January 2016

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

PEDIATRICS AT THE EDGE: HEALTHY FROM THE START Concussions What to Do

Let’s Talk about Teen Suicide Educating on

E-Cigs

How to Support

LGBT Youth SB 277 Vaccine Bill FAQ

VOL.89 NO.1 January 2016

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

January 2016 Volume 89, Number 1

Pediatrics at the Edge: Healthy from the Start FEATURE ARTICLES

MONTHLY COLUMNS

10 Youth Suicide Risk: Let’s Talk About It

Eli Merritt, MD

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Membership Matters

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President’s Message Richard Podolin, MD

12 LGBT Youth: How You Can Support Lesbian, Gay, Bisexual,

and Transgendered Patients

Geoffrey Hart-Cooper, MD 13 Bullying: Is it Just a Part of Growing Up?

Nicholas Carlisle

15 Parental Notifications: Supporting Access to Abortion for Teens

Pratima Gupta, MD, MPH 16 Adverse Events and Health: The ACE Study meets

Psychological Theory

Kory Stotesbery, DO 19 Concussions: How to Handle Them

Neelesh Kenia, MD

21 E-Cigarettes: Safer Does Not Mean Safe

Katie Kramer, MD, Carly Andler, MD, Meg Davis, MD, and

Miheer Sane, MD 22 Obesity: Continuing the Long Campaign

Shannon Udovic-Constant, MD

23 One Giant Step for Health Policy? Antibiotic Resistance and

Agricultural Process

David Wallinga, MD

Editorial and Advertising Offices: 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

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Guest Editorial Katherine Herz, MD

28 Medical Community News 29 Classified Ads 29 Welcome New Members 30 Upcoming Events

OF INTEREST 6 Introducing Richard Podolin, MD: The 2016

President of the SFMS 24 SB 277: Vaccine Bill FAQ 25 CURES: What to Know and Do Now 26 Covered California: Physician FAQ for 2016 30 Cannabis Legalization and Kids: A Report from

the Lieutenant Governor’s Commission

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

New POLST Forms Take Effect January 2016

New SFMS Member Benefit: Discounted Tickets to the California Academy of Sciences SFMS members and their practice staff can enjoy a 15 percent savings off admission tickets to the California Academy of Sciences via our exclusive eTicket program. Members can go to www.calacademy.org/etickets2 and enter sales code “sfms” to take advantage of this member discount.

Changes to Enrollment Requirements for Medicare Part D Prescribers

Beginning on June 1, 2016, all physicians and other providers who prescribe Medicare Part D drugs must be enrolled in Medicare or have a valid record of opting out. Failure to do so will result in a denial of the pharmacy claim or the beneficiary’s request for reimbursement.

All physicians and other prescribers who are not currently in compliance are encouraged to complete their Medicare enrollment or submit an opt-out affidavit no later than January 1, 2016. This will ensure sufficient processing time so that their Part D patients will continue to have access to necessary medication without interruption.

If you are unsure if you are compliant with this requirement, please review the CMS prescriber enrollment file at https://data.cms.gov/dataset/Medicare-Individual-ProviderList/u8u9-2upx.

Enrollment applications can be submitted on paper or online via PECOS, Medicare’s online portal for physician enrollment. To enroll offline using a paper enrollment form, complete the CMS-855O application and mail to Noridian. Providers should be aware, however, that this form only allows you to enroll in Medicare for the purpose of ordering and certifying services and items, and to prescribe Part D drugs. It will not allow you to bill or be paid for Medicare services. To apply as a Medicare provider with full billing privileges, you will need to complete Form CMS-855.

Visit http://bit.ly/1IVlYha for more information.

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Physician Orders for Life-Sustaining Treatment (POLST) forms will change on January 1, with the full implementation of AB 637, a new law endorsed by the SFMS that allows nurse practitioners and physician assistants—under the supervision of a physician and within their scope of practice—to sign POLST forms and make them actionable medical orders.

The revisions to the form were approved by the Emergency Management Services Authority Commission at their December meeting. The new form is not valid until January 1, 2016. Previous versions of POLST are still valid if signed by a physician.

Nurse practitioners and physician assistants are advised to only use the revised POLST form (with an effective date January 1, 2016) because previous versions do not contain the necessary signature lines or clarifying language and instructions.

For more information or to download the new form, please visit http://bit.ly/1ReZXMX.

Update: Hardship Exemption for Medicare Meaningful Use Program

Congress adopted a last minute bill that allows the Centers for Medicare and Medicaid Services (CMS) the authority to grant a blanket exemption for all eligible physicians from the 2015 meaningful use penalties. This action prevents CMS from implementing Medicare payment penalties for physicians who fail to demonstrate meaningful use of a certified electronic health record (EHR) system in 2015.

In order to avoid a Medicare payment reduction, physicians must attest that they met the requirements for meaningful use for a period of 90 consecutive days during calendar year 2015.

Because CMS published updated regulations on October 16, 2015, eligible professionals were unable to report until fewer than the ninety required days remained in the calendar year.

CMS had stated that it would grant hardship exemptions for 2015 if providers were unable to attest due to the late publishing of the rule, but the law only authorized it to grant such exemptions on a case-by-case basis. This new law grants CMS the authority to make an automatic exemption once it receives a hardship exemption application. It also streamlines the exemption process, alleviating burdensome administrative issues for both physicians and the agency.

Under the new law, physicians are still required to file for a hardship exemption to avoid a payment adjustment for 2015 no later than June 30, 2016.

Hardship applications will be available in early 2016 at http://www.cms.gov/EHRIncentivePrograms.

The California Medical Association (CMA) and the American Medical Association worked frantically these last few weeks to get the bill passed. CMA extends a huge thank you to Majority

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

Leader Kevin McCarthy (R-CA) and Minority Leader Nancy Pelosi (D-CA) for agreeing to keep the House in session and pass the bill on unanimous consent.

Flu Update: 2015-2016 Influenza Season

Influenza season is here. The San Francisco Department of Public Health is advising all people age six months and older to get a flu vaccine every year. The SFMS is encouraging physicians to continue recommending influenza vaccination to patients who have not yet received it. Although flu activity remains low across the US, two deaths have been reported in California this season. Please visit http://bit.ly/1jTBQ83 for a list of resources available for San Francisco physicians.

CMA Passes SFMS Resolution Urging U.S. Chamber of Commerce to Cease Tobacco Advocacy Efforts

CMA reinforced its long-established stance against tobacco use at the 2015 House of Delegates.

Resolution 107-15 authored by the San Francisco Medical Society strongly objects to pro-tobacco efforts by the U.S. Chamber of Commerce in other parts of the world. It asks CMA to call on the Chamber to immediately halt all advocacy efforts on behalf of tobacco companies and urges all conscientious companies that are members of the Chamber to either take similar action or quit their membership to protest such anti-health efforts.

This resolution comes at a time when CMA—as part of the Save Lives California Coalition—is seeking to reduce those numbers by implementing a needed $2 per pack tax increase on cigarettes sold in California—a concept that’s already gained an overwhelming number of supporters across political party lines.

SFMS Membership Expired December 31; Renew Your Membership Today to Strengthen the Physician Voice

SFMS would like to thank our 1,800+ members for their support of the local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the cause of physicians and their patients as we face the many challenges during these changing times.

Please take a moment to renew your support of SFMS by remitting payment for your 2016 dues today. There are three easy ways to renew your dues again this year: • Mail / fax in your completed renewal form; • Renew online at sfms.org using your credit card; or • Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

January 2016 Volume 89, Number 1 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

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JANUARY 2016 SAN FRANCISCO MEDICINE

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INTRODUCING RICHARD PODOLIN, MD The 2016 President of the San Francisco Medical Society will help us improve our services to early career physicians, and be a model for other initiatives.

What are some of the biggest opportunities or challenges you see in health care within the next year? I

Why are you a member of SFMS? I believe it is imperative that physicians unite and advocate for the well-being of their patients, their community, and their profession. The SFMS and the CMA may not win every battle, but they have a long history of leadership and effective advocacy on issues I care deeply about. I’m also a member of my specialty society, but the great majority of issues effecting health care and my profession cross specialty lines.

Why is being an active member in organized medicine important for your patient-care philosophy?

Our patients’ health is as profoundly affected by factors in their environment and the choices they make as it is by any pill or procedure we give them. They rely on our expertise and on access to high quality and compassionate care. I consider it part of my professional responsibility to address these issues, but as an individual there’s little I can do. I’ve seen that by joining organized medicine and working with my colleagues we can have great impact.

Can you tell us about any goal(s) you hope to accomplish in your new position as SFMS President?

We need to maintain our unwavering commitment to leadership and advocacy in public health. Part of that effort is ensuring that San Francisco maintains a vibrant, thriving, and diverse medical community. We need to keep asking ourselves if we are doing all we can to support physicians in all modes, and stages of practice.

Do we have the best processes to determine what our members want and need from their medical society? How do we know that we are meeting those needs? I’m very enthusiastic about the New Leadership Council we will launch this year. I believe it 6

think it’s critical that as physicians move into employment models and give up ownership of their practices they don’t, at the same time, give up ownership of their profession. Health care organizations are exerting increasing control over practice workflow and clinical pathways. Physicians need to maintain the prerogative to exercise clinical judgment and they need to maintain their role as stewards of medical quality. This doesn’t require an adversarial stance, but it does require a seat at the table.

On the opportunity side, the emerging science of obesity and metabolic disorder offers a chance to reverse one of the most widespread, devastating, and costly epidemics to plague our nation. But the transition from science to public policy will be challenged at every step by entrenched, well-funded interests such as the beverage industry. The public holds us in esteem as advocates for their health. We need to leverage that influence and work together with public officials to curb this epidemic.

How do you balance your work and personal life, and still manage to find time to participate in SFMS activities? It helps that my children are grown and I have a very

understanding wife. I’m still hoping to find that balance. I’m always inspired by the members of the Medical Society who give much more than I do.

Any advice for new physicians transitioning into practice from residency? Don’t be embarrassed to ask for

help. Medicine is a challenging field. You will not in any way be diminished in your colleagues’ eyes if you admit that you are uncertain how to manage a problem. My partner and I have been in practice together for twenty-five years and we run difficult cases by each other on a regular basis.

What about you would surprise our members? I love to play guitar and sing and I’m absolutely horrible at both. I don’t think that last part would surprise anyone.

If you weren’t a physician, what profession would you most like to try? I’d like to be a musician, but was born

with congenital absence of talent. Really, I have always believed that being a physician is the most rewarding career one could hope for. What we do is important. We’re challenged with interesting and new problems daily. We are forced to keep learning. We work collegially with others who share the same goal. We meet lots of interesting people and we are given the privilege of entry into their lives. And every day patients express gratitude for what we do. I can’t think of a more stimulating and fulfilling profession.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

PRESIDENT’S MESSAGE Richard Podolin, MD

San Francisco Medical Society At Your Service Recently, I was in our doctor’s cafeteria speaking with a distinguished surgeon who was decrying the current state of medical practice. His assertion was that in the current health care environment doctors are treated as commodities rather than professionals.

“Doctors have no power—zero,” he stated emphatically, “And do you know why? Because they won’t get together!”

Although I disagreed, I certainly understood his frustration. The source of his ire was not inadequate reimbursement, but rather what he saw as institutional disregard for the value of his clinical expertise. He had just had his orders, which reflected many years of experience and direct observation of a particular patient, countermanded by a non-physician practitioner who was not on site. It’s ironic that when physicians have the greatest capacity to alter the course of disease and improve outcomes, many physicians feel a sense of powerlessness over the tide of change affecting their own professional lives.

Physicians are less independent than they once were and this has many roots. The complexity of modern medicine requires a team approach. Medicine is a high-risk, but intrinsically human enterprise and so subject to the imperfection that characterizes all human endeavors. To the extent that checks and oversight reduce the consequences of inevitable errors, physicians should embrace these processes. But of course, the greatest limitation on physician independence has resulted from the changing relationship between physicians and payers, a transformation that is accelerating as physicians choose to practice in employed models. It is precisely in this environment that it is most essential for physicians to unite to influence the course of medical practice, even when they cannot independently control it.

