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April 2012 | Volume I /No. 3

A Publication of the San Mateo County Medical Association

SAN MATEO COUNTY PHYSICIAN | page 1


SMCMA services

Join a SMCMA Committee One of the ways that you can participate with SMCMA is by joining one or more of its committees. By volunteering, you’ll get a chance to make decisions that directly impact the health care industry as well as the opportunity to network and share ideas with your San Mateo County physician colleagues. Below you will find a list of the 2012-2013 SMCMA Committees: BIOETHICS - George Prozan, M.D. - Chair Reviews/updates/recommends policies regarding bioethical practices. COMMUNITY HEALTH – James Missett, M.D. – Chair Investigates/studies community health concerns. EDITORIAL - Russ Granich, M.D. – Chair Reviews and assists in determining content for San Mateo County Physician. FEE AND INSURANCE MEDIATION – Dirk Baumann, M.D. – Chair Reviews patient complaints on physician fees and recommends remedies. FINANCE – Amita Saxena, M.D. - Chair Reviews/advises on Association fiscal matters. LEGISLATIVE – Alberto Bolanos, M.D. - Chair Monitors/discusses/determines Association’s stance on state/federal legislation MEDICAL - LEGAL LIAISON – William Tatomer, M.D. – Chair Physicians and lawyers meet to promote better relations between the medical and legal professions. MEDICAL REVIEW & ADVISORY – Robert Benner, M.D. - Chair Consults the Association’s group professional liability carrier provides advice on malpractice claims. PROFESSIONAL RELATIONS – Barry Oberstein, M.D. – Chair Investigates/attempts to resolve standards of medical care/ethics issues. SAN MATEO HEP B FREE - Dirk Baumann, M.D. - Chair Promotes hepatitis B and liver cancer prevention and treatment educational outreach/advocacy efforts. If you have an interest in one or more of the above SMCMA Committees, in preparation for the 2012-2013 Committee appointment process, please contact SMCMA at smcma@smcma.org or (650) 312-1663. We

About the Cover: The photo was taken by Poppy Richie. Poppy is the wife SMCMA’s Controller, Jim Richie. It was taken at Filoli.

San Mateo County Physician April 2012 Vol. I / No. 3

Table of Contents President’s Message.........................5 Executive Report................................7 Having Conversations with Terminally Ill Patients..............................................8 Asperger’s Syndrome..........................................9 Hot Topics in Infectious Disease.............................................10 Making Changes to a Medical Record..............................................12 2012 Heart Failure Update.............................................13 Expert Fees for Treating Doctors.............................................14 Membership Update and Classified Ads..................................18

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The Health Benefits Exchange By gregory Lukaszewicz, MD

Vision and Mission Statement of the California Health Benefits Exchange “The vision of the California Health Benefit Exchange is to improve the health of all Californians by assuring their access to affordable, high quality care. The mission of the California Health Benefit Exchange is to increase the number of insured Californians, improve health care quality, lower costs, and reduce health disparities through an innovative, competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value.� On March 26, the United States Supreme Court began hearing arguments regarding the constitutionality of the individual mandate and other components required by the Patient Protection and Affordable Care Act (ACA). The case was brought by the state of Florida, twenty five additional states and the National Federation of Independent Businesses. Though many consider that without the individual mandate the entire ACA may not survive, certain provisions of the ACA have already come into law while others may also come to fruition regardless of what the Supreme Court rules this summer. One such component of the ACA is the American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges which would be

established to create a marketplace for small businesses (up to 100 employees) and individuals (who fall within 133-400% of the federal poverty level) to purchase subsidized, standardized health insurance at a competitive price beginning in January, 2014. California was in fact the first state to begin setting up a Health Benefit Exchange in 2010 after the passing of the ACA. In order to develop the Health Benefits Exchange (the Exchange), California has established a five member independent board appointed by the governor and the state legislature. The board includes Diana Dooley, Secretary of the California Health and Human Services Agency and one physician, Robert Ross, MD, CEO of the California Endowment, as well as three others with extensive political and public policy experience. It is unfortunate however, that a practicing physician is not a member of this Board. The Exchange Board has so far developed mission and vision statements, hired executive and senior staff, begun a search for a subcontractor to design and provide information technology services, begun receiving stakeholder input regarding marketing, enrollment and eligibility, and initiated a search for a research firm to help establish criteria for the Qualified Health Plans which would participate in the health exchange.

