to potently reduce oxidative stress (see “Suppression of Oxidative Stress by Beta-Hydroxybutyrate, an Endogenous Histone Deacetylase Inhibitor” by Shimazu et al) Ketogenic diets have traditionally been maligned by the medical community, largely through a misunderstanding of the differences between the pathologic state of diabetic ketoacidosis (ketone levels 15–25) and the benign state of nutritional ketosis (ketone levels 0.5–5). While further studies are needed, the findings in this study suggest an underlying epigenetic mechanism through which ketogenic diets may serve www.sfms.org

to prevent oxidative stress and cellular free-radical formation and, thus, might actually slow aging and prevent a variety of diseases, from coronary artery disease to Alzheimer’s and beyond.

4. The Vivus Corporation’s recent FDA approval for an anorectic medication composed partly of phentermine for long-term use Let me clarify: I do not believe that Qsymia, the extendedrelease topiramate-phentermine combination, offers therapeutic benefit proportionate to its cost in comparison with cheaper, older generic anorectics. However, Vivus’s management of the studies needed to assure the FDA that this phentermine extended-release topiramate combination is safe and effective to administer long-term is a positive development.

Bariatrician survey data suggests that the vast majority have been using Schedule III and Schedule IV anorectics offlabel safely and effectively long-term for years—but under a chronic and low-level fear of harassment by the Drug Enforcement Administration. Since FDA concerns were not evidencebased, this peeling back of the proverbial onion can only be helpful in further confirmation of their invalidity. The approval of Qsymia for long-term treatment and further studies in progress may therefore pave the way for FDA reevaluation of its regulatory stance around long-standing, safe, and effective use of generic anorectics such as phentermine, phendimetrazine, and diethylpropion.

Also noteworthy on the medication front: The selective serotonin 2c receptor agonist lorcaserin (Belviq) and a combination bupropion SR and naltrexone SR are both pending FDA approval on the year 2014 horizon.

5. Recognition that, for the vast majority of patients, exercise is a lousy weight-loss tool I know this sounds heretical, but the truth will set us all free. While a great wellness tool—think cardiovascular, metabolic, mental, and musculoskeletal health—and an important component of weight maintenance, the ill-founded belief that exercise produces weight loss has lead too many down a (sweaty and demotivating) garden path. Living in our “toxic environment” (per Yale Professor Kelly Brownell)—rife with ubiquitous and cheap carbohydrate rich foods—you cannot outrun your mouth. Effectively busting that exercise myth is essential.

Why? Because patients need a clear and transparent understanding of what really works to achieve and sustain a healthy weight that’s based on science, not catchy marketing or popular magazine advice. The food industry has a great stake in convincing us that our sedentary lifestyles and lack of exercise, rather than the adulterated food supply they’re selling us, is the cause of the obesity epidemic; but I’ll quote the “consensus statement” from the American Heart Association and the American College of Sports Medicine on this subject: “It is reasonable to assume that persons with relatively high daily energy expenditures would be less likely to gain weight over time, compared with those who have low energy expenditures. So far, data to support this hypothesis are not particularly compelling.” www.sfms.org

Exercise as a “not particularly compelling” weight-management tool bears out our experience at JumpstartMD with more than 10,000 patients. This should not discourage exercise or the pursuit of improved fitness, but rather spur patients to focus on nutrition first to lose excess weight, and then integrate exercise to promote health and positive body composition changes and to foster long-term success as a complement to weight-loss maintenance.

6. Everyone eats food: The visions of Alice Waters and Michael Pollan Alice Waters, the matriarch of the Bay Area good food movement, has become queen not of haute cuisine but, to use her own words, “simple foods”—foods sourced locally and grown sustainably. She is also founder of the Edible Schoolyard Project and Chez Panisse Foundation, and she has led many back to the pleasures of their kitchens by way of their gardens. Fellow Berkeley resident Michael Pollan has given us embraceable, actionable, pithy phrases everyone can rally around, such as “Eat foods. Not too much. Mostly plants.”

“Don’t eat anything your great-grandmother wouldn’t recognize as food.” “Shop the peripheries of the supermarket and stay out of the middle.” His next book on the importance of cooking is due out shortly.

Along with doctors like Steve Phinney, Ronald Krauss, and Robert Lustig, leading food and nutrition thinkers like Pollan, Waters, and Gary Taubes are creating a dialogue around the new science that makes one thing clear: Nutrition is the linchpin on which the solution to the obesity crisis must turn.