Legally, salaried physicians have the option of joining a union, but most haven’t. Private physicians can join a union, but they cannot bargain collectively to improve payment, benefits, or working conditions. But all physicians—salaried and private—have the right to band together and to use their collective voice to influence legislators, government entities, and the public in ways that have profound impact on the environment of practice, including, but certainly not limited to, the financial sustainability of medical practice and, consequently, access to care. The most obvious examples of this were the recent successful efforts of the CMA to defeat the repeal of MICRA and nationally the role of organized medicine in passage of the “doc fix” bill ending the annual threat of draconian cuts in Medicare payments to physicians. Contrary to the assertion of my surgical colleague, because the public continues to hold physicians in esteem as good stewards of the public’s health when physicians do unite our voice carries weight that is disproportionate to our numbers or the size of our “war chest.”

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In this time of transformation, physicians cannot afford to dwell on their lost independence. We have a need and an obligation to bring our expertise to the table. In an article on the evolving nature of professionalism published in JAMA the authors assert, “physicians themselves also have a professional responsibility to press for such changes across the spheres of influence that define their environment- from the immediate microsystem in which they practice to the broader external environment that shapes how care is delivered . . . Striving to create environments that cultivate professionalism in practice is perhaps the ultimate expression of professionalism.” 1 Physicians, hospitals, and insurers are not adversaries in the push for quality care. Hospitals and payers have a legitimate interest in medical quality and commit effort and resources to promoting it. But the public understands that they have competing priorities. Only physicians are expected to lay aside other considerations and advocate solely for the best care of their patients for reasons of professionalism and because of the human relationship that underlies all patientphysician encounters. We are, in addition, expected to be wise stewards of health care resources and advocates for public health. It is precisely because we and our medical societies honor all these responsibilities that our voice is distinctly heard amid the cacophony of other interest groups.

Back in the doctor’s cafeteria I asked my surgical colleague if he was a member of the San Francisco Medical Society and he admitted that he wasn’t. I reminded him of the recent string of successes that organized medicine had achieved when doctors, in fact, came together in via medical societies.

“You’re right,” he admitted. “You have my vote.”

“I don’t want your vote,” I responded.

“I know,” he laughed, “you want my dues.”

Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff and currently serves as vice-chair of the Community Board. He graduated from Stanford University School of Medicine, did his residency in internal medicine at the University of Chicago, and his cardiology fellowship at UCSF.

Reference Lesser CS, et al. JAMA, 2010, 304(24) 2732-2737.

JANUARY 2016 SAN FRANCISCO MEDICINE

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GUEST EDITORIAL Katherine Herz, MD

Pediatrics: The Past As Prologue?

During the autumn of 2014 I vacationed in Paris, where I encountered daily reminders of the recent centennial of World War I’s grim start. So began a seemingly insatiable interest in history I had previously only glanced over in high school.

This has made for a year of somewhat awkward cocktail chatter—“Have you read anything interesting lately?” can be a dangerous question—but my more intrepid friends wade in and have wondered aloud why this, of all things, has captured my attention. Odd though it may seem, I find many echoes of modern life in this particular past, and many of these themes are reflected in our first issue of this new year.

In some ways, we’ve come far—especially in the field of Pediatrics, which is the focus of this issue. No longer do parents need worry about losing a young child to diptheria, for instance, as detailed in a novel I just read. Thanks to vaccines, this disease is unknown to us except through historical description.

Many of us pediatricians have started to worry about resurgence of such dreadful diseases as a result of low vaccination rates. In a major victory for the health and well being of California’s children, SB 277—championed by pediatrician and State Senator Richard Pan, MD—is now state law. Starting January 2016, we will have implementation of much more strict vaccine requirements for school entry. Many physicians have questions about how the law works and what is our role in enforcement. A frequently asked question article on page 26 addresses some of the most common queries.

World War I nurses told stories of horrifying suppurative wounds that developed into blood poisoning, a glimpse into the dark past without antibiotics. To prevent this history from returning as our present reality will require careful stewardship of these “miracle” medicines. The SFMS has championed important efforts to ensure antibiotics are reserved for appropriate use, as highlighted in an article on the importance of limiting overuse of antibiotics in food animals.

The First World War brought mental health issues to the fore of medicine, with the appearance of “shell shock”, the rise of questions regarding how trauma affects the brain, debate surrounding proper diagnosis and treatment of psychiatric conditions, as well as emphasis on resilience and recovery from profound stress. The brain is vulnerable in ways we are still learning. A major concern for today’s youth is possible brain injury from sports. See our article on concussion diagnosis, treatment, and return to play guidelines for an overview on the latest. We address here as well the all-toomodern affliction of depression in young adults as well as the mounting evidence that childhood stressors play an especially important role in undermining adult health.

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The World War I era also saw the emergence of contraceptive options from the shadows of society and an emphasis on the importance of family planning for the health of all.

One might consider such issues outside the bounds of pediatric practice, but of course our adolescent patients number amongst the most vulnerable when it comes to unintended pregnancy. We include here an article on an upcoming ballot initiative that could result in reduced access to care. Defeating such proposals will be a worthy goal of advocacy efforts in the New Year.

The San Francisco Medical Society has an impressive record when it comes to public health efforts and political action. Several other articles in this issue highlight some of last year’s victories and suggest future efforts. Many of these victories are a stream of important steps toward better health for all. I believe our members should be especially proud of the SFMS’s history of steadfast service, of championing the welfare of society’s marginalized and underserved, and of insisting on care where others might threaten revanche.

The next year promises more acute challenges to America’s social cohesion. Instead of prologue, may the past serve as guide toward progress. As we enter this general election year, may we all muster the energy to show once more what this Society has demonstrated time and again: the power of making your case. I feel fortunate and grateful to stand with all of you in the fight for—as one of our great statesman said at another contentious time—the better angels of our nature. (President Lincoln, first inaugural address, March 4, 1961.)

Happy 2016.

Guest Editor Katherine Herz is a general pediatrician. She graduated with a BA in economics from Princeton, received her MD from and completed residency training at UCSF, and earned a Master of Science in Health Services Research during an Agency for Healthcare Research and Quality Fellowship at Stanford.

She is an SFMS board member and delegate to the CMA.

JANUARY 2016 SAN FRANCISCO MEDICINE

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Pediatrics

YOUTH SUICIDE RISK Let’s Talk About It Eli Merritt, MD The call came in shortly after 2:00 p.m. on a Wednesday. The father who left the voicemail said he wished to speak to

me as soon as possible about his sixteen-year-old daughter who had recently been hospitalized at John Muir Hospital in Concord.

I called him back by the end of the day. He was from Palo Alto and had gotten my name from a Stanford doctor who knew me well from my residency days. Wisely, the father was conducting due diligence about the next best step for his daughter upon discharge from the hospital.

The daughter, whom I shall call Nancy, had been under psychological care in one form or another since age ten. She had been diagnosed with depression and anxiety and took a low dose of Zoloft daily. In the outpatient world, she already had a therapist, a psychiatrist, and an eating disorder specialist. Added to this, she was enrolled twice weekly in a dialectical behavior therapy group.

He asked if she should return to this therapeutic framework, enter a residential treatment program, or begin a partial hospital program (PHP) or intensive outpatient program (IOP). More broadly, the father was desperate to know what all parents in similar painful circumstances want to know: “What do we do?”

A junior in high school, Nancy made excellent grades. Nonetheless, he said, she worried constantly about tests, college applications, and friends. Three days before our call Nancy told her mother that she could not stop thinking about suicide. It had been going on for days. She had visions of cutting her wrists with a box cutter her father kept in the garage for breaking down cardboard for recycling.

After this she said something more concerning.

“I’ve made my peace with death,” Nancy apparently said in a depressed manner, her head low, eyes averted.

An hour later the mother and father took her to the emergency department for evaluation and she was admitted. The morning of our phone call a social worker had told the parents she would probably be released within forty-eight hours.

“Have you talked to her about it and told her how you feel?” I asked the father.

“Talked to her about what?” he responded.

“Her death by suicide and how it would affect you.”

He was taken aback, even a bit put off, by the nature of my question.

“No, I haven’t,” he answered.

During that phone call and one more the following day I helped the father to understand the intricacies of psychiatric care and I honestly shared what my personal decision-making process would look like if it were one of my two sons who was hospitalized for similar risk. I educated him about the genetics of depression and grounded him in the science of “gene-environment interactionism,” the most accurate model for understanding depressive illnesses and suicide risk.

But what mattered most in our conversations was my specific 10

recommendation that he have an open-hearted, loving conversation about suicide with his daughter. I counseled him to talk about it—directly, earnestly, not avoiding the words “death” and “suicide.”

My suggestion was that he take time for contemplation and get in touch with how he would feel if she were gone. He should find a quiet place to sit with a few simple tools—a pen and paper. On them he should write down his thoughts and feelings. He would feel pangs of grief, probably, and that was okay. In one sense that was the point: to express his true feelings about her death, including love, grief, and fear.

I counseled that after free writing he should prune the page of everything extraneous, distilling his flow of sentiments down to a single loving essence. Whenever he felt ready, at a time when his daughter was nearby and he felt soft and tender, even tearful, he should go to her and talk about it.

Talk About It

Between 2005 and 2012 mortality rates declined for all ten leading causes of death in the United States with one exception: suicide. Uniquely, this form of death increased from 10.9 per 100,000 to 12.6 per 100,000. In 2013, the latest year for which national data are available, suicide accounted for 41,149 reported deaths, 11,226 of which were adolescents and young adults aged fifteen to thirtyfour years old. In 2013 suicide was the second leading cause of death in youth.1 Morbidity is another metric by which to measure the impact of suicidal behavior. Each year, according to a 2015 CDC report, approximately 157,000 youth between the ages of ten and twenty-four receive medical care for self-inflicted injuries at emergency departments across the nation.2 Over the past year youth suicide has received increased media attention in the United States. Specifically, the Bay Area has been affected by an adolescent suicide cluster in Palo Alto that generated much local coverage. Nationally, the New York Times ran a feature article in July of this year entitled “Suicide on Campus and the Pressure of Perfection.” In April Frank Bruni in the Times penned “Best, Brightest—and Saddest?” about the Palo Alto teenage deaths, most of which occurred on Caltrain tracks. Most recently, in December of 2015, The Atlantic released “The Silicon Valley Suicides: Why Are So Many Kids with Bright Prospects Killing Themselves in Palo Alto?” by Hanna Rosin.

Partially by coincidence, partially not, my book, Suicide Risk in the Bay Area: A Guide for Families, Physicians, Therapists, and Other Professionals, came out in the midst of this growing local and national attention to a tragic and preventable form of death. My reasons for writing the book were multifaceted, including the loss of my mother by suicide in the 1970’s, the loss of a patient by suicide in 2008, and, most assuredly, the unnerving news of an increasing rate of youth suicide both in the Bay Area and the nation.

Most of all, my interest lies in the area of youth suicide prevention.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

Nothing is more devastating than the loss of a young life not yet lived.

These deaths are fully preventable, and it is my belief that no effort, no energy, and no expense should be spared in studying youth suicide and tackling it from every possible angle in American society, including enhanced medical student, resident, and physician education.

What does the research show? Most prominently, it shows that removal of access to lethal means of suicide—like firearms and medications fatal in overdose—saves lives; substance abuse, comorbid with mood disorders, is deadly; medications, especially lithium and clozapine, can be anti-suicidal; psychotherapy and follow-up care after suicide attempts both independently reduce risk; and physician education in depression recognition and treatment lowers suicide rates.3 In my book I underscore another powerful intervention to lower suicide risk: talk about it. My clinical experience, along with growing evidence, bears out the efficacy of this intervention. In particular, a missing link in suicide prevention is training parents and other family members to talk openly and honestly with someone who is at risk of suicide; that is to speaking lovingly and compassionately with the at-risk person about possible death by suicide. I identify an entity called the “suicide complex” that blocks communication about suicide risk at all levels, leaving at-risk individuals isolated, ashamed, and guilt-ridden. As a consequence, their illnesses go underrecognized and undertreated. Research in family therapy in youth suicide risk validates the role of parent-child communication and compassion in reducing repeat attempts in suicidal adolescents between the ages of twelve and seventeen.4

Physician Interventions

Physicians are typically trained to screen for suicide risk and, in the event of suicidal ideation or contemplation of a method or plan, to refer the patient or to call for an immediate consult, depending upon acuity. These are validated, critical approaches to suicide risk. But there is more a physician can do. Vitally, you, the doctor, can take out time to talk about it with patients, parents, and other family members.

Imagine you are a primary care doctor seeing Nancy in your office and she acknowledges to you that she is having thoughts of suicide. Let’s even imagine she says, “I’ve made my peace with death.”