The next step for the Exchange Board is to establish the Essential Health Benefits that all plans must include under the ACA and which would encompass ten broad categories including emergency services, ambulatory patient services, preventative and wellness services, prescription drugs, maternity and newborn services, mental health and substance abuse services, hospitalization, rehabilitation services, and pediatric services. In 2010, the Secretary of the Federal Health and Human Services requested general recommendations from the Institute of Medicine (IOM) regarding the Health Exchange Benefits. In 2011 the IOM released its report and its main recommendation which was to set a premium target to guide which benefits should be included to meet that target. However, the report was largely ignored and it was decided that the board will not set specific benefits but will rather select an established, existing health plan as the benchmark which will be used to set the benefits package to be offered by all the Qualified Health Plans participating in the Health Benefits Exchange. Four levels of plans (Bronze, Silver, Gold, Platinum) will be offered based upon the amount of cost sharing and coverage which each level provides. In addition, a catastrophic only plan will be available to individuals under continued on page 17

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EXECUTIVE REPORT

Physician Artists Display Their Work By sue u. malone

Quite some time ago, a few physicians commented on how nice it would be if the Association organized a display of visual artwork created by members for display in SMCMA offices. This idea began the series of art exhibits offered over the following years. The first exhibit was held in 1993. We were most fortunate that Ronnie Goldfield, who then ran Gallery 30 in Burlingame, and was the wife of psychiatrist, Michael Goldfield, offered to be our Curator. SMCMA was then located on the top floor of 400 El Camino Real, a suite with wide stretches of hallways, which was a perfect venue to display the art. The 83 pieces of visual art that year, including sculpture and jewelry, were displayed for one month. Opening night festivities, in addition to art, wine, and food, included songs sung by the Cardiac Arrhythmias, a seven physician musical group, all of whom are now retired (Sam Marty, Jack Posnick, Owen Doyle, Harvey Small, Ralph Behling, Ray Kauffman, and Steve Rovno). It was a great event. The enthusiasm of the artists to “do it again” resulted in the second and third exhibits held in 1995 and 1998. Once again, we persuaded Ronnie Goldfield to serve as Curator, who organized the display of the 87 and 70 works of art in 1995 and 1998, respectively.

Some seven years passed before the call got louder to once again feature the visual artistic work of our members. By this time, SMCMA had been forced out of its premier space at 400 S. El Camino Real as our lease came due at the height of the “dot com” era when rents skyrocketed. This time we couldn’t use SMCMA’s office for the display since the large amount of wall space was gone. However, I knew the manager of the Hillsdale Shopping Mall, Larry Ivich, through my Rotary affiliation, and called upon him to offer us vacant space in the Mall. It turned out that a jewelry stores, Biddle, Bailey & Banks had recently vacated space on the second floor, which was a great venue to feature the works of art. By this time, having worn out Mrs. Goldfield, we turned for help to ArtShare, and for the technical side we found moonlighters from Stanford’s Cantor Museum. Holding the exhibit at the Mall for the first time offered the opportunity to let the public view the art pieces during the week-long exhibit after opening night. Now we jump to 2012 and the murmuring started again. How nice, it was suggested, to have a physician event for members and their families to display physician art. So here we are in the throes of planning for our fifth

exhibit. Ironically, since our 2005 exhibit, though the old Biddle, Bailey & Banks space has had a number of other tenants, including a Gallery, the space is vacant and the Hillsdale Mall has once again allowed us use this site. Again, we turned to ArtShare and the Cantor Preparators. The exhibit will be kicked off with an Opening Reception on the evening of May 3rd, followed by a week-long display for the public and, of course, for any physicians who could not make the opening night reception. We hope you will attend, enjoy the exhibit and would welcome your feedback. By the way, if there are still any of you out there that have not yet identified yourself as someone who dabbles in the realm of visual artwork, please let me know - we can always make room for you. Actually, this year the Hillsdale Mall is going to place posters around the center announcing the public exhibit. For further event details, please view the Art Exhibit announcement on page 16 of this issue.