I am grateful for their leadership, the tangible impact this new thinking has had on the Bay Area food movement and on the health of my patients, and the longer-term impact it will have in the evolution of my field.

7. Building the future Yes, everyone eats food; yet our modern food supply barely resembles food any longer. We’re sold “toxic” nutritional time bombs in pretty, easy-to-consume packaging served up fast, cheap, and everywhere you look. At a recent lecture given

by Dr. Robert Lustig, he said that 80 percent of the 600,000 foods listed in our food supply have added sugar. Average American consumption of sugar has increased from 5 pounds per capita in the eighteenth century to 35 pounds in the nineteenth century to 156 pounds today. Ouch.

The problem is arguably complex, but the solution is simple: real food. It does not lie in the substitution of one toxic product for another, such as liquid “shakes”; chemically preserved “meals”; or pointless point systems that allow Twinkies, tuna, and taffy interchangeably. All calories are not created equal.

At JumpstartMD, our practices hinges on this belief. Our clinical outcomes have been proven up to three to four times more effective than traditional offerings, and more than 80 percent of our maintenance patients remain within one pound of their losses because we help them learn healthy habits tailored to their needs and built upon a foundation of whole, fresh, real food meal strategies that are meant to last a lifetime.

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Bariatric Medicine Continued from the previous page . . .

Moving toward “the” solution to this daunting problem is by necessity a collective process that—like our practice at JumpstartMD—will employ a comprehensive approach that’s informed by the seven elements outlined in this piece, and those yet to come. It is this collaborative passion and perpetual search for improvement that I find one of the most exciting elements of bariatric medicine today.

Sean Bourke, MD, is cofounder and CEO of JumpstartMD (www.jumpstartmd.com), Northern California’s largest nonsurgical medical weight management practice. A member of the SFMS and the American Society of Bariatric Physicians, Dr. Bourke is a graduate of Yale University and the University of Southern California School of Medicine. He received his postgraduate training in Emergency Medicine at Stanford University. JumpstartMD has two offices in San Francisco and seven others encircling the greater Bay Area.

Neurology Continued from page 25 . . . deeper brain electrodes for extended-duration monitoring. If the focus of seizure generation can be identified, then surgical removal of the focus is considered.⁹ This requires a careful assessment of the risks of tissue removal in terms of affecting memory or other eloquent functions. Such determinations are made after careful assessment by the neuropsychologist. In the setting of refractory epilepsy, where a structural brain lesion cannot be identified or safely resected, the placement of a vagal nerve stimulator may reduce seizure frequency with an acceptable safety profile.10 Within neurosurgery, there have been exciting developments. Among the most exciting are the newer sites within the brain where stereotactic electrodes can be placed to treat movement disorders such as Parkinson’s disease¹¹ and essential tremor, obsessive compulsive disorder, and severe depression that is refractory to conventional treatments.¹² Current research is directed at identifying additional sites where stimulation may influence other complex behavioral disorders. Similarly, stimulation of the spinal cord with epidural electrodes connected to an impulse generator can reduce both neuropathic and somatic pain disorders that prove to be refractory to conventional measures, such as failed-back syndrome and post-spinal cord injury pain syndromes.

The treatment of brain tumors has advanced in many ways—from the understanding of genetic, hormonal, and environmental mechanisms to the safety and efficacy of tumor treatments. For gliomas primary to the brain, the maximal safe excision of the tumor improves survival,¹³ on occasion using complex brain mapping techniques in an awake individual.¹⁴ For benign tumors such as meningiomas and vestibular schwannomas, surgical excision is now sometimes limited to less-than-complete removal to enhance safety, knowing that added techniques, such as stereotactic radiosurgery, can control the residual tumor for years to come.¹⁵ Pituitary tumors, 28 29

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if they produce prolactin, can often be controlled with drug therapy. If they are non-hormone secreting, such tumors are now treated with combined neurosurgical and ENT endoscopic techniques that provide a panoramic view, and added safety for the patient.¹⁶ Spine surgery is currently undergoing a critical reevaluation of the historic technique of spinal fusion, recognizing that many patients can undergo minimally invasive decompressive surgery while avoiding the morbidity of fusion altogether.¹⁷ In those that need correction of instability or spinal alignment, the methods of fusion are gradually becoming less invasive and morbid.¹⁸ Much more controversial is the use of artificial discs, which may play some role in the treatment of cervical spine disease; however, they remain extremely controversial in the treatment of low back pain.¹⁹ Neurosurgeons now recognize that among the most important aspects of our care is the costeffectiveness of our diagnostic treatment and surgical interventions. More and more spine research focuses on or includes quality-of-life data.