What do you do? The intervention begins with the calm recognition that what the sixteen-year-old needs is to talk about complex and confusing feelings rather than be hurried to the emergency department, perhaps by police. What would benefit Nancy the most is for her doctor to be comfortable hearing her story. Ask gentle, open-ended questions just as you would to obtain any other history.

What’s going on? When did it start? Has it happened before? What makes it better and worse? What happened recently to bring it on?

Instead of conducting a rapid suicide risk assessment show your caring and curiosity to understand her experience. We all want deeply to be understood by others, and in suicide risk nothing is more essential. Talk and listen primarily to understand and, as part of that meaningful human interaction, determine level of risk.

Once you have connected, expressed concrete hope, and assessed risk consider the best plan whether it be follow-up the next day, medication, referral, or immediate psychiatric consultation.

The second intervention is to speak separately with family members and encourage them to talk about it. Family conversations about suicide are challenging, to say the least. But they can be deeply moving and even life saving. Guide family members to speak WWW.SFMS.ORG

directly about death by suicide with loved ones and to express their true feelings of grief and lifelong pain in the event of such a loss.

Encourage them to listen, empathize, and validate. These three— listening, empathizing, and validating—constitute a matchless triad in talking with someone with suicide risk.

Nancy

Nancy’s father contacted me several weeks after our initial two calls. He reached out to let me know that he and his wife had spoken to his daughter about suicide risk. They sat down with Nancy in her bedroom after the writing exercise. The essence they developed, he said, was a commitment do anything for the sake of her health. She could get C’s and D’s. It didn’t matter. She could change schools. She could take a gap year before college. The father told her he would take a leave of absence from his job to be with her. The parents would get their own therapeutic help. The whole family, perhaps, could take a hiatus from the Bay Area and go on a self-fashioned one-year sabbatical.

Stated in another way, the essence Nancy’s parents communicated was that nothing was more important to them than Nancy, just as she is, and that nothing would cause them more lifelong hurt and sadness than her death by suicide. They would move mountains to keep her alive. They did not just entertain these thoughts privately. They did not assume she already knew them. They did not affirm their love for her offhandedly on a multitasking busy day.

They took out time. They prepared. They made her the center of their attention and felt their love—and the prospect of her death—in their hearts. Then, in a moment of clarity for them all, they connected at the deepest level with their daughter. The father and mother came to tears. So did Nancy.

“It was wonderful for all of us,” he described to me. Nancy’s parents reached her emotionally, not intellectually. I believe that we should all—family members, friends, therapists, teachers, pastors, and especially doctors—aim to develop that ability to the fullest extent possible. Talking about suicide is tough. It’s not a panacea.

However, it is a vital intervention that ignites human connection and hope. It breaks through the “suicide complex” that obstructs identification, treatment, and prevention. Physicians have the opportunity with every patient experiencing suicidal thoughts to talk about it in the office and, whenever possible, to encourage family members to go directly to the heart of the matter and talk about it with loved ones in a deep, emotional, transformative way.

Talk about it. The conversation begins in the doctor’s office.

Eli Merritt, MD, author of Suicide Risk in the Bay Area: A Guide for Families, Physicians, Therapists & Other Professionals and past president of the San Francisco Psychiatric Society, directs a mental health and care navigation practice in San Francisco called Merritt Mental Health. He is a member of the SFMS.

References 1. Centers for Disease Control and Prevention. CDC national health report highlights, 2012. Centers for Disease Control and Prevention. Ten leading causes of injury and death, 2013.

2. CDC Youth Suicide Report, 2015.

3. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005 Oct 26;294(16):2064–74.

4. Guy SD, Matthew BW, et al. Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2010 Feb;49(2):122–131.

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Pediatrics

LGBT YOUTH How You Can Support Lesbian, Gay, Bisexual, and Transgender Patients Geoffrey Hart-Cooper, MD One week after we welcomed the nationwide legalization of same-sex marriage, I was sitting in a provider’s

office while he awkwardly skirted around his version of a sexual history. In spite of his vague questioning, I mentioned I had a male partner. His gaze abruptly jumped from me to his prescription pad, muttering “You know you have to be careful with what you people do.”

This slight remark deteriorated my trust into mutual misunderstanding. I was reluctant to follow his advice and never filled the prescription.

Instead I waited a few more months to be seen by another provider. I was shocked that these encounters still happen in San Francisco, the city known for gay acceptance. For lesbian, gay, bisexual, and transgender (LGBT) patients living in less accepting regions of the country, these experiences are even more frequent. The unfortunate but predictable product of these lapses is that LGBT patients are less likely to access medical care.

Less access to medical care is associated with health disparities, which are especially notable among LGBT adolescents and young adults. One study found that lesbian, gay, and bisexual youth were six times more likely to report a suicide attempt when compared to their heterosexual peers. We see higher rates of depression and anxiety, as well as a greater burden of sexually transmitted infections. In 2013, about 9,000 of the 12,000 HIV infections in youth (ages thirteen to twenty-four years) were among young gay and bisexual men.

These youth face formidable social and political barriers in coming out and living openly as LGBT. While mainstream acceptance of the LGBT community has made coming out easier for some, many youth are forced out of their homes or threatened by physical, emotional or verbal violence when they self-identify.

Once they self-identify, LGBT youth face bullying and workplace discrimination. Despite these challenges, the majority of states do not provide adequate legal protection—LGBT youth are protected by anti-bullying laws in only twenty-one states and nondiscrimination in a mere nineteen. Conversion therapy, the medically-unfounded practice of attempting to change one’s sexual orientation to heterosexual, is banned in only five states.

As a medical community, we have a unique opportunity to promote the health of these vulnerable youth. If you do not work with youth, you can be an advocate in your community. If you work with youth, you can commit to providing culturally competent medical care and impact these youth with every clinical interaction. As clinicians, we must support disclosure of sexual orientation, learn health needs of LGBT patients, and examine 12

how our own beliefs and experiences might distract from the appropriate medical care we intend to provide.

LGBT youth are invisible until they disclose their sexual and gender identity. However, many providers are inadequately trained in how to ask these questions with sensitivity. Consequently, many of these youth remain inaccessible. Recent surveys show between 9-17 percent of youth report a sexual orientation other than heterosexual and 4-13 percent of youth reported having sex with a person of the same gender. To many these numbers seem high, which highlights the importance of creating the opportunity for our patients to share this information with us. Once we know who these youth are, we can help them.

Providing care for LGBT youth requires broad and variable skills because LGBT patients and families are not a heterogeneous group. Every patient has different healthcare needs, resilience levels, risk behaviors, and access to support. For example, your approach to preventive health for a young lesbian woman will be different from a transgender youth, and counseling a questioning teen about coming out to his parents will be different than counseling a gay teen on pre-exposure prophylaxis for HIV. Like any aspect of medicine, we are not expected to know every detail. You are not expected to know the answer to every question these youth have. Instead, you can educate yourself to provide the best immediate care, and then know how to refer your patient for more in-depth assistance. To teach yourself, there are many resources available within the American Academy of Pediatrics, The Fenway Institute, and the Gay and Lesbian Medical Association. Your community also likely has many local resources to help you, such as your local LGBT center, local PFLAG chapter, or an adolescent medicine provider.

The final piece is to examine our own biases. Cultural differences between providers and patients can introduce unconscious bias, which limits effective care. Some of us grew up in places where discrimination towards the LGBT community was accepted. Others may not have encountered open LGBT friends or colleagues. Exploring your own unconscious biases is key to becoming the most effective provider for your patients. You can take the Implicit Association Test as a first step (https:// implicit.harvard.edu/implicit/takeatest.html). Additionally, the University of California San Francisco has done excellent work in this field and has a very informative website to help you understand your own unconscious biases.

Given the complex foundation for health inequity among LGBT youth, each one of us can make a meaningful contribution as an advocate, clinician, or clinician-advocate. We are trusted adults and respected voices for our patients, but also for our

Continued lower right . . .

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Pediatrics

BULLYING Is it Just a Part of Growing Up? Nicholas Carlisle I was the target of bullying throughout all four years of high school. Back then nobody called it bullying.

It was just boys being boys and you were seen as weak if you complained. My experience was not unusual. According to In Plain Sight (2014), a UNICEF report on violence against children, approximately thirty percent of adolescents across the world are the target of bullying. In most of these countries ageold habits of denial are still strong, leading students to under- or zero-report what they are suffering.

Bullying is a significant health issue. Beyond the more obvious physical effects that come physical aggression, all types of bullying can contribute to anxiety, depression, eating disorders, post traumatic symptoms, suicidal and violent ideation. Bullying is particularly devastating when a child is target because of core characteristics such as their skin color, body type, disability, religion or sexual orientation or gender identify, because that can lead to shame based trauma. The impact is compounded when a child is the target of other adverse childhood experiences.

In October the California Medical Association adopted an SFMS-submitted resolution calling for two actions: First is a call for physicians to include peer bullying in any screening for adverse childhood experiences that they provide to California youth. This is timely. Denial is still strong and shame impedes many youth from admitting that they are the target of bullying. The most basic screening question is: “what do you do at recess at your school?” This surfaces the student’s social world and the social isolation that is often the most immediate impact of being taunted, ostracized or the target of cyber shaming.

The second part of the resolution calls for the state of California to pass legislation requiring local education agencies to adopt policies that prohibit student discrimination, harassment, intimidation, and bullying and to train school personnel how to comply with the policy. Schools have a critical role in ending bullying and yet few teachers have actually been trained in how to intervene effectively. The only way this deficit is likely to be

overcome is through mandating that all teachers be trained and in allocating specific line-item funding towards this so that antibullying programming does not compete with academic programming for funding.

The state of California sidestepped addressing this deficit through its passage of Seth’s Law (2012), in which it asked the California Department of Education to track whether school districts had adopted a policy against discrimination, harassment, intimidation, and bullying. It allows California to say that it now has joined the majority of U.S. states in passing anti-bullying legislation. However, by avoiding any real mandate on schools to address bullying, the state avoided making any commitment to funding. The result is a statute that has no teeth and an estimated 1.5 million bullied California students will continue to receive limited or no help from their schools.

The tragedy is that schools can learn quite rapidly how to prevent bullying and solve the incidents that still occur. California teachers trained by No Bully, the non-profit that I started in 2009, are solving over ninety percent of cases of bullying through leveraging student empathy for their peers. Similar to many pressing social issues, there are effective remedies if we come together to address bullying. The CMA resolution, which now goes to the AMA for national adoption, can have a significant part to play in making childhood bully-free.

Nicholas Carlisle is the CEO of No Bully, a San Francisco-based non-profit organization that has created bully-free campuses for over 120,000 students. He graduated from Oxford University, qualified as a barrister with a human rights focus and served as chairman of the non-profit section of Amnesty International in Britain.

He practiced in California as a child and family psychotherapist and researched with Professor Eric Rofes the effects of school bullying, published in 2007 in the Journal of Traumatology. Nicholas gave a TEDx talk on bullying in 2015. To find out more about No Bully or to get involved visit www.nobully.org

Continued from adjascent page . . . families and communities. Reducing disparities among LGBT youth starts with you. In committing yourself to becoming a culturally competent provider with your patients and in your community, you help our entire country take a step towards LGBT equity.

Geoffrey Hart-Cooper is a resident in the Pediatric Leadership for the Underserved (PLUS) track at the University of California

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San Francisco. His passion for LGBT youth health and wellness is focused on provider capacity building and empowerment. He completed an applied epidemiology fellowship at the Centers for Disease Control and Prevention, where his research focused on STD and HIV prevention in gay and bisexual men. He is a member of the San Francisco’s Getting to Zero Campaign focused on achieving the UNAIDS goal of zero HIV infections, AIDS-related deaths, and HIV-related stigma.

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Pediatrics

PARENTAL NOTIFICATIONS Supporting Access to Abortion for Teens Pratima Gupta, MD, MPH As an obstetrician-gynecologist my top priority is ensuring that all patients (irrespective of their age) re-

ceive quality reproductive health care—including birth control, sexually transmitted infection prevention, and pregnancy care. I see many adolescents in my practice and it is not my, or anyone else’s, place to judge their reproductive decisions. Each of these adolescents is unique, and their needs change over time. The same person who wants to prevent pregnancy may come to me later with questions about trying to conceive. They all need support and they all need access to medical services. Whether an adolescent chooses to continue or end the pregnancy, regardless of our feelings are about abortion, we can all agree that ensuring our patients’ safety is of utmost importance to us as health care providers.