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Having Conversations with Terminally Ill Patients By Russ Granich, md Most of us will have to interact and communicate with a patient and/or family when the patient is terminally ill. These discussions can be very difficult and uncomfortable for a variety of reasons. As physicians, we are also considered healers and our task is to fight illness, it is a life long battle and death is often perceived as, or at least feels like, failure. Our culture tends to ignore death. We go about our lives as if we will never die; few people make any plans; people rarely talk about death and we perceive it as a terrible event. Telling someone they are going to die goes against our training, culture and emotions. As a seasoned Palliative Medicine consultant I am engaged in these conversations daily, yet it was very difficult at first. Like every thing else, practice makes it easier. However, what really helped was the realization that I was helping people and providing them a much needed service. I receive many more expressions of appreciation now than I ever did as a primary care doctor and hospitalist. As Maya Angelou said: “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” The California Health Care Survey reported last February that 80 percent of elderly patients want to have these discussions. However, less than 50 percent talk with their physician or families. A study published in JAMA (2008:300(14)1665-73) showed that having palliative care (PC) discussions can help families cope better with death. A article in NEJM (2010;363:733-42) demonstrated that patients with NSC lung cancer, who received PC, survived longer and coped better than patients without PC, despite similar cancer treatments. We don’t really know why, but I suspect the reduction in stress, better understanding of their disease and the

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feeling that their doctors really understand their condition probably all contribute to these improved outcomes. It is important to initiate these discussions, but how does one overcome the reluctance? There are innumerable classes, books and articles, but there is no one formula or magic wand to help. Rather, having a better understanding and being more motivated is critical. Then add your own style and personality. Here are a few vital points I’ve learned over the years: • Always remember you are there to inform and provide options: Don’t have a specific outcome in mind; A meaningful conversation that results in full code is a success. • It is not about you: Keep your feelings and beliefs to yourself. When you respond, your feelings are not important, acknowledging their feelings are important. This is the difference between sympathy and empathy. For example: “I know how difficult...” is sympathy. “This must be very difficult...” is empathy, it validates their feelings and lets them know you recognize and understand they are having difficulty. You will never know how they feel but you can know they are having these feelings. Putting “I” in the conversation can actually interfere with good communication. • Talk in a normal, yet empathetic, conversational tone. It makes the conversation seem natural and provides comfort. • Be curious, not furious: This is the mantra of one of my colleagues. Basically, it means if a family expresses anger, mistrust, etc., try to figure out why they feel that way rather than react defensively. Sometimes just acknowledging their anger is all you need. For example, a delayed diagnosis often leads to anger which will always surface until you deal with

it. If it is your responsibility, consider apologizing. If not, try something like: “I wasn’t involved in your husband’s evaluation, but it must have been a very frustrating experience. However, I am here for you now and want what’s best for your husband, so let’s move forward from here.” • Don’t be afraid to say the “D-word”, namely death. Euphemisms are often misunderstood. • Be honest and give your opinion. As physicians, we often talk of risk to benefit ratio or odds of success, rather than directly advising a patient of the likely outcome. If a friend decided to cross the Pacific Ocean in a row boat, you would tell them they will die, even though there is a very small chance they won’t. When we talk about an ICU patient with multisystem failure who was extremely sick at baseline, we know they will die soon, yet we often say things like “we don’t know for sure”, etc. Like your risk-taking friend, they need the benefit of your perspective, without too much watering down. • Ask more, tell less. Physicians tend to ramble when having uncomfortable conversations. You need to give information, but the majority of your time should be listening, not talking. Find out what people think and what they feel. Don’t assume and don’t stereotype because you most likely will be wrong. Be courageous and have that conversation! You may be uncomfortable but it is your responsibility to your patient to do your best and to do whatever it takes. As the Chinese statesman, Zhu Rongji said: “Even if a minefield or the abyss should lie before me, I will march straight ahead without looking back.” Dr. Granich is the Chief of Palliative Care Medicine at Kaiser Permanente in South San Francisco