Brian T. Andrews, MD, FACS, FAANS, is chairman of the department of neurosciences at California Pacific Medical Center and heads the California Pacific Neurosciences Institute in San Francisco. He practices neurological surgery at CPMC and his hobby is creative writing. He is a member of the SFMS. A full list of references is available online at www.sfms.org.

www.sfms.org

Evolving Frontiers in Medical Specialties

Nurse Practitioners Implementing the Affordable Care Act David Vlahov, RN, PhD As health care reform takes effect and the population ages, the demand for health services increases; many have raised alarms about critical shortages in the health care workforce. Primary care is usually

front and center, and while much of the attention has focused on physicians, any response to shortages should consider the contribution that advanced practice nurses, especially nurse practitioners, can make. One proposed solution to meeting population health needs is to expand the role of nurse practitioners in many more areas of the country and to allow them to provide a wider range of preventive and acute health care services. Some physician groups oppose an expansion of nurse practitioners’ scope of practice, citing concerns over patient safety.

When the Institute of Medicine (IOM) of the National Academy of Sciences issues a report, the IOM panels and review process ensure that conclusions and recommendations are based on solid science. This is a profound principle, one that those of us in health care have long held dear. It is scientific evidence that will be central to ensuring the safest, highest-quality care.

So why is it that as numerous articles raise alarms about a physician shortage, they ignore or minimize scientific evidence from the IOM and others that there are alternative and, perhaps, more efficient and lower-cost ways to fill some of the gaps?

The authors of a 2010 IOM report entitled The Future of Nursing: Leading Change, Advancing Health amassed and reviewed evidence about the role of advanced practice nurses (APNs).1 Multiple studies—including randomized controlled studies—over several decades had shown that APNs provide high-quality and safe patient care in multiple clinical settings.

One of the earliest trials on quality of care between nurse practitioners and physicians was the Burlington randomized trial in 1974; this study showed equivalence.2 Systematic reviews have summarized the more extensive literature and are important so as to avoid cherry-picking studies for the conversation. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote, “appropriately trained nurses can produce as high-quality care as primary care doctors and achieve as good health outcomes for patients.” As with all Cochrane groups, they also acknowledged that the research was limited.3 Another recent systematic review of twenty-three studies on nurses prescribing medication concluded that nurses sometimes differ from physicians in the number of patients they prescribe or in the choice of type of medication. Clinical parameters were the same or better for treatment by nurses; perceived quality of care by nurses is similar or better; the authors noted that most studies had limitations.4 Although most of the many studwww.sfms.org

ies were performed in the 1980s and 1990s, new studies are in progress.5 In terms of costs, some studies also show that APNs can be trained in less time and for less expense than physicians, and are lower cost in practice even as patients remain satisfied with the care they receive from APNs.6,7 There is a caveat; the lower cost in practice exists if the nurse practitioners are used to the fullest extent of their training.8,9 These are all relevant metrics for the accountable care organizations springing up around the country in response to the Affordable Care Act. Nurse practitioners work together with physicians to provide excellent patient care. This partnership is critical as each brings strengths to the table. Traditional education has trained each profession in silos and team building has been secondary.

This is now changing. Health sciences campuses are building interprofessional health education programs. Here in San Francisco, an important demonstration project is the Veteran’s Administration’s Center for Excellence in Primary Care Education.

It brings together medical residents, nurse practitioner students, and other health professions to train together as teams in an environment where physicians and nurse practitioners carry full patient panels.

Another model for practice has been the Nurse Managed Clinic, with the assistance of funding from the Human Resources Service Administration (HRSA). For the past fifteen years at the Glide Memorial Church, the University of California, San Francisco School of Nursing has staffed a nurse-managed, federally qualified health center. The school has also been a key part of the nurse-managed clinic at the Women’s Community Clinic. Both provide services to underserved populations and education to prepare advanced practice nurses.

These models of nurse practitioner education and services complement and expand primary care. In an era of expanding health needs and a shrinking primary care physician workforce, nurse practitioners can contribute to the nation’s health care delivery.