In the public and highly politicized dialogue about abortion in America, we tend to talk about women who have abortions on one hand and women who have children on the other. It’s as if all women fall neatly into one of these two categories, when, in actuality, these are often the same woman at different points in her life. These are our sisters, our friends, our daughters, us.

Many women who have abortions will go on to become mothers and sixty percent of women having abortions already have a child. When a woman needs to end her pregnancy it is imperative that she have the means to see a licensed, trained, and quality provider for her procedure.

According to the Guttmacher Institute, each year almost 615,000 U.S. women aged fifteen to nineteen become pregnant.

Despite recent declines in teen pregnancy due to increased contraceptive use, the U.S. teen pregnancy rate continues to be one of the highest in the developed world. Eighty-two percent of teen pregnancies are unplanned and twenty-six percent end in abortion. The reasons teens most frequently give for having an abortion are that they are concerned about how having a baby would change their lives, cannot afford a baby now, and do not feel mature enough to raise a child. As of May 2014, laws in thirty-eight states required that a minor seeking an abortion involve her parents in the decision.

California voters have defeated three parental notification measures from threatening teenagers’ health in recent years.

Unfortunately, signatures are being collected for yet another initiative for the 2016 ballot that would amend the California constitution to require physicians to deliver a written notice to a parent or legal guardian at least forty-eight hours before performing an abortion involving an unemancipated minor. In addition, the initiative would require physicians only to perform the abortions on teens—reversing recent California legislation allowing advance practice clinicians to perform first trimester uterine aspirations.

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We can all agree that it’s best when a pregnant teen involves her parents, and that’s one of the first questions I ask any teenage patient. If she hasn’t, I encourage her to do so. Happily, the vast majority of teens do tell their parents when they are pregnant.

Sadly, some teens live in chaotic, troubled, or even abusive homes. Some live in families where a relative has caused the pregnancy.

These young women will be harmed by parental notification initiatives because they will be forced to choose an unrealistic option of judicial bypass to avoid notifying a parent.

Faced with these options some scared, pregnant teens will feel they have nowhere to turn. Some young women will try to harm themselves to induce a miscarriage. Some will seek an unsafe, illegal abortion. And some teens, feeling desperate, may even try to kill themselves.

Up until now, California is one of the few places where there have actually been proactive advances in reproductive health.

Certified nurse midwives, physicians assistants, and nurse practitioners (collectively known as advance practice clinicians) can now train in and offer first-term surgical abortions; minors can ensure confidentiality while seeking reproductive health services; and a provision requiring insurance coverage of all FDAapproved contraceptive methods with no cost-sharing was recently passed. California is truly a model of safe abortion care and increasing reproductive health-care access for the rest of the country. That being said, not all Californians can even access abortion care easily for there is an undue burden placed on women living in rural and low-income areas. If a parental notification initiative were to become law, one of our most vulnerable populations, pregnant teens, would lose their dignity and their care be compromised.

I recently treated a patient, I’ll call her Peggy, whose older sister fought horribly with their parents when they learned she planned to have an abortion. Fearing the same response to her own pregnancy, Peggy sought advice from a friend who suggested she use household cleaning products to cause a miscarriage.

She came to me a few weeks later after noticing spotting. Peggy was lucky she sought medical advice when she did before her friend’s misguided advice harmed her health. If this parental notification initiative passes I fear many more teens will harm themselves out of fear and desperation.

Immigrant teens are particularly vulnerable to parental

Continued on page 17 . . .

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Pediatrics

ADVERSE EVENTS AND HEALTH The ACE Study Meets Psychological Theory Kory Stotesbery, DO The Adverse Childhood Events (ACEs) Study conducted between 1995 and 1997 by Kaiser Permanente opened the door to one of the most important discussions

in modern medicine: how early can we intervene to affect modifiable risk factors for disease? In evaluating the lives of 17,000 participants, the study compared the subjects’ lifetime health outcomes and the quality of their childhood and family functioning. The yield of the ACEs study was the finding that emotionally challenging experiences in childhood can have a very significant impact on the lifelong health of the person and their family. Substance abuse, mental illness, cardiovascular disease, and STDs among others all had significant relationships to those people with a history ACEs. While the study has been a landmark in the field of preventative medicine and hopefully for the future of healthcare policy, the concept is nothing new for mental health providers. An appropriate mental health evaluation always takes time to discuss a patient’s life history. When particular attention is placed on the linear narrative of a person’s life with an ear for any trauma, the pieces quickly come together. Clients with histories including multiple psychiatric hospitalizations, chronic substance abuse, and extensive self-harm, or even persistent mood or anxiety disorders often have some degree of childhood trauma to talk about. For many providers this is anecdotal knowledge gained throughout their career. There is, however, very clear psychological theory to explain why there exists an association between negative health outcomes and ACEs. The concept at hand is that of Attachment Theory and Object Relations Theory. Information from studying maternal deprivation in Rhesus monkeys and human orphans led John Bowlby to develop his Attachment Theory. Bowlby postulated that a parent’s ability to provide a sense security determined whether a child would develop an emotional attachment to their parent. This security could only be conveyed through repeated experiences where the parent proved being worthy of attachment. Drawing comparisons between animal behavior and human evolution, Bowlby proposed that the dynamic of a secure, high-quality attachment renders a survival advantage to a species. The strong, protective mother lioness is more likely to have her cubs right on her hip where they are most likely to survive.

Day after day, she shows them she can hunt prey. She shows that she will protect them from predators. She shows them she will sacrifice anything so they can live. She loves them. This experience then also sets a precedent those cubs will rely upon for the rest of their lives.

Here, the Object Relations Theory developed by Melanie Klein takes center stage. The child who grows up in a secure, loving attachment spends their childhood absorbing the lessons of their loved ones. These experiences, or objects, serve as 16

a basis on which all future life experiences will be measured.

As the child moves into adulthood, selecting friends and mates, pursuing careers, and any other structure of independent life, they will reference back to childhood to make those decisions.

A securely attached child enters adulthood confident they can become an adult just as their parents did. A sometimes subconscious process, this dynamic of referencing past objects also explains how an ACE can impact a person’s health outcomes.

This dynamic is easy to understand at face value, but it is actually much more complex. It is intuitive that a neglected child may struggle with depression, which may contribute to the use of substances, which can yield a myriad of health problems.

However, it is the more subtle ACEs that can be harder to understand. Why is it that something as common as divorce could result in cardiovascular disease? Why would the death of a favorite relative lead to an unplanned teen pregnancy?

Jean Piaget helps us understand this with his discussion of the egocentrism of childhood. According to Piaget, as we develop as children our life experiences are organized into schemas which we use to understand the world around us. These schemas, much like the objects mentioned above, are broad generalizations we use as reference points the rest of our lives.

This is relevant to ACEs as Piaget proposes that children operate in an egocentric way that assumes they are responsible for everything that happens around them. This explains the child that grows up thinking his parents divorced when he was fouryears-old because he was a bad child. It explains the child who believes that somehow her bad grades are causing her mother to be in and out of the hospital with Sickle Cell Crises. So too then, a child grows up believing his ACEs are his fault. They are his fault because in his mind he is a flawed and imperfect being.

It is the only answer their subconscious mind can understand.

It is the answer because in his mind his life to this point has proven it must be correct.

To synthesize this a bit, we now are proposing that a single ACE can have a tremendous impact on a developing human being.

A parent dealing with substance abuse problems may not be emotionally, mentally or physically present enough to convey that they are a secure person to which their child should attach.

Similarly that parent is the most important object their child will integrate into their schema. A parent struggling with addiction may not offer the best example of how an adult navigates life. In the egocentric model this translates to an internalization that may say: “I am not even good enough that my mother could stand to be around me sober. I am not good enough that the most

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

important person in my life wanted to cure her addiction. If my own mother cannot give me that, who in the world ever will?”

It stands to reason that a person living their life with those thoughts in their mind may experience some poor health outcomes. This “flawed” individual may not see the value in a healthy diet. “What’s the point?” They may not place much value in seeing physicians regularly “They didn’t help my mom, why should I trust them to help me?” So too might such a person embrace self-destructive patterns as they try to live up to the example of worthlessness their childhood gave them. It may even be less complex—maybe an ACE is responsible for your patient struggling to comply with a diabetes regimen.

How powerful might it then be to know your patient’s life history to identify unique ways to help them maintain their health? How valuable could it be for a healthcare provider to step in and start exposing this person to positive objects, restructuring their schema, and helping them unlearn what life has shown them?

In understanding these concepts we are faced with a very clear directive: the health care system must develop a way of providing interventions for patients with ACEs throughout their lives. Youths need a system that can identify and support them as the ACEs occur. Adults need regular access to support to maintain the lessons that will allow them to shed the ghosts of their past. What this translates to is a complex network of medical and mental health providers that can work in concert to prevent the negative impact of ACEs. Collaborative care between primary care and mental healthcare can offer the screening and evaluative component. Psychotherapy will likely need to be a cornerstone of the treatment arm of this system. Community-based interventions can enact a culture shift that will foster open discussion of ACEs, mental health, and an expectation of a prevention-focused healthcare system.

Kory Stotesbery, DO, practices adult and child psychiatry in San Francisco and Walnut Creek. He received his adult psychiatry training from Thomas Jefferson University in Philadelphia and is board certified in Adult Psychiatry. He completed a child and adolescent psychiatry fellowship at Children’s National Medical Center in Washington D.C. and a psychoanalytic fellowship at the Baltimore Washington Center for Psychoanalysis. He is a member of the SFMS.

Parental Notifications Continued from page 15 . . . notification initiatives. In many of the communities I serve some parents don’t want their children to date, let alone have sex. If this initiative passes many of my patients will face a frightening dilemma. And when I go home at night I will worry about their health. What path will my patient choose? What terrible decision might she make? Please, for the safety of your daughters, your friends’ daughters, all of our daughters, vote NO on parental notification initiatives.

Pratima Gupta, MD, MPH, is currently the Reproductive Health Advocacy Fellow with Physicians for Reproductive Health.

Dr. Gupta has worked at Kaiser Permanente since September 2007.

She completed a fellowship in family planning at the University of California, San Francisco, in 2005. During this fellowship, she also received a master’s in public health from University of California, Berkeley, in global health. Dr. Gupta is also the volunteer medical director of St. James Infirmary and a volunteer assistant clinical professor at University of California, San Francisco. Her interests include increasing access to and medical education around family planning options, adolescent health care, global health (especially in South and Central America, India, and Africa), and sexual minority health. She serves on the mayor of San Francisco’s Task Force on Anti-Human Trafficking, the board of directors of the California Family Health Council, the San Francisco Medical Society’s delegation to the California Medical Association, and ACOG District IX’s Legislative Committee.

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References

1. Child and Adolescent Psychiatry, A Comprehensive Textbook. Lewis, Melvin 2. CDC Webpage on Adverse Childhood Events Study. http://www.cdc.gov/violenceprevention/acestudy/index.html

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com WWW.SFMS.ORG

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Pediatrics

CONCUSSIONS How to Handle Them Neelesh Kenia, MD Concussions are in the news and entertainment media almost every day. A few recent examples include:

Concussions, a movie starring Will Smith that highlights the concussion epidemic in the NFL is hitting the theaters this month. Its release will likely bring the discussion about concussions further into the forefront.

In November 2015, U.S. Soccer announced changes in recommendations on heading the ball to try to reduce the incidence of head injuries in younger kids.

On March 17, 2015, USA Today reported that Chris Borland, a twenty-four-year-old San Francisco 49ers linebacker who emerged as one of the league’s promising young talents last season as a rookie is retiring out of concern for the long-term effects of potential concussions and head injuries associated with a long-term football career. Borland first revealed his decision to ESPN’s Outside the Lines. “I just honestly want to do what’s best for my health,” Borland told Outside the Lines. “From what I’ve researched and what I’ve experienced, I don’t think it’s worth the risk.”This was hard for many local 49er fans to hear, but it underscores the dangers of head injuries, especially on the football field. Some people felt that a declaration such as his could spell the beginning of the end of the NFL as we know it; but to date, the NFL is as strong as ever.

As concussions have become more prevalent, various organizations and governments have tried to implement changes to reduce their incidence. California has been on the forefront of these efforts.