Asperger’s Syndrome By Dale Jacknow, md Asperger’s Syndrome (AS) was first described in 1944 by Austrian physician Hans Asperger. He described a group of children who demonstrated deficits in nonverbal communication skills, such as understanding of facial expression and body language, and in the ability to take another person’s perspective. Asperger’s work remained relatively unknown until 1981, when Dr. Lorna Wing wrote a landmark publication introducing the term “Asperger’s Syndrome”. In 1994, Asperger’s Syndrome was added to the DSM-IV as part of the Autistic Spectrum Disorders. With the upcoming publication of the DSM-V, the specific diagnosis of Asperger’s Syndrome is slated to be subsumed under the single diagnosis of Autism. This is a highly controversial issue as many in the field (myself included) maintain that there are clear qualitative differences between AS and autism proper. Regardless of specific diagnostic labels, recognition and treatment of all autistic disorders is of increasing importance as current statistics indicate that one out of 70-100 children is diagnosed with an autistic disorder. As with all children who have autistic disorders, children with AS present with core deficits in their social communication and reasoning skills. However, by definition, children with AS are of at least normal intelligence (and many children with AS are of gifted intelligence), and they present with less severe impairments. Although not part of the formal diagnostic criteria, children with AS also typically struggle with problems in fine and gross motor functioning and they commonly experience high levels of anxiety. In addition to their deficits in social communication and reasoning, children with AS also present with encompassing areas of interest, such as fixation on license plates or ceiling fans. Children tend to be highly

preoccupied with their interests and often will veer off topic in order to bring the conversation around to these subjects. For example, I recently worked with a six-year-old boy who is consumed with memorizing the call numbers assigned to various radio stations. In the midst of talking about his upcoming ski trip to Tahoe, he asked, “Did you know that the in the U.S., radio stations west of the Mississippi have call letters starting with K but all the ones east of the Mississippi start with W?” Although children with AS can amass a wealth of information about the subject matter, their knowledge often is rote and factual in nature, rather than reflecting a deeper understanding of the topic. Current treatment is targeted to address the functional impairments. For example, because children with AS struggle to acquire social knowledge implicitly through observation and imitation, they benefit from explicit teaching to help them break the social “code”. This teaching typically takes place in social skills groups, which are small group therapy settings led by a professional, such as a language pathologist. During social skills work, children are taught social conventions in an explicit manner, such as how to read body language, and how to recognize and respond to teasing. They then have opportunities within the therapy setting to practice their skills. Although current therapy addresses functional impairment, fascinating research is underway to elucidate and treat the underlying differences in brain chemistry. Recent research indicates that insufficient activation of GABA, an inhibitor of neurochemical transmission, leads to the some of the core deficits seen in children with AS. Researchers at Vanderbilt University found that when given GABA agonists (such as Arbaclofen), children with AS

demonstrated improvement in their ability to recognize social cues. Research into oxytocin, known as the “bonding hormone” also shows promise. In a 2011 NIMH study, children with High Functioning Autism and Asperger’s Syndrome who were given oxytocin via nasal spray demonstrated increased attention to social information and an enhanced ability to recognize emotions. Impairment in immune function also has been implicated as an underlying cause of autistic disorders. Based on this theory, Dr. Eric Hollander (Albert Einstein School of Medicine) is embarking on a line of research in which he will be treating adults with autistic disorders with whipworm eggs (Trichuris Suis Ova, a pig parasite), which cannot infect or reproduce in humans. However, once swallowed, the eggs hatch and the worms, which live for about two weeks, spur the production of T2 helper cytokines. The resulting increased production of T2 cells is thought to rebalance the immune system and already has been shown to be effective in pilot studies of inflammatory disorders, such as Crohn’s disease. As should always be the case when treating children with developmental impairments, intervention should involve finding ways to harness their strengths. In children with AS, their areas of preoccupying interest often can evolve from the acquisition of mass amounts of rote information to a deep well of knowledge that can be applied to a career. As a result, children with AS can develop into adults who are leaders in the fields of their areas of interest. Dr. Jacknow is board certified in pediatrics and behavorial/developmental pediatrics and practices in San Mateo.