David Vlahov, RN, PhD, is dean and professor of nursing and professor of epidemiology and biostatistics at the University of California, San Francisco. Prior to arriving in San Francisco two years ago, he was senior vice president for research at the New York Academy of Medicine and a professor of epidemiology at the Columbia University and Johns Hopkins University Schools of Public Health. A full list of references is available online at www.sfms.org.

april 2013 San Francisco Medicine

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Evolving Frontiers in Medical Specialties

The Rules of Primary Care Creating Safe, Smart Ways to Serve Growing Pool of Patients Paul R. Phinney, MD California physicians strongly supported the Affordable Care Act because it promised first, to expand access to health coverage to all while, second, ensuring the high quality of medical practice in our state. But those who now invoke the ACA as the sole

justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures on them are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

Doctors and health care experts believe that California can accomplish both of the ACA’s objectives without eroding quality or jeopardizing patient safety, providing access to safe and high quality care for everyone. After all, the new health care laws were specifically written to increase reliance on team-based care, in which physician assistants, nurse practitioners, medical assistants and other professionals work under the supervision of highly trained and experienced physicians. This model leverages the skills and experience of all health professionals and has a proven record of quality and efficiency based on clinical integration.

Proposals to expand so-called “scope of practice” would only further fragment the health care delivery system, encourage overreliance on specialty referrals, and create a dangerous disincentive away from the proven model of physician-supervised, team-based care. Expanding scope of practice will not ensure access to care, either. Non-physician providers are not simply sitting in the wings waiting to provide care and in fact, they provide care under supervision now.

Recklessly allowing certain health professionals to operate outside of their training puts patients in harm’s way. Simply changing the law cannot duplicate the years of graduate training, full-time residencies and thousands of hours of clinical rotations physicians undergo to equip them with the necessary knowledge and understanding of complicated and hard-to-diagnose, hard-to-treat diseases.

Yes, there is a troubling physician shortage in California, especially among primary-care physicians—which is why bridging the physician gap has been a leading priority of the California Medical Association for more than a decade. But clearly, the solution isn’t to devalue the primary role of trained physicians—it’s to attract and retain more physicians.

The most immediate way we can add more physicians is by increasing the number of residency slots throughout the state. Assembly Bill 1176, introduced by Assemblyman Raul Bocanegra, D-Los Angeles, would do just that. The bill will follow the example of other states by creating a funding

30 San 31 SanFrancisco FranciscoMedicine Medicine april april2013 2013

source for California residency training programs, which are now grossly underfunded. Medical residency programs train doctors after they have earned their MD degrees. On day one of residency physicians are seeing patients and have more medical training than nurse practitioners do at the height of their NP graduate education. The severe underfunding of medical residency programs in California has forced thousands of new MDs to leave the state for their residencies, where the majority of them stay to join or open practices.

Increasing the number of residency slots for physicians educated in California will keep those physicians in the state and can provide immediate relief for newly insured patients looking for quality medical care as the Affordable Care Act goes into effect.

In addition to residency slots, California needs more medical schools. In August of this year, the University of California, Riverside, will open the doors of its full-time medical school. Originally started as a biomedical sciences program, students previously would begin their medical education at Riverside and complete training at the UCLA Geffen School of Medicine. With a broad base of support, UC Riverside was able to expand its program and will now be a four-year medical training program of its own. However, to stay operational, the school will need to secure additional funding, which AB 27 (Medina) and SB 21 (Roth) aim to achieve.

The Affordable Care Act has offered a chance for the medical community to be innovative and groundbreaking in the way health care is delivered to patients. We must seize this opportunity to show that integrated care led by a physician is not only the safest but the most efficient and cost-effective way to make the ACA a success.

Paul R. Phinney, MD, is the president of the California Medical Association and a practicing pediatrician in Sacramento.

Another version of this piece was published in the Sacramento Bee on March 29, 2013.

www.sfms.org

Evolving Frontiers in Medical Specialties

Choosing (Ever More) Wisely An Update from the “Moral Center of Care”

In order to ensure that ongoing reforms work—i.e., that costs are controlled without sacrificing quality—practicing physicians will have to lead the way.

Or so former Medicare Director Donald Berwick, MD, remarked at a recent conference. “You’re going to need a kind of momentum from professionals—the moral center of care—to change with the proper ways, with the proper skills and models, and that’s a much finer-grained thing than changing a rule or a law,” he said. “You’re seeing [that momentum] a bit. I just think we need more of it.”