In 2013, California enacted a law, AB25, that required any athlete suspected of having a concussion be removed from play and be evaluated by a licensed health care provider before returning. It also required education by the athlete, parents, and coaches.

In 2015, California passed AB2127. This new law limited practice time to no more than two full contact, ninety-minute practices per week in season and prohibits any full contact practices in the off season. It also required that all athletes complete a graduated return-to-play protocol of no less than seven days in duration under the supervision of a licensed health care provider As of 2015, all fifty states and DC have legislation in place regarding concussions. Concussions are very common. The CDC reports that approximately 1.6 to 3.8 million concussions occur annually in sports. Despite all the information available to athletes on concussions, this is likely a gross underestimation as many concussions go undiagnosed and many athletes still continue to play with concussive symptoms. There is rarely a week that goes by that I don’t see a patient with a concussion in either my pediatric or sports medicine clinic. As concussions get more media attention and more prominent athletes speak out about concussion, hopefully this will change.

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What is a Concussion?

A concussion is currently defined as “A complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.” Common aspects of a concussion include: • It may be caused by direct blow to head/neck or body with force transmitted to head, however direct head impact is not necessary • It results in rapid onset of short-lived neurologic impairment that usually resolves spontaneously • It may result in neuropathologic changes, but acute symptoms largely reflect functional disturbance rather than clinical injury. As such, traditional imaging such as CT and MRI are normal.

Currently, it remains a clinical diagnosis based on typical symptoms and exam findings. We no longer grade concussions based on any grading scales.

How Do We Evaluate a Suspected Concussion?

History. Initial evaluation should include a symptom questionnaire that includes a variety of symptom complexes that can be indicative of a concussion. These include: • Physical/Migraine complex • Headache • Nausea/vomiting • Light and sound sensitivity • Balance • Visual disturbances • Emotional • Irritable, sad, more emotional • Cognitive • Amnesia • Confusion/”in a fog” • Poor concentration, memory • Inability to process new information • Somatic • Sleep disturbance • Loss of Consciousness Asking about these symptoms is very important in making the diagnosis of a concussion and following progression of these symptoms and eventual resolution of these symptoms is a key part of the management.

Physical Exam. The initial physical exam should focus on ruling out more serious conditions such as skull fractures, intracranial bleeds and cervical spine injuries. If concerns for any of Continued on the following page . . .

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Concussions Continued from the previous page . . . these are present, then further imaging should be considered.

Initial (especially sideline) evaluation should also focus on cognitive function, using the SCAT 3-Sideline Concussion Assessment Tool (http://bjsm.bmj.com/content/47/5/259.full. pdf). This includes evaluation of orientation, memory, and concentration among other things.

The concussion exam should be a more focused neurological exam, rather than a “complete” neurological exam. This includes balance testing. The Balance Error Scoring System (BESS) can be done easily in the office and can pick up vestibular deficits following a head injury. In my practice, I do baseline BESS testing in all my adolescent well care exams for a baseline. In recent years, more evidence is showing that concussed athletes will often have vestibular as well as oculomotor symptoms. As such, the exam should also include pursuits, saccades, convergence, doll’s eye reflex and observation for nystagmus.

These findings can help pick up athletes who may say there are asymptomatic. They are also important as treatment can be tailored to help with these symptoms.

Neuropyschological Testing. Computerized neuropsychogical testing such as ImPACT can be helpful in adolescent athletes, but is not necessary for the management of concussions. If available, it is most useful if a baseline evaluation has been done, but it is still just a piece of the puzzle and should not be used as the only piece of information for management decisions.

How Do We Treat Concussions?

The initial treatment of concussions remains rest, both cognitive and physical. Historically, we’ve always recommended resting until asymptomatic, however newer research is finding that though initial rest is still important, prolonged rest is usually not helpful and can actually be detrimental. Thus, after one to two days of rest, gradual reintroduction of both cognitive and physical activity can be helpful, as long as it does not exacerbate symptoms.

Returning to school should be gradual with accommodations based on symptoms. This may include modified school days, limited homework, shortened class time, postponing testing, and/or avoiding loud areas for example. Prolonged absence from school, however, can often be counterproductive. Thus after one to two days out of school in most cases kids should return, even if only for short periods of time. Sometimes students need to start with only a few hours a day of school and then progress to full days, but the early light stimulation can aid in recovery.

Light physical activity after the first one to two days of rest can also be helpful. This, however, does not mean immediate return to sports, rather activities such as walking, stretching. After symptoms have subsided and when back to full cognitive activity, athletes can start the return to sports protocol. As per CA law AB2127, return to full contact sports should be no sooner than seven days after diagnosis by a physician. The progressive return should start with rest, then light aerobic activity, moderate aerobic activity, strenuous aerobic activity, non-contact training drills, contact practice and then return to play.

The California Interscholastic Federation (CIF) has excel-

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lent handouts for general concussion information, school accommodations, return to learn, and return to play. These are extremely helpful resources that can be given to patients, parents, teachers, and coaches to aid in keeping everyone on the same page and a student athletes progress (see http://cifstate.org/ sports-medicine/concussions/index).

When Should We Consider Further Treatment or Referrals?

Most young athletes will recover in three to four weeks. If symptoms are not resolving by three to four weeks, other treatments should be considered. Tricyclic antidepressants such as amitriptyline and antiepileptics such as topiramate can be helpful for prolonged headaches. Vestibular-ocular rehabilitation can be helpful to improve balance and oculomotor function.

Melatonin can be helpful for sleep disturbance.

If symptoms persist, the diagnosis is not clear, there are complicated return to learn/play decisions, or there is consideration of retirement from sport following a concussion, specialty referral should be considered. Depending on your practice resources, this can be to sports medicine physicians, pediatric neurologists, neuropsychologists, or multidisciplinary clinics.

How Do We Prevent Concussions?

To date, no changes in the technology on helmets or any other headgear has been shown to decrease rates of concussions. The only things that have been proven to reduce the risk of concussions are rule changes (such as outlawing spear tackling) and reducing exposure. CA2127’s rules limiting contact practice helps to this end. A recent study at the University of Wisconsin showed a greater than fifty percent reduction in concussions during high school practice after implementing a similar law limiting contact practice. USA Hockey recently changed their rules outlawing body checking in kids under thirteen. U.S. Soccer changed its rules outlawing heading in kids under ten in all play and limiting heading to practice only in kids aged eleven to thirteen. This currently only applies to the U.S. Soccer Academies, but these changes will likely be implemented more widely across the country.

What Does the Future Hold?

We know a lot more about concussion now than we did just a few years ago. When I was in fellowship ten years ago the standard of care was to allow kids to return to play right after a concussion as long as their symptoms resolved. This would clearly be considered malpractice now. As much as we know, there is still a lot we don’t know and hopefully as more and more research is being done, we’ll continue to evolve our understanding.

My hope is with more education for patients, parents, teachers, coaches and physicians, the care for the concussed athlete will continue to improve and we can recognize and treat concussed athletes promptly and return these athletes to school, sports, and life in the safest way possible!

Neelesh Kenia, MD, is a general pediatrician and a sports medicine doctor at Kaiser Permanente in San Francisco. He is assistant clinical professor of pediatrics at UCSF, and supervises pediatricians-in-training in the Residents’ Continuity Clinic at Kaiser Permanente.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

Pediatrics

E-CIGARETTES Safer Does Not Mean Safe Katie Kramer, MD, Carly Andler, MD, Meg Davis, MD, and Miheer Sane, MD As pediatricians, a large part of what we do is screening and counseling around potential dangers to our patients. For younger patients, we discuss car seats, child proof-

ing, and always keeping one hand on that newly rolling four-monthold on the changing table. For teenagers, we routinely screen for sexual activity, mental health, and substance abuse. Recently, when one high schooler in my clinic was asked about tobacco use, she proudly stated that she has never tried cigarettes and she never plans to. She knew that they are “dangerous, addictive, and gross.”

However, when asked about electronic cigarettes in particular, she casually mentioned that she and her friends have tried them several times. She viewed them as “fun and safe.” This is a smart and responsible teenager, who clearly had a wonderful knowledge base around traditional cigarettes, was alarmingly naive about e-cigarettes. This story has become far too common and illustrates the success of targeted marketing towards the teenage population. As pediatricians, in our clinics we have seen first-hand the concerning rise in use of e-cigarette products within the youth population as well as the glaring lack of adequate education around these products.

Use of e-cigarettes has grown widely over the last several years, specifically among the teenage population. Last year, nearly 25 percent of California middle school and high school students reported using electronic cigarettes. Even more concerning is that nearly half of those students have never previously used tobacco products (Bostean et al. 2015). Although e-cigarettes are often marketed to adults as tools to “quit smoking,” studies have shown that among teenagers, first time users of e-cigarettes were more likely to use traditional cigarettes and other drugs, suggesting that e-cigarettes may be a gateway substance to more dangerous activity in the future. In fact, using e-cigarettes may be making using marijuana easier for teenagers. Another recent study showed that 27 percent of teenagers who have used both e-cigarettes and marijuana in the past reported using the e-cigarette device to vaporize cannabis, hash oil, and wax THC (Morean et al. 2015).

While the health effects of traditional cigarettes are well known and widely publicized, little is known about the long-term dangers of e-cigarettes. The term “vaping” is used to market them, which leads to a false sense of safety. The substance is not in fact a water vapor but instead an aerosol. When talking to teens, it is useful to compare e-cigarette aerosol to hairspray, this better conveys the potential harm than does the word “vapor”. Currently there is no scientific evidence that supports the safety of electronic cigarettes.

The aerosol actually contains the same harmful chemicals as traditional cigarettes, including nicotine, propylene glycol, volatile organic compounds (benzene, toulene), tobacco specific nitrosamines (TSNAs, carcinogenic compounds), various metals, flavorants, and many more although in smaller quantities. All of these substances can be potentially dangerous when inhaled.

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Nicotine itself is addictive, can cause birth defects, and is known to activate multiple pathways increasing the risk for many diseases such as cancer and heart disease. Additionally, unlike traditional cigarettes, electronic cigarettes are not recognized as a “tobacco product” and are therefore not included in the Tobacco Control Act signed in 2009. This federal statute provides strict regulation on tobacco product ingredients, packaging, advertising, and flavoring.

Since e-cigarettes are unregulated, each product has varying levels of nicotine and other dangerous substances. Adolescents may be getting different doses of exposure each time they “vape”.

One reason use of e-cigarettes among teenagers is growing so rapidly may be because of blatant targeted marketing to youth. E-cigarettes have over 7,000 flavors, including pineapple, cinna-bon, gummy bear, etc. These are clearly not targeted to the adult population.

Under the Tobacco Control Act there are strict laws for traditional cigarettes limiting color and design of advertisements in hopes to discourage young people from using them. E-cigarettes are not included in these laws. Nicotine is lethal if ingested, especially in small children where small amounts are harmful. In 2014, a toddler in New York died after ingestion of liquid nicotine from an e-cigarette, the first reported child death from the substance. The poison control center has reported a rapid uptick in the number of exposures to liquid nicotine, most often in children under six years old. In fact, year to date, the poison control center has received 2,689 e-cigarette devices and liquid nicotine reported exposures nationally. This is nearly double the number from two years ago. One can imagine that a product with bright colors, cartoons, and “cherry soda” flavoring is a magnet for young children. Until there is better child proofing on these products, the number of exposures will continue to rise.

As pediatricians, it is our role to educate teenagers and their families about the prevalence of e-cigarettes, the confusing advertising, the potential for nicotine addiction and the adverse health effects that may come with regular use. Although e-cigarettes may be somewhat safer than regular cigarettes, they are by no means safe and we need to erase that misconception. In California there is currently ongoing legislation working to regulate e-cigarettes similar to traditional tobacco products. Senator Mark Leno of San Francisco has proposed a bill (SB X2-5) that would put the same restrictions on e-cigarettes that are on other tobacco products, although it may be years before it is passed and put into effect. Until there are stricter rules, it is up to families, teachers, pediatricians and other advocates to continue to educate our youth about this potentially dangerous substance. We need to act now so our country does not relive its history with traditional cigarettes and avoid putting our youth at risk for developing addiction and poor health in the future.

The authors are all pediatric residents at UCSF Benioff Children’s Hospital who just completed an advocacy project about educating practitioners and patients on the issue of electronic cigarettes.