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Hot Topics in Infectious Disease By Kim erlich, MD “It is time to close the book on infectious diseases, and declare the war against pestilence won.” --William Stewart MD, Surgeon General of the United States, in a speech given in 1967. “The global HIV/AIDS epidemic is an unprecedented crisis…… We have 30 million orphans already.” --Kofi Annan, Secretary General of the United Nations 1997-2006, and 2001 Nobel Peace Prize Recipient “Increasing global populations and environmental selection pressure is a recipe for disaster; in time we will see spread of a highly transmissible agent that carries a high mortality, and both our scientists and our governments will be powerless to stop it.” --Anonymous 2011 Since the infamous words in 1967 attributed to Surgeon General William Stewart, we have seen a steady increase in the numbers and magnitude of infectious agents resulting in global disease, suffering and death. Although we have made great progress in the management, prevention, and control of numerous infectious diseases, the books (and the cyber-files) are larger and more voluminous than ever, with no evidence that we will ever be able to “close the book” on infectious diseases. Numerous Infectious Diseases made headlines in 2011, and at least one Hollywood movie, Contagion, made millions in the box office and gained public attention. Let’s look at a few of the “Hot Topics in Infectious Diseases” that will likely remain in the headline news in 2012. Multi-drug Resistant Bacteria Increased antibiotic selection pressure, routine use of antibiotics in animal feed,

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and the ability of bacteria to share genetic information between species has resulted in a steady increase in bacterial clones with acquired resistance to commonly prescribed antibiotics. While this phenomenon was historically a problem confined to intensive care units and large tertiary care centers, multi-drug resistant bacteria are now common in local communities and throughout the world. The most well known example of this phenomenon is the global spread of methicillin-resistant Staphylococcus aureus (further discussed in this article) , but other examples include vancomycin resistant enterococcus, extended spectrum beta-lactamase (ESBL) producing gram negative rods, carbapenemaseproducing Enterobacteraciae (CRE), and multi-drug resistant gonorrhea. Many of the newer antibiotic resistant gram negative rods are resistant to nearly all antibiotics, with the exception of some older compounds such as polymixin and colistin. Strategies to combat the spread of these organisms throughout the population include preventing routine addition of antibiotics to animal feed, and limiting injudicious use of antibiotics in humans through strategies such as the Centers for Disease Control’s “Get Smart About Antibiotics” campaign. Clinicians need to be aware of the bacterial resistant patterns in their community, and to resist the impulse to over-prescribe antibiotics when they are not needed. Methicillin Resistant Staphylococcus aureus Of all the multidrug resistant organisms, methicillin resistant Staphylococcus aureus (MRSA) has been the most widespread and problematic. Initially seen only in intensive care units and tertiary care centers, clones of MRSA have now

spread throughout the community and are found in all corners of the world. The most prevalent community acquired MRSA strain, USA-300, carries genes for resistance to all beta-lactam antibiotics and produces the PantonValentine leukocidin enzyme with increased virulence and propensity for skin and soft tissue infections. In our community, up to 45 percent of all S. aureus isolates are MRSA. Fortunately, several antibiotics, such as vancomycin, linezolid, daptomycin, TMP/SMX and clindamycin, are still effective in treating most of these infections, but there is growing concern that resistance to other antibiotics may be only a matter of time. The global spread of community acquired strains of MRSA has changed the paradigm for clinicians who deal with patients who are suspected or confirmed to have S. aureus infection. In many instances, patients who present with suspected S. aureus infection, such as boils or abscesses, should be placed initially on antibiotic regimens which provide coverage against MRSA while awaiting definitive culture results. Since S. aureus is the most common pathogen resulting in post-op infections, and since antibiotics are frequently used pre-operatively to prevent post-op wound infections in certain procedures, important unanswered questions include: 1) when should routine pre-operative antibiotic prophylaxis provide coverage against MRSA? And, 2) how important is pre-op screening for MRSA and pre-op decolonization? These questions require rigorous studies to help guide clinicians. Clostridium difficile Clostridium difficile, an anaerobic spore-forming bacillus, causes pseudomembranous colitis, manifesting as diarrhea that often recurs and can progress to toxic megacolon, sepsis, and death. The numbers of cases of C.