Choosing Wisely seems an example of what Berwick prescribes. A project of the American Board of Internal Medicine and headed by UCSF Dean and ABIM Chair Catherine Lucey, MD, “CW” was the focus of the entire January/February issue of San Francisco Medicine. For those who missed that issue—available on SFMS.org—CW is undertaken from the conviction that, as Berwick says, physicians are far and away the best equipped to discern how to make care more efficient and to encourage patients and physicians to follow evidence-based guidelines in managing health problems, while avoiding procedures that could cause more harm than good.

To that end and to start, in 2012 nine national specialty societies developed lists of the five most commonly overused tests and procedures. In February, seventeen more specialties joined with their own lists. Thirteen more are expected later this year.

Thus, soon very few, if any, specialties will be unrepresented. The lists are here: http://www.choosingwisely.org/doctor-patient-lists/.

Some of the interventions on the lists will be obvious; others less so. CW provides evidence-based rationales for the inclusion of each item, plus information for patients as well.

“It will take greater social and political will to unseat the forces that maintain the status quo of the country’s health care delivery system,” says Berwick. “We can fix it . . . it can be done.

Probably not outside-in, but inside-out.”

Medicare/Medi-Cal Dual Eligible Patients Update: Some Good News From CMA, March 25: The Department of Health Care Services (DHCS) announced that the federal Centers for Medicare and Medicaid Services (CMS) has given approval to the project to require Medicare/ Medi-Cal dual eligibles to enroll in a managed care plan. The project, which was previously known as the “Coordinated Care Initiative,” will now be called CalMediConnect. CMA will continue to review the 100+ pages of the MOU and will provide a complete analysis in the next week.

Comment from Andrew Calman, MD, Chair of the SFMS Political Action Committee: “There is much good news: patients can opt out at any time, the proposed six month ‘lock-in period’ was defeated, there is a much www.sfms.org

Steve Heilig, MPH

Specialty Society Lists of Five Things Physicians and Patients Should Question: * Indicates new list as of February 21, 2013 American Academy of Allergy, Asthma & Immunology American Academy of Family Physicians* American Academy of Hospice and Palliative Medicine* American Academy of Neurology* American Academy of Ophthalmology* American Academy of Otolaryngology—Head and Neck Surgery Foundation* American Academy of Pediatrics* American College of Cardiology American College of Obstetricians and Gynecologists* American College of Physicians American College of Radiology American College of Rheumatology* American Gastroenterological Association American Geriatrics Society* American Society for Clinical Pathology* American Society of Clinical Oncology American Society of Echocardiography* American Society of Nephrology American Society of Nuclear Cardiology American Urological Association* Society for Vascular Medicine* Society of Cardiovascular Computed Tomography* Society of Hospital Medicine—Adult Hospital Medicine* Society of Hospital Medicine—Pediatric Hospital Medicine* Society of Nuclear Medicine and Molecular Imaging* The Society of Thoracic Surgeons* To see the full lists and much more, see: http://www.choosingwisely.org/doctor-patient-lists/ longer implementation and enrollment timeline than originally proposed, and the methodology seems designed to provide at least some safeguards against predatory low-ball reimbursement rates from the health plans. I encourage everyone who sees Medi-Medi patients to download and read the MOU: http://www.calduals.org/cci-documents/ca-demo-documents/

The ‘passive enrollment’ of dual-eligibles will still be disruptive to patient care, but given the current climate and the degree to which Governor Brown was pushing this plan, it is difficult to imagine that the outcome could have been much better than this. Kudos to CMA for making this a priority.” april 2013 San Francisco Medicine

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In Memoriam

Nancy Thomson, MD

Kevin D. Harrington, MD Kevin Harrington, MD, a retired member of the San Francisco Medical Society, died on Monday, January 7, 2013, at his Mill Valley home in the presence of his wife, Peggy. He was a passionate defender of the undefended and a true Renaissance man with interest in music, art, and books. He was born in San Francisco, November 30, 1938. He graduated from the Town School, Lowell High School (1956), Yale University (1960), and UCSF Medical School with honors (1964). He interned at the Hospital of the University of Pennsylvania in 1965, served three years in the Army (1966–1969), and did an orthopedic residency at UCSF (1969–1972). He was assistant chief of orthopedic surgery at San Francisco County Hospital from 1972–1977 before entering private practice in San Francisco.