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Pediatrics

OBESITY Continuing the Long Campaign Shannon Udovic-Constant, MD In my advocacy work as a pediatrician one of the issues that continues to be considered one of the main priorities for physicians is childhood obesity.

It has been a priority for many years, yet sadly there has not been a lot of improvement in the rates of childhood obesity.

In the November 2015 issue of Health Affairs an article was published showing the results of a microsimulation model of the national implementation of different interventions targeted at obesity prevention over a ten year period to see what would have an impact on decreasing obesity prevalence and also be cost-effective. They looked at seven interventions and found three interventions to meet both criteria. The seven interventions studied were:

1. An excise tax of one cent per ounce on sugar-sweetened beverages, applied nationally and administered at the state level.

2. The elimination of the tax deductibility of advertising costs for television ads seen by children and adolescents for nutritionally poor foods and beverages.

3. Restaurant menu calorie labeling, modeled on the federal menu regulations to be implemented under the Affordable Care Act.

4. Implementation of nutrition standards for federally reimbursable school meals sold through the National School Lunch and School Breakfast Programs, modeled on US Department of Agriculture (USDA) regulations implemented under the Healthy, Hunger-Free Kids Act of 2010.

5. Implementation of nutrition standards for all foods and beverages sold in schools outside of reimbursable school meals, modeled on USDA regulations implemented under the Healthy, Hunger-Free Kids Act.

6. Improved early childhood education policies and practices, including the national dissemination of the Nutrition and Physical Activity Self- Assessment for Child Care (NAP SACC) program.

7. A nationwide fourfold increase in the use of adolescent bariatric surgery.

The three interventions that would pay for themselves by reducing obesity healthcare costs were an excise tax on sugarsweetened beverages, elimination of the tax subsidy for advertising unhealthy food to children, and nutrition standards for food/drink sold in schools. These results show the importance of primary prevention.

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This study reinforced the efforts that SFMS has taken over the past years in trying to influence public policy to reduce the obesity costs to our healthcare system. SFMS/CMA has a long history of advocating for the taxation of sugar-sweetened beverages. CMA now has policy to support this as well due to a resolution brought forward by SFMS. As physicians we want to impact the health of our communities. We can counsel our patients oneon-one about the harm of a diet high in sugar or we can have a larger impact by increasing the cost of sugar drinks and fund larger educational efforts. In the fall of 2012 a ballot initiative in Richmond to tax sugar-sweetened beverages lost due to enormous amounts of money from soda companies.

In 2013, SB 622 by Monning attempted a California statewide tax, but failed; in 2014 a San Francisco tax was defeated, although it did receive more than half of the votes (two-thirds were required). However, a one-cent per ounce tax passed in Berkeley in the same election. It is disappointing at how slowly this important policy has moved forward, but advocates vow to continue their work. California is a leader in the area of eliminating sugar-sweetened beverages from vending machines in schools. In addition California has implemented menu labeling for foods at restaurants. Yet we have not addressed nutritional standards for food sold in schools.

We all know the consequences of obesity including an increase in diabetes and coronary artery disease with its resultant increase in health care costs. This published study in Health Affairs supports the importance of public policy positions to reduce obesity in the coming years. It even shows cost-effectiveness. After reading this article I was invigorated. It justified that SFMS/CMA is on the right path with our push for taxation of sugar-sweetened beverages. In addition it highlighted the other areas that I’d like SFMS/CMA and then AMA to target.

We must continue our advocacy efforts to decrease obesity not only for our patients’ health but also to bend the cost curve for American health care. It must be done. We must carry this message to our legislators and policy makers in California and Washington DC. Are you with me?

Shannon Udovic-Constant, MD, is a San Francisco-based pediatrician with the Permanente Medical Group and is a long-time advocate on health care policy. She is a SFMS past president and is currently a trustee on the CMA Board. She is also on the Political Action Committee for the CMA (CALPAC) and the SFMS PAC.

Reference: Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement Gortmaker, et al. Health Aff November 2015 34:1119321939; doi:10.1377/hlthaff.2015.0631

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

Pediatrics

ONE GIANT STEP FOR HEALTH POLICY? Antibiotic Resistance and Agricultural Process David Wallinga, MD A new technical report from the American Academy of Pediatrics (AAP) says unnecessary use of antibiotics in

food-producing animals is endangering medicine’s ability to treat life-threatening infections in young patients.

More than two million Americans become ill with antimicrobial-resistant infections each year, with more than 23,000 resulting deaths, according to the report.1 For many types of infections, the highest incidence was among children younger than five years old.

“Like humans, farm animals should receive appropriate antibiotics for bacterial infections,” notes Dr. Jerome Paulson, co-author of the AAP report. “However, the indiscriminate use of antibiotics without a prescription or the input of a veterinarian puts the health of children at risk.”

The AAP’s new policy came just one month after the CMA adopted new policy on this topic as well, with a more general medical focus. The CMA policy was developed and submitted by the SFMS. CMA is in good company lending its voice to address the unnecessary use of antibiotics in food animal production. Earlier this fall, Drs. Tom Newman and Michael Martin of UCSF issued a “call to action for health care providers” to advocate for reducing agricultural antibiotic use in the pages of the American Journal of Public Health—noting that 70 percent of all medically important antibiotics are used in food animals, and not for treating ill humans.2 In the pages of Forbes Dr. Bill Frist, the former senate majority leaders, also opined on the need to end routine antibiotic use in livestock production.

In California, a major agricultural state, CMA has an especially important role to play in supporting California’s SB 27, the first state law to prohibit routine use of medically important antibiotics in livestock, other than for disease treatment, surgery, and control of disease outbreaks. Governor Brown has signed the bill into law, but solid implementation of it will be crucial.

One serious hurdle before CMA’s leadership is that its new policy falls short of the standards set by the landmark California law.

The original resolution presented to the House of Delegates was promising. It said: “RESOLVED, that CMA encourages bulk purchasers of foodstuffs, including restaurant chains, school and hospitals, to adopt policies encouraging and, where feasible, requiring procurement of foodstuffs from food animals raised with no medically important antibiotics or, alternatively, from animals only given such antibiotics on a nonroutine basis and for a diagnosed disease;” This statement was consistent with the new AAP technical report, as well as with what major poultry producing companies, like Perdue, Tysons, and Foster Farms have already committed to produce, and what companies like Chipotle, Chik-fil-A, and Subway say they already buy or plan to buy in the near future. The policy as adopted was amended, however, to read as follows: “RESOLVED: That CMA encourages bulk purchasers of foodWWW.SFMS.ORG

stuffs, including restaurant chains, school and hospitals, to adopt policies encouraging procurement of foodstuffs from food animals raised with no medically important antibiotics except when given on a therapeutic basis (emphasis added) by a licensed veterinarian with an established veterinarian-client-patient relationship;” The problems of this version may not be apparent, at first glance.

In the human context, “Given on a therapeutic basis” would seem to be entirely appropriate.

Not so in agriculture. The Food and Drug Administration, which regulates animal antibiotics, has made it very clear that it considers “therapeutic use” of antibiotics to include routine prophylaxis or prevention in addition to uses associated with the treatment of frankly diseased animals, or control of sickness in a flock or herd when some of those animals are already sick. In other words, FDA’s definition of antibiotics for therapy includes giving antibiotics routinely to young animals weaned so early that there premature immune systems cannot be counted on to keep those animals healthy, or to large numbers of animals crowded under less-than-hygienic conditions such that the risk of illness is high.

It’s a critical loophole in FDA’s approach that medically important antibiotics can be added routinely to animal feed for these purposes just so long as a veterinarian has written a prescription or “feed directive” for them. And it’s a loophole called out in the new AAP technical report.

In an ideal world, the CMA’s new policy would be modified to more closely align with California’s landmark law and with the language of the original resolution. The loophole could be easily closed with the addition of a few words to define “therapeutic basis as follows: “ . . . except when given on a therapeutic basis (on a nonroutine basis, or for a diagnosed disease) by a licensed veterinarian with an established veterinarian client-patient relationship.”

The new AAP report also expresses concern that “a voluntary Food and Drug Administration initiative and measures proposed by members of Congress to reduce the drugs’ nontherapeutic use have met with opposition from the agriculture and farming industry.” Medical policy needs to be as strong and specific as possible to address this crucial threat to our medical arsenal and our health.

David Wallinga, MD, is Senior Health Officer at the Natural Resources Defense Council in San Francisco. Since 2000, he’s been a member of the steering committee for Keep Antibiotics Working: the Campaign to End Antibiotic Overuse.

References

1. Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics. Jerome A. Paulson, Theoklis E. Zaoutis, Pediatrics. December 2015, Volume 136, Issue 6.

2. Antibiotics Overuse in Animal Agriculture: A Call to Action for Health Care Providers. Martin MJ1, Thottathil SE1, Newman TB1. Am J Public Health. 2015 Dec;105(12):2409-10. doi: 10.2105/AJPH.2015.302870. Epub 2015 Oct 15.

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SB 277: FREQUENT QUESTIONS On June 30, 2015, Governor Jerry Brown signed the SFMS/CMA-endorsed State Bill (SB) 277 into law. SB 277 eliminates the personal belief exemption from school vaccination requirements, barring parents from skipping their children’s school-required immunizations unless they have a medical exemption from a physician. The SB 277 immunization requirements apply to students first admitted to school, child care, or entering seventh grade starting in 2016.

When do children need to be vaccinated? Starting in 2016, children will need the appropriate vaccinations or will need to have a medical exemption prior to enrolling in public or private elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers.

However, immunizations are not required for children who participate in home-based private schools and independent study programs that do not require classroom-based instruction; nor does it prevent those in individualized education programs from accessing necessary special education or related services. Physicians can find immunization schedules for the appropriate age ranges on the California Department of Public Health (CDPH) website Shots for Schools, http://www.shotsforschool.org/laws/sb277faq/.

Can physicians sign personal belief exemptions (PBEs) after January 1, 2016? No. Schools will no longer accept PBE forms, effective January 1, 2016.

If the sibling of my patient has reported adverse reactions to vaccines, am I required to provide that patient with a medical exemption? Medical exemption determina-

tions are at the discretion of the licensed physician. SB 277 clarified that “family medical history” may be considered in making the determination, but there is no specific provision in the law that mandates a medical exemption based on family medical history.

What must be a part of the written statement for a medical exemption? A written statement providing a medi-

cal exemption for a patient should state that, due to the physical condition or medical circumstances related to the child, immunizations are not considered safe for that child. The statement need to include: • The general nature (e.g., immunodeficiency, prior adverse reactions including allergy, medication that requires delay in vaccination) of the medical condition for which the physician does not recommend immunization.

• The vaccine(s) from which the child is exempted.

• Duration of the medical exemption, and the expiration date if the exemption is temporary.

Physicians should keep in mind that a physician must make reasonable efforts to limit use or disclosure of protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. (45 C.F.R. §164.502(b)(1).)

Does SB 277 affect existing personal belief exemptions? If a personal belief exemption (PBE) has been submitted 24

prior to January 1, 2016, a child will be allowed to remain enrolled until entry in the next grade span. These grade spans are defined as: Birth to Preschool; Kindergarten and grades 1 to 6, including transitional kindergarten; Grades 7 to 12, inclusive.

Can students take PBEs with them when they switch schools? Students who have a PBE on file before January 1, 2016,

may take it with them if they switch schools until they enter a new grade span (see question #5).

Will a personal belief exemption from another state or country be valid if the student enrolls in a California school? No.

If a student has a conditional admission, where the student is allowed to attend school while they catch up on one or more immunization, can the physician decide what the catch-up schedule will be or is there a specifically required catch-up schedule? CDPH does have

a conditional admission immunization schedule for schools that lays out a catch-up schedule when children are conditionally admitted but are not fully immunized prior to admission. Physicians can find information on conditional admission and related immunization schedules at http://www.shotsforschool.org/laws/conditional-admission. However, physicians always have the discretion to adjust the schedule based on the particular patient’s needs and the physician’s professional judgment.

Can a physician be held liable for providing—or not providing—a child with a medical exemption from vaccination requirements? SB 277 does not alter current law

regarding physician liability for medical exemptions from vaccine requirements. No applicable provisions protect a physician from liability for providing or not providing a medical exemption. Physicians must continue to exercise their professional judgment in providing or not providing any medical exemption from the vaccination requirements to ensure that it falls within the standard of care.