difficile have increased dramatically over the past several years, and newer, more virulent strains have appeared. The number of patients hospitalized due to C. difficile more than doubled between 2000 and 2009, and this trend is expected to continue. The most worrisome endemic strain, the NAP-1 strain, results in increased toxin production, more prolonged and severe clinical illness, and increased mortality. Risk factors for C. difficile include exposure and acquisition of the organism, antimicrobial exposure (which disrupts the protective normal intestinal flora), advanced age, underlying illness, immunosuppression, use of tube feeds, and possibly gastric acid suppression (specifically proton pump inhibitors). Although effective treatments are available for C. difficile, including PO vancomycin, metronidazole, fidaxomicin, and vancomycin enemas, recurrence rates are high. Clinicians should be aware of the increased incidence and virulence of Clostridium difficile in the community, and should restrict the use of proton pump inhibitors and antibiotics to only those patients who need them. Shortage of Effective Antibiotics There have been very few new antibiotics developed and brought to market, and virtually no new classes of antibiotics developed over the past recent years. The reasons for this include issues such as 1) biochemical challenges in developing new compounds, 2) strict FDA regulations on efficacy and safety for any new product brought to market, 3) the expense involved by a pharmaceutical company in research and development necessary for product licensure, 4) the low profit margin in antibiotics which are used for short durations as compared to drugs prescribed for more chronic conditions which are administered for longer periods of time, and 5) observations by the pharmaceutical industry that when new broad spectrum antibiotics are developed, Infectious Diseases physicians implore their colleagues to not use these more expensive, broad

spectrum drugs with regularity for cost issues and for fear of developing bacterial resistance. This strategy of reserving newer agents is sensible from a cost containment and antibiotic stewardship perspective, but this creates a dis-incentive for pharmaceutical companies to commit resources to the development of new antibiotics. The “perfect storm” of increasing bacterial resistance to current antibiotics and the lack of new products on the horizon may be setting the stage for an upcoming crisis. The Infectious Diseases Society of America has called for a “10 by ‘20” initiative - which hopes to build a sustainable R&D infrastructure and produce 10 new antibiotics by the year 2020. All clinicians should act as stewards to our current supply of antibiotics, and should avoid the impulse to overprescribe antibiotics when they are not needed. Foodborne Illnesses With dramatic changes in agriculture practices over the past 30 years we have seen increasing outbreaks of food borne pathogens being transmitted to large numbers of people over widespread geographic distances. Recent examples include outbreaks due to salmonella, E. coli 0157:H7, campylobacter, and listeria. Implicated foods have included strawberries, sprouts, peppers, cantaloupes, raw milk, prison “moonshine”, ground beef, deli meats, cheeses, romaine lettuce, spinach, peanut butter, etc. The most notable outbreak in 2011 was a Listeria monocytogenes outbreak, which occurred due to consumption of contaminated cantaloupes distributed from a single farm in Colorado. This was the largest Listeria outbreak ever reported, with at least 146 cases occurring in 28 states and resulting in 30 deaths with one miscarriage. With increasingly large industrial sized farms, and more widespread food distribution throughout the world, we can expect to see even greater numbers of people affected from food transmitted pathogens over wide geographic areas. Clinicians need to be aware of food borne outbreaks as they are