He was a member of the Alpha Omega Alpha Honor Medical Society, the Association of Bone and Joint Surgeons, and the Russell Hibbs Orthopaedic Society. He had numerous visiting professorships throughout the United States, Europe, and South America. He held numerous academic appointments, authored more than 100 papers on orthopedics, and presented at professional meetings worldwide. He was on the editorial board of several orthopedic journals and authored a book on the orthopedic management of metastatic bone disease. He served on UCSF’s Medical Admissions Board for many years and was a consultant to the National Football League Players Association. He also served on the board of the San Francisco Boys’ Chorus and the American Bach Soloists.

Harrington epitomized his dedication to the Hippocratic Oath, “to preserve the finest tradition of his calling and experience the joy of healing those who seek his help.” He volunteered at the Albert Schweitzer Hospital in Haiti and at the Hole in the Wall Gang camp in Connecticut. After retiring from his practice in 2003, he committed his time, talent, and great enthusiasm to the Marin Community Clinics, where he spearheaded and expanded orthopedic services to the underserved of Marin County. He was awarded the Community Champion award in 2012 by MCC for his commitment to the ideal “that all patients deserve quality care and attention no matter their financial circumstances.”

Kevin Harrington was married to Peggy Zanotti Harrington, also an MD, for thirty-two years and is survived by their five children; five grandchildren; his sister Erin Van Speybroeck of Boston; two nephews and a niece; and his first wife, Margaret Plumley Stephenson.

SFMS/CMA Joins Amicus Briefs Challenging Proposition 8 and the Defense of Marriage Act In February, the SFMS and CMA joined the AMA and dozens of other health care organizations in filing an amicus brief with the US Supreme Court challenging California’s Proposition 8, which denies state recognition of same-sex marriages.

A similar brief was also submitted challenging the Defense of Marriage Act, which denies benefits to same-sex partners of federal employees.

“CMA strongly supports efforts to reduce health care disparities among members of same sex households, including measures to afford such households equal rights and privileges to health care, health insurance and survivor benefits,” said CMA President Paul Phinney, MD. “We also recognize that denying civil marriage contributes to worse health outcomes for gay and lesbian individuals, couples, and their families.”

The brief states that the listed Amici—which includes leading associations of psychological, psychiatric, medical and social work professionals— have sought to present an accurate and responsible summary of the current scientific and professional knowledge concerning sexual orientation and families relevant to this case.

These briefs were filed based on policy passed at last year’s House of Delegates: Date Adopted: 10/15/2012 Status: Adopted

Resolved #1 - That CMA support efforts to reduce health care disparities among members of same-sex households including minor children Resolved #2 - That CMA support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits afforded to opposite-sex households Resolved #3 - That CMA recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families.

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San Francisco Medicine april 2013

www.sfms.org

HOSPITAL NEWS KAISER

SFVAMC

Chinese

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

James K. Yan, MD

Transcatheter aortic valve replacement (TAVR) represents a milestone in minimally invasive cardiac therapy. The pivotal PARTNER trial evaluated this technology in two groups of patients: those who were not candidates for traditional, open-heart aortic valve replacement surgery and those who were at high risk for open aortic valve replacement. For the inoperable group, patients undergoing TAVR had a dramatic survival advantage compared to those who were treated with medical therapy. Based on these results, in 2011 the FDA approved the Edwards SAPIEN valve for use in TAVR for patients considered inoperable or at high risk for conventional, open aortic valve replacement.

Kaiser Permanente Northern California’s regional TAVR program is headquartered at the San Francisco Medical Center, which has performed more than forty TAVR procedures since beginning in July 2012. Potential candidates undergo a thorough, multidisciplinary evaluation to ascertain their risks for conventional surgery and also undergo a geriatric neuropsychiatric and social work evaluation to assess any underlying cognitive issues. Dr. Edward McNulty, an interventional cardiologist and member of the Kaiser TAVR team, says, “A real challenge is determining whether the very issues that preclude conventional aortic valve replacement also preclude a meaningful quality of life following TAVR.” Once the evaluation is complete and patients are felt to be candidates, they are brought to a “hybrid operating room,” a suite with a robotic C-arm to permit X-ray guidance for positioning the new valve, typically inserted through an artery in the groin. A team of specialists from multiple disciplines performs the procedure: cardiac surgeons, vascular surgeons, interventional cardiologists, cardiac anesthesiologists, and noninvasive cardiologists all participate.