What do I do if a parent or guardian terminates the physician-patient relationship as a result of my decision not to provide a medical exemption? When a patient

expressly discharges you, you should follow up with a letter: Confirming that the patient has terminated the relationship; Emphasizing the need for follow-up care; Where possible, referring the patient to other sources of care.

For which diseases is vaccination required? When medical exemption is not provided, SB 277 requires vaccinations for Diphtheria, Haemophilus influenzae type b, Measles*, Mumps*, Pertussis, Poliomyelitis, Rubella*, Tetanus, Hepatitis B, and Varicella*. The law also allows CDPH to include additional vaccinations it deems appropriate; however, the law allows for personal belief exemptions if the vaccinations are added to the list above by CDPH.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

CURES: WHAT TO KNOW AND DO NOW All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish, or order controlled substances, as well as a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate), now have until July 1, 2016, to register to use Controlled Substance Utilization Review and Evaluation System (CURES). SFMS and CMA worked to extend the CURES registration deadline for six months. However, SFMS/CMA recommends that any physicians who need access to CURES not wait for streamlined registration and begin the process for registration as soon as possible.

CURES Registration

What changes to the CURES registration process will occur on June 30? On or after June 30, a new applicant must ini-

tiate an online registration process in order to gain access to CURES. Once complete, the process will provide access to both CURES 1.0 and 2.0.

In order to complete the application form, prescribers and dispensers must produce copies of their state medical or pharmacist license, Drug Enforcement Administration (DEA) registration certificate (prescribers only), and California driver license or other official government photo identification, and have these copies notarized.

The notary must affirm that the person appearing is the person identified in these supporting documents. These notarized documents must then be uploaded in PDF format with the CURES online application. The current registration process of mailing in notarized documents will no longer be supported.

What happens to prescribers who have submitted application documents under the old registration requirements but have not yet been granted access? Pre-

scribers and pharmacists who submitted application documents using the old registration method prior to June 30 will continue to have their registrations processed. If approved, these applicants will be granted access to both CURES 1.0 and 2.0. Based on communications with the Department of Justice, CMA has produced a summary of what CURES users should know about the launch of the new system, including updates on access and registration changes:

What do currently registered prescribers need to know about any changes that take place on June 30 that might impact their ability to access CURES? Cur-

rent CURES users will be able to access the new system, CURES 2.0, with their current user ID and password. Upon initial login to CURES 2.0, users will be required to update their security questions and answers and re-establish a new password. Users must also review their CURES account profile to verify their information is accurate, make necessary updates, and acknowledge CURES Terms and Conditions. Once this has been completed, the user may begin searching patient information in CURES.

Are there limitations to what Internet browsers can be used to access CURES 2.0? Are particular browsers recommended over others? CURES 2.0 users must use WWW.SFMS.ORG

Microsoft Internet Explorer version 11.0 or higher, or current versions of Mozilla Firefox, Google Chrome, or Safari. Earlier versions of Internet Explorer will not be supported. CURES 1.0 will remain accessible to users with unsupported versions of Microsoft Internet Explorer. If you have input on this issue, please contact CMA’s Legal Information Line at (800)786-4262 or fkader@cmanet.org.

Will there be a new webpage for logging into CURES 2.0? Users should go to the current CURES login webpage, where

they will be redirected to the new CURES 2.0 login screen or may choose to use version 1.0.

If a current CURES user is locked out of the system for some reason, how can he/she regain access? There will

be online assistance for users in case they need their login information. Additionally, users may contact the CURES Help Desk at (916)227-3843 or cures@doj.ca.gov (email address will become effective on June 30).

CMA tells California Supreme Court it must protect patient data in CURES CMA has filed an amicus brief with the California Supreme Court asking that it give meaningful privacy protection to patient data contained in the CURES database.

This case, Lewis v. Superior Court (Medical Board), examines the constitutionality of the Medical Board of California’s practice of routinely data-mining the confidential prescription records of California patients. In response to a patient complaint—a complaint that had nothing to do with Dr. Lewis’s prescribing practices—the medical board investigator accessed from CURES the prescribing records of every single one of Dr. Lewis’s patients during a three-year period.

In addition, it obtained three years of confidential prescription records for all medications, including non-controlled substances. The information obtained identified patients by name and included details about medications prescribed to them. The medical board did not obtain any patient authorizations or warrants or issue subpoenas prior to accessing this patient data.

CMA’s amicus brief underscores the importance of confidentiality of medical information as an indispensable component of quality medical care. It explains the importance of recognizing that patients have a privacy interest in their medical information maintained in CURES, despite the government’s arguments that patients have a diminished expectation of privacy in their prescription data.

The brief shows how prescription records can reveal sensitive information about an individual’s medical condition and argues that the medical board’s routine, unfettered, and indiscriminate access to prescription data from CURES circumvents existing laws protecting the confidentiality of medical records.

The brief also addresses the heightened importance of protecting patient privacy rights in the digital age where technology has facilitated the government’s ability to store and mine large amounts of data.

The ACLU of California and the Electronic Frontier Foundation also filed amicus briefs in this case in support of Dr. Lewis. The California Supreme Court will likely schedule oral arguments in this case in 2016.

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COVERED CALIFORNIA

What Physicians Should Know for 2016 In 2015, Covered California, California’s health benefit exchange, enrolled approximately 1.3 million individuals in qualified health plans. With Covered

California estimating it may enroll an additional 300,000 plus during the 2016 open enrollment period (running November 1, 2015, through January 31, 2016), and two new plans in the mix, it is critical that physician practices understand their participation status, which products are being offered, and what changes to expect in 2016. SFMS has compiled the following guidelines to assist physician members with Covered California in 2016.

Changes to the Covered California Plan Offerings for 2016

Anthem Blue Cross and Blue Shield of California, both of which offered an EPO in certain geographic areas previously, will no longer be offering an individual/exchange EPO product in 2016. Instead, both plans will be offering PPO plans.

Blue Shield of California sent notice of the change to its Exclusive EPO provider network on October 15, 2015. The notice states there will be no change to the provider agreements or reimbursement rates. While the product type is changing, the provider network will not change. Patients who select the PPO product will have access to the narrowed individual/exchange network only, rather than the broader provider network. Enrollees who chose to transition the Blue Shield individual/exchange PPO product will receive new ID cards reflecting their new PPO plan.

Anthem Blue Cross will no longer be offering its EPO network in California for individual/exchange enrollees. There will be no change to the provider network or reimbursement rates.

Re-verify Participation Status and Review Provider Network Tied to Various Products

With the change in some product types and the addition of two new health plans offering coverage for 2016, SFMS encourages practices to re-verify their participation status. Practices also should re-verify the participation status of the physicians and other providers (e.g., physicians, facilities, etc.) to whom they may refer patients using the plan’s online provider directory search.

When searching the provider directories, ensure the correct product type has been selected. You will need to check your participation status for each product type offered in your area (e.g., PPO, HMO, EPO, HSP), but you do not need to search every metal tier. For almost all product types, the “Bronze 60” metal tier can be selected as the default. Many plans are utilizing narrowed networks for the exchange, so the search results in a provider directory for a standard commercial PPO plan will likely differ from those of an exchange provider directory.

Practices can contact the plans directly with questions or concerns regarding physician participation status. Physicians are encouraged to re-verify their participation status on the individual exchange plans’ online provider directories.

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2016 Covered California Qualifying Health Plan Naming Convention

[carrier name] + [metal tier name] + [actuarial value (AV)] + [product type (e.g., EPO, HMO, PPO)].

For example, Anthem Bronze 60 EPO is the Anthem EPO plan offered under Covered California’s bronze tier.

Re-verify Patient Eligibility

SFMS is urging all physician practices to verify patients’ eligibility and benefits effective January 1, 2016. The beginning of a new year means exchange/mirror product calendar year deductibles and any visit frequency limitations start over.

Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan). With open enrollment, there may also be changes to patients’ benefit plans, or patients may even be insured through a different plan. This reinforces the importance of verifying eligibility each time the patient is seen. Additionally, verifying eligibility will alert the practice as to whether the patient is delinquent on paying their premium and/or is in the federal three-month grace period.

Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice, as your ability to collect decreases significantly after the patient leaves the office.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

PLAN NAME Anthem Blue Cross

WEBSITE

HOW TO DETERMINE PARTICIPATION STATUS

CONTACT INFORMATION

www.anthem.com CA and click “Find a Doctor”

Under “Select a plan/network,” select the category of “Medical Networks on Exchange” and select the appropriate product type (e.g., HMO, PPO).

For a complete list of Anthem exchange/mirror product names, click here. http://www.cmanet.org/files/assets/news/2014/11/blue-cross2015-exchange-plan-names.pdf

Network Relations (855) 238-0095 or networkrelations@ wellpoint.com

Blue Shield of California

www.blueshieldca. com Hover mouse over “Explore” in the blue ribbon at the top, then click on “Find a Provider.”

Chinese Community Health Plan

www.cchphmo. com/sites/default/ files/pdfs.Provider_ Commercial.pdf

Health Net

www.healthnet.com Click on “Provider Search” toward the bottom.

https://healthy.

Kaiser kaiserpermanente.

Permanente org/health/care/

Click “Explore” in the blue ribbon towards the top of the page. Under Provider Services “Step 1” click the green “Select a Plan” button. Under “medical plan and (800) 258-3091 network,” click the drop down arrow and select 2016 Individual and Families PPO Plans (including Covered California)” then select the “Sub Plan” based on metal tier. Practices can select the “Bronze 60” product as the default. Then click the green “set plan” button. Next, under “search by doctor name” enter the physician’s last, then first name, select a specialty, and enter the practice zip code under “located near.” Then click the blue “find now” button.

Network is primarily using Chinese Community Healthcare Association Via the Chinese Com(IPA). munity Healthcare Association (415) 2160088 x2806 Click “Provider Search-Find a doctor.” After selecting a plan year and a location type, under “Filter by Plan/Network” Under “Covered California” select one of the following: • EPO – PureCareOne Small Business (this is the SHOP product) • HSP – PureCare Individual & Family Plans • PPO – Small Business (this is the SHOP product) In the search box under the green ribbon towards the top right of the page, enter the physician’s name and select “in Doctors.”

Provider Services (800) 641-7761 or provider_services@ healthnet.com

All providers are included in all product types.

consumer/locateour-services/ doctors-andlocations Select your region and click “Go”.

Metal Level Platinum Gold Silver

Bronze

WWW.SFMS.ORG

Lowest Cost

2nd

3rd

4th

5th

Chinese Community Health Plan - Copay HMO

Kaiser - Copay HMO

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HeathNet - Coin PPO

**Based on 2nd lowest rate

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Kaiser - HSA HMO

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JANUARY 2016 SAN FRANCISCO MEDICINE

27

MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD

Two programs at Dignity Health Saint Francis Memorial Hospital—advanced CT scanning and Hyperbaric Oxygen Therapy— provide world-class medical services to patients in the San Francisco Bay Area. The expansion of a third—the Phoebe Cowles Center for Comprehensive Pain Treatment— will allow us to integrate diverse aspects of successful pain management in a first of its kind center for the region.

Despite the broad benefits of CT scanning to diagnose common acute illness and both diagnose and monitor chronic diseases our caregivers are always looking to minimize radiation exposure. With patient safety in mind, Saint Francis has acquired of one of the most advanced CT scanners in the Bay Area.

The 160-slice volumetric scanner allows rapid scanning of large body areas and performs advanced imaging, including detailed evaluation of the vascular system and coronary arteries, while allowing our caregivers to implement state-of-the art radiation reduction methods that dramatically decrease exposure. Scans of large body areas now use 4050 percent less radiation compared to other standard scanners. Saint Francis also offers the only hospital-based Hyperbaric Oxygen Therapy program in the Bay Area. Staffed by hyperbaric medicine physician specialists and a hyperbaric certified nurse, the program provides advanced treatment for decompression sickness, gas gangrene, crush injuries, and chronic non-healing wounds. Benefits include the promotion of angiogenesis and fibroplasia/collagen synthesis in wound healing; a 10- to 15-fold increase in oxygen dissolved in the plasma; aid in vasoconstriction and edema reduction without tissue hypoxia; and stimulation of neovascularization in ischemic tissues. We offer state-of-the-art Sechrist monoplace hyperbaric chambers for patient privacy. Additionally, with a $2 million commitment from patient and benefactor Phoebe Cowles, Saint Francis recently broke ground on the new Phoebe Cowles Center for Comprehensive Pain Treatment.