Recovery is typically much faster than for conventional surgery, but these patients are complicated and often require intensive followup. Nonetheless, “we have seen many patients thrive with a new lease on life thanks to this technology,” says Dr. McNulty. www.sfms.org

Immune dysfunction is common in elderly veterans and in veterans suffering from PTS. Many VA researchers are seeking the root cause of immunosuppression. One recent study entitled: “The Rel/NF-kB pathway and transcription of immediate early genes in T-cell activation are inhibited by microgravity,” published in December in the Journal of Leukocyte Biology, found new regulators of Tcell immune function.

Since previous studies have shown that spaceflight causes immunosuppression in astronauts, the authors used spaceflight conditions on the International Space Station (ISS) Laboratory platform to find key regulators of the immune system. In these studies, human T cells were activated in spaceflight and exposed to normal gravity and microgravity.

Resulting data found forty-seven genes that were dysregulated in the absence of earth’s gravity. These forty-seven genes point to new key regulators of immune function, and many of them are potential new immune therapeutic targets for treatment of immune disease.

The Hughes-Fulford Laboratory continues its NIH-sponsored studies on ISS this fall. The human T cells will be prepared at Kennedy Space Center and delivered to ISS by SpaceX3 in November 2013. The new studies are centered on finding potential therapeutic miRNAs, a new class of regulatory molecules that control the very early steps in human T-cell activation. In the future, these new therapeutic targets have the potential to offer novel treatment for veterans who suffer from immunosuppression.

The authors of the paper were Tammy T. Chang, Chai-Fei Li, Jim Boonyaratanakornkit, Grazia Galleri, Maria Antonia Meloni, Proto Pippia, and Millie Hughes-Fulford. The first and last authors are VA employees.

Happy New Year with the Year of the Snake. Those born in the Year of the Snake are said to be intelligent and quick-thinking, but they can also be dishonest and prone to showing off.

The Chinese Hospital Board of Trustees inaugurated its new president on January 28, 2013, at the Four Seas Restaurant with Mr. Tommy Ng to lead the board this year. He will continue the strong guidance that the hospital will need in the building of our new hospital.

The demolition of our old hospital building at 835 Jackson Street has begun, with visible outward signs. Jackson Street has been closed to pedestrian traffic. Earth movers and bulldozers are readily visible. Chinese Hospital hopes to have the new building up and functional by 2016.

The Ms. Chinatown pageant was held February 16. The winner of the pageant was Leah Li from Mercer, Washington. Other winners included Miss Chinatown USA/Miss Talent: Leah Li (Mercer Island, Washington); Miss Chinese Chamber of Commerce: Katherine Chu (Los Altos Hills, California); Miss Chinese San Francisco: Sanyee Yuan (Concord, California); Second Princess: Anna Zhang (Houston, Texas); Third Princess: Kendy Cheung (Chicago, Illinois); Fourth Princess: Erica Lee (Honolulu, Hawaii); Miss Congeniality: Leah Li. Chinese Hospital recently had a state surveyor inspect our Medication Error Reduction Program (MERP). This was a threeday survey, and our nursing staff and doctors performed well. Chinese Hospital continues to be always vigilant in maintaining goodquality care practices at all times. Kudos to our staff and doctors.

april 2013 San Francisco Medicine

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CPMC

UCSF

Michael Rokeach, MD

Michael Gropper, MD

A new logo and tagline have been developed for CPMC. They build on the excellent standing of CPMC and highlight our relationship to Sutter Health and our sister affiliates.

By linking our brands more prominently, we will help raise awareness of the Sutter Health network within the communities we serve.

Our new tagline, “We Plus You,” celebrates our commitment to provide personalized care through partnerships. It also better reflects the unified network of care that the Sutter Health family provides for patients throughout Northern California. “We Plus You” will replace “With You. For Life,” Sutter Health’s current tagline, as well as our CPMC’s “Handson Healing.”

CPMC is pleased to announce the appointment of Dr. Mohammed Kashani-Sabet as the medical director for cancer programs. In this newly created role, Dr. Kashani-Sabet will lead strategic efforts to develop new cancer programs that build on our current strengths.

Dr. Kashani-Sabet is an internationally recognized dermato-oncologist who specializes in the care of patients with cutaneous malignancies, specifically melanoma and cutaneous lymphoma. His federally funded laboratory research program is focused on the development of novel biomarkers for melanoma and the identification of novel targets for cancer therapy. He has served as director of the Melanoma Program at CPMC and senior scientist at the CPMC Research Institute since 2009.