28

St. Mary’s

Robert Weber, MD

Two new technologies at Dignity Health St. Mary’s Medical Center are allowing us to improve treatment and dramatically impact patient quality of life—The Cardio Medication Event Monitoring HF System (CardioMEMS) and High Density Radiation (HDR) treatment.

Both significantly reduce patient discomfort while improving accuracy in the care we offer.

Patients with congestive heart failure have traditionally been required to readmit to health care facilities frequently for monitoring. CardioMEMS uses a miniaturized wireless monitoring sensor to transmit pulmonary artery pressure data directly to health care providers, eliminating this timeconsuming and often dispiriting process, and allowing for personalized and proactive heart failure management to reduce the likelihood of hospitalization.

Designed to last the lifetime of the patient, the sensor is implanted during a minimally invasive procedure. At home, patients use a portable electronic unit to take daily sensor readings—a simple, quick process involving no pain or sensation. The readings are transmitted to a secure website where the patient’s clinicians can monitor the flow of fluid and adjust medication as necessary. High Density Radiation (HDR) is a hyper-accurate treatment for cancer cells, similar to the common external radiation beam, which ensures the maximum radiation dose is given to cancerous tissues while minimizing exposure to the surrounding healthy tissue. The most significant benefit of HDR is that treatment can be completed in five days, versus six weeks with the common external beam. During HDR treatment the surgeon implants a small balloon catheter at the site of the tumor after removal. Several days later, the patient returns and the HDR machine is affixed to the catheter, where it can deliver radiation precisely to the area where the tumor was located. For many patients and cancer types, HDR offers a much quicker and more effective method of radiation treatment.

SPMF

Bill Black, MD, PhD

Pediatrics at Sutter Pacific Medical Foundation is growing. Our goal is to make health care convenient and accessible for patients.

To that end, we have added several boardcertified pediatricians to our multi-specialty group, making pediatric care available in several neighborhoods: Presidio Heights, Potrero Hill, and the Mission and Lakeshore districts.

Stonestown Pediatric Medicine Office, the most recent expansion, is a well-established practice headed for more than forty years by Mitchell Sollod, MD, and more recently his daughter Janet Sollod, MD. The practice, at 595 Buckingham Way in the Lakeshore District near Stonestown Galleria, became part of Sutter Pacific Medical Foundation in October. Dr. Mitchell Sollod is board certified in pediatric allergy and immunology as well as pediatrics. The practice also includes Nanci Tucker, MD, and another pediatrician, Robert Saken, MD. These pediatricians are in the same building as two of our internal medicine physicians, Charles Delatore, MD, and Robert Napoles, MD. In the Mission neighborhood, pediatric care is offered by Jonathan Lee, MD, and Judith Jones, MD, at 1580 Valencia St. Both are family medicine doctors offering the full scope of care to pediatrics and adults.

In Potrero Hill, at 350 Rhode Island Ave., our pediatricians include David Tejeda, MD, and Agnes Alikpala, MD. Two family medicine physicians in that office, Benjamin Ordaz, MD, and Robert Vazquez, MD, see children. Nurse practitioner Marina McIver treats teens for acute care and adolescent gynecological issues. Inessa Gofman, MD, has joined pediatricians Deborah Wyatt, MD, and Stacy Drasen, MD, at our care center in Presidio Heights at 3838 California St. Dr. Gofman had been providing care in our San Rafael care center before relocating to San Francisco.

Health care close to home is a huge help to busy families. At each of our offices, the families we serve are telling us how much they enjoy the convenience of having their pediatrician in the neighborhood.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

CPMC

Edward Eisler, MD

The following members of the medical staff have been re-elected and will continue their service as Medical Staff Officers: Dr. Edward Eisler, Chief of Staff, Dr. Robert Margolin, Vice Chief of Staff, Dr. Nobl Barazangi, Treasurer and Dr. Oded Herbsman, Secretary.

Members-at-Large for the 2016-2017 term will be Dr. Aravind Mani, Dr. George Horng and Dr. Andrea Yeung.

Congratulations to Dr. Judith Doyle, who has been appointed as Chair of the Department of Pathology for a five-year term, effective January 1, 2016. Many thanks to Dr. John Moretto for his past services as Department Chair.

A gathering of about 200 people applauded as the final thirty-foot steel beam was bolted into place during a topping out ceremony at the replacement hospital on the St. Luke’s campus. Sutter Health leaders, physicians, employees, city officials and construction workers celebrated the milestone at a topping out party held in November.

Employees had the opportunity to sign the beam before it was lifted up and dropped into place. Once the hand-signed beam was bolted into place, it marked the completion of the steel frame structure. Construction will continue on the new replacement hospital. The replacement hospital is scheduled to open in 2019.

CPMC is preparing to enroll patients into a study of a new drug for people with the most common type of advanced (stage IV) non-small cell lung cancer patients. CPMC will be one of the few sites in Northern California offering the trial to patients with this potentially lethal illness. The drug shows significant promise in saving the lives of patients with late-stage disease who have few options for therapy,” said Kramer. While the first U.S. Food and Drug Administration approval of nivolumab for advanced NSCLC was for people who have received prior chemotherapy, there have been few recent therapies offering similar treatment benefits in patients unable to tolerate the regimens.

WWW.SFMS.ORG

Gun Safety Keeping Children Safe

Welcome New Members!

AMERICAN ACADEMY OF PEDIATRICS

ACTIVE REGULAR MEMBERS

Research shows guns in homes are a serious risk to families: • A gun kept in the home is 43 times more likely to kill someone known to the family than to kill someone in self-defense.

• A gun kept in the home triples the risk of homicide.

• The risk of suicide is five times more likely if a gun is kept in the home.

Kiyomi Elyse Ameriks, DO Psychiatry Winston Chung, MD Psychiatry Patrick Jarret Kenney, DO Internal Medicine Jennifer Fung Yee Ng, MD Internal Medicine Joanna Joy Oda, MD Ophthalmology Saqib S Rizvi, MD Occupational Medicine Ruby Shandilya, MD Psychiatry Corey Chan Young, MD Obstetrics and Gynecology

Advice to parents: • The best way to keep your children safe from injury or death from guns is to NEVER have a gun in the home.

• Do not purchase a gun, especially a handgun.

• Remove all guns present in the home.

• Talk to your children about the dangers of guns, and tell them to stay away from guns.

• Find out if there are guns in the homes where your children play. If so, talk to the adults in the house about the dangers of guns to their families.

For those who know of the dangers of guns but still keep a gun in the home.

• Always keep the gun unloaded and locked up.

• Lock and store the bullets in a separate place.

• Make sure to hide the keys to the locked boxes.

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29

UPCOMING EVENTS 1/13 Webinar: Physician Engagement vs. Patient Education | 12:15 p.m. – 1:15 p.m., CMA webinar | Meaning-

ful Use Stage 2 includes several measures that will require health care organizations to engage with their patients electronically.

Engaging patients about patient portals, direct messaging, clinical summaries and more is just the first step. This webinar will cover not only what to educate patients on, but how to educate them while striking a balance between an informed patient and a patient burdened by information overload. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit.ly/1UKVHDW.

1/28: Society of Physician Entrepreneurs Quarterly Meeting | 6:30 p.m. – 9:00 p.m., San Mateo County Medi-

cal Association Office, 777 Mariners Island Blvd., San Mateo | Mobile connectivity is providing new data and new insights!

The Society of Physician Entrepreneurs (SoPE) San Francisco Bay Area Chapter invites you to their quarterly meeting featuring a panel of experts discussing how digital health is changing health care. The event is open to all physicians, and dinner will be provided. For more information, visit http://bit.ly/1IFgBNz.

3/3-4 Conference: Developmental Disabilities – Update for Health Professionals | UCSF Laurel Heights

Conference Center | This annual interdisciplinary conference chaired by long-time SFMS member Lucy Crain, MD, offers a unique, practical update for primary care and subspecialty health care professionals who care for children, youth, and adults with developmental disabilities and complex health care needs. The 2016 conference will cover topics across the lifespan on a broad range of developmental disabilities including autism spectrum disorders, Down syndrome, and co-morbidities of dementia and aging with developmental disabilities. Visit http://www.ucsfcme.com/2016/MOC16001/info.html for course outline and registration information. Attendees are eligible to receive up to 15.00 AMA PRA Category 1 CreditsTM.

3/10-11: Stepping Up to Leadership Conference |

Sheraton San Diego Hotel & Marina, 1380 Harbor Island Dr., San Diego | The Stepping Up to Leadership program offered by the Institute for Medical Quality and the PACE Program at UC San Diego trains medical staff leaders in issues of communication, problem-solving, and improving outcomes for patients and staff.

Stepping Up to Leadership offers unique interactive learning opportunities, excellent faculty, and course work on effective staff leadership, improved communication skills, using quality measures effectively, legal considerations, and managing disruptive or impaired colleagues. It helps physicians learn best practices and explore creative approaches for resolving common problems encountered as a medical staff officer or department or committee chair. The course gives both experienced and new physician leaders the opportunity to gain practical knowledge and skills, and to learn the tools and techniques that are essential to effectively lead a medical staff. Learn more at http://www.imq.org/ Hospitals/SteppingUptoLeadershipConference.aspx.

30

CANNABIS LEGALIZATION AND KIDS A Report from the Lieutenant Governor’s Commission

Anticipating the possibility of cannabis legalization in California in 2016, Lt. Governor Gavin Newsom convened a commission on the topic in 2015 to provide research and recommendations on how best approach this change. The SFMS’s Steve Heilig served on the commission, along with addiction medicine, legal, and other experts. The “Youth Education and Prevention Working Group” developed an extensive policy paper, with a summary below. For the full report and more, see the “Publications” section of www.safeandsmartpolicy.org

Executive Summary

Californians are reasonably concerned about the impact upon youth of adding marijuana to the drugs that are already legally available for adults, such as tobacco and alcohol. It is well known that marijuana use among youth has been a reality for decades.

While any marijuana use by youth is a central concern, the data show that the vast majority of youth who try marijuana only experiment with it in a limited or occasional manner. However, a minority of teens is at risk of experimenting at a very young age or engaging in more regular or more excessive use. This same demographic is also at greater risk for problems with alcohol and other substance abuse, disciplinary and other problems in school and are more likely to get caught up in the criminal justice system.

Available data support the following conclusions:

1. Regular or heavy marijuana use at an early age can be associated with reduced educational attainment and educational development.

2. Criminal sanctions for marijuana use and possession have multiple negative impacts on youth, especially for youth of color, with regard to educational attainment and employment opportunities, while also reducing law enforcement resources for addressing more serious crime.

3. Significant improvements are needed to make drug safety education more scientifically accurate and realistic.

4. Well-designed and implemented regulations have the potential to better protect youth.

5. Sufficient funding available from marijuana tax revenue could close many gaps in current community-based support for at-risk youth.

6. School-based approaches such as Student Assistance Programs (SAPs) are effective in improving school retention, academic achievement and reduction of drug use.

7. Universal availability of school-based services combined with an evidence-based approach to drug education could become a reality under a Tax and Regulate public health approach to marijuana policy.

8. A framework of regulations governing the marijuana industry designed to protect youth will also be needed to limit youth access to marijuana and foster an environment for prevention and education programs to be maximally effective.

SAN FRANCISCO MEDICINE JANUARY 2016 WWW.SFMS.ORG

The CMA/SFMS’s exclusive new Workers’ Compensation program can help your practice save money!

Savings

CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.

Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.

Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.

Call Mercer today at 800-842-3761 for a premium indication.

CMACounty.Insurance.service@mercer.com or www.CountyCMAMemberInsurance.com.

See how CMA/SFMS’s Workers’ Compensation team can help you save!

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*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • Copyright 2015 Mercer LLC. All rights reserved. • 71364 (1/16) 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

San Francisco Medical Society 1003A O’Reilly Ave. San Francisco, CA 94129 Return Service Requested

Advancing cancer research Advancing and care. cancer research and care.

Our physicians and researchers are making new discoveries to help in thephysicians fight against With nationally recognized cancer experts Our andcancer. researchers are making new discoveries to help and of clinical trials, we nationally provide access to promising new in thedozens fight against cancer.

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Comprehensive cancer access care at to Sutter Health new CPMC. and dozens of clinical trials, we provide promising It’s another way we plus you. cancer therapies.

Comprehensive cancer care at Sutter Health CPMC. It’s another way we plus you.

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