Effective March 2013, Dr. Max Wu will assume the position of chief of the Division of Nuclear Medicine, replacing Dr. Stephen Bunker. Many thanks to Dr. Bunker for his past services as division chief. Dr. Andrew Lasher is currently serving as interim Internal Medicine Residency Program director. A search committee is interviewing candidates for the program director, and additional associate program leadership positions are expected to be filled soon.

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More than three years after its official opening, the UCSF Orthopaedic Institute at Mission Bay has become the most comprehensive location in the Bay Area for outpatient treatment, research, and training in musculoskeletal conditions, injuries, and sports medicine. Led by Thomas Parker Vail, MD, the institute is designed to serve patients needing diagnosis, treatment, imaging, outpatient surgeries, specialty care in joint replacement, spinal conditions, hand and upper extremity conditions, foot and ankle problems, and sports medicine as well as performance diagnostics, rehabilitation, human performance assessments, and prosthetics and orthotics. The facility, located at 1500 Owens Street in San Francisco, allows physicians, therapists, and radiologists to serve each of these needs under one roof.

The past year has seen some particularly noteworthy additions to the institute’s capabilities.

One such addition is joint replacement specialist Erik Hansen, MD, who joined the UCSF Arthroplasty Service late last year. Dr. Hansen’s clinical focus includes adult reconstructive surgery of the hip and knee and primary/revision total hip and knee replacement procedures. He also has a clinical and academic interest in the direct anterior hip approach for hip joint replacement. Last fall, the Orthopaedic Institute also saw the opening of both a multidisciplinary concussion clinic for athletes with head injuries and the UCSF Skeletal Health Service, a regional referral center for the diagnosis and treatment of bone disorders such as osteoporosis, genetic bone disorders, and metabolic bone disease. The service’s integrated group of specialists is dedicated to providing the most effective care possible to patients, as well as advancing care through research and the use of digital technologies. Led by Aenor Sawyer, MD, an orthopedist with a background in skeletal health and physical therapy, the center is one of only a handful in the country that combines total orthopedic care with the treatment of metabolic bone disease for patients of all ages. Bone health evaluation, education, and treatment (including physical therapy) are all available. For more information on these and all of the institute’s services, go to www.ucsfhealth.org/orthoinstitute.

San Francisco Medicine april 2013

St. Mary’s Peter Curran, MD

The St. Mary’s family celebrated a very special occasion with the retirement of Helena Lim, director of Pharmacy, after forty-five years of service at the hospital. This was her first job out of training and the event was packed with friends and well-wishers who will miss her dedication and friendly smile. In an era where business regards job change as evidence of upward mobility and success is measured with quick fixes, it may be prudent to weigh the benefits of staying put for the duration of one’s career.

Studies suggest that the most important factor in determining whether an employee stays with a company or leaves for something better is the work environment. The salary or title may be the initial attraction, but successful companies realize it takes more than that to maintain employee satisfaction and keep the best talent within the ranks. Google recently eliminated the contemporary work from home model, which provided more flexibility at perhaps the expense of productivity. After World War II Japan rewarded hardworking employees with a culture of keeping a job for life. Employers avoided the high costs associated with employee turnover and the risk of losing staff to a competitor. The postwar period in Japan lead to several decades of rapid growth and relative prosperity for its population.

St. Mary’s wants to encourage strong employee morale and a sense of a single mission of providing excellent care to the community we serve. The Employee Recognition Dinner and summer family picnics are small ways of saying thank you to our colleagues. When asked if she would repeat a career that spanned eight U.S. presidents, Helena Lim replied, “Possibly, if I could have more time off.” We salute you, Helena!

www.sfms.org

“When I found out how much money I could save ($1,650) on the sponsored workers’ compensation program, I joined CMA. The savings paid for my membership and then some. Now I have access to everything CMA offers.”

Nicholas Thanos, M.D. CMA Member

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FInd tHe beSt SPeCIAlISt FOr yOur PAtIent with one call We make it easy to transfer and refer your patients to specialists at CPMC, part of the Sutter Health network. One call allows you to match your patients’ needs with the right specialist, notify admissions, get authorizations and more.

And we’re available 24/7, so you never have to wait to find the best possible care for your patients. It’s another way we plus you.

call our referral and transfer center 24/7 888-637-2762 cpmc.org