occurring, and test patients who present with suspicious symptoms – even if they are not geographically linked to the source of the outbreak. Influenza: Human, Swine, Avian Influenza strains continue to circulate throughout the globe in a predictable fashion, but each year brings unpredictable and unexpected events. The relatively mild influenza season we have seen so far this year is in stark contrast to events in recent years. This year, a new H3N2 variant containing human, swine and avian genetic material has been recognized in the US, but thus far it has not spread widely. Influenza virus continues to drift and shift in the antigenic components, and the viruses ability to mix genetic material with animal influenza strains assures that we will see continued new influenza strains developing in mixing hosts, such as pigs, over time. In 2009, the novel H1N1 “swine flu” strain was recognized early by epidemiologists and scientists, but despite a prompt and organized response we were unable to contain it or prevent global pandemic spread. We were fortunate in 2009 that this H1N1 strain carried a relatively low mortality rate. By comparison, the H5N1 “bird flu” strain which was recognized in the early 2000s still circulates in low numbers and has resulted in 677 human cases with 340 deaths (50 percent mortality) since 2003. Fortunately, person-to-person transmission of this highly lethal strain is uncommon. However, scientists fear that it may be just a matter of time before we see a re-assorted influenza virus strain that spreads as readily as the 2009 H1N1 strain and has the virulence and mortality of the H5N1 strain. Influenza A has become resistant to older medications such as amantadine and rimantadine, but remains susceptible to oseltamivir and zanamivir. A recent Cochran metaanalysis has called into question the actual efficacy of oseltamivir, but the CDC still recommends this agent for individuals who are at risk for severe illness. Vaccination plays the most continued on page 17

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Making Changes to a Medical Record: Corrections Vs. Alterations By mary-lynn ryan Appropriate, consistent and accurate medical record documentation promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among different members of the healthcare team. The medical record is also the best evidence of care provided, should that care ever be questioned in medical liability litigation. Physicians can preserve the medical record’s effectiveness as a patient care tool and as a defense tool by resisting the temptation to inappropriately change the record. Whereas appropriately executed corrections are a relatively benign aspect of documentation, medical record alterations can cast doubt on the physician’s credibility and make an otherwise defensible case one that has to be settled. Defining Alterations: When a physician receives notice of a lawsuit and goes back to the medical record to “clarify” certain points for the purpose of aiding the defense of the claim, it is an alteration. Medical record alterations are considered a deliberate misrepresentation of facts. When an alteration is discovered during medical liability litigation it seriously impacts the ability to defend the claim. Additionally, many medical liability policies exclude coverage for claims in which the medical record was altered, which means the physician may end up paying for a judgment and defense costs out of pocket. Defining Corrections: When a physician changes a patient’s medical

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record during the normal course of treatment, before the issue of a claim or lawsuit arises, it is a correction. Corrections are acceptable, provided the changes are made appropriately. Tips for Appropriate Medical Record Correction •

Develop a medical records correction policy that incorporates the following recommendations: o Mark the original (erroneous) entry through with a single line. Do not obscure the entry with correction fluid or ink. Do not attempt to write the intended number or word on top of the erroneous one(s) (i.e., “write over”). o Sign, date and time the new (correct) entry. Never “back date” an entry to the medical record. o If appropriate, direct the reader’s attention from the original, erroneous entry to the corrected entry, especially if it is not readily apparent that the subsequent entry is a correction. o After a corrected entry has been added, never physically remove or erase an erroneous entry from the patient’s chart. The earlier (erroneous) entry may have been relied upon by other members of the healthcare team. To physically remove it would therefore falsely represent the integrity of the record.

Develop policies and procedures that address making an addendum (or late entry). Write a note as an addendum if there is a need to write an entry in the record that is not contemporaneous with the finding or treatment being described. Place this addendum entry chronologically in the record, based on when it is being entered in the record. At the beginning of the addendum, explain to what the addendum refers. Sign, date and time the addendum entry.

Electronic Health Records Users of electronic health record (EHR) systems should not be able to make changes to a computerized record indiscriminately or anonymously. When medical practices select an EHR system, they should ensure that once information is entered it cannot be removed. Although many software vendors claim that information cannot be removed or altered, practices should perform due diligence to confirm vendors’ security claims. In a properly functioning EHR system, any changes to the medical record must be made as addendums and dated appropriately so that later they cannot be construed as alterations. Conclusion Physicians should never place themselves in the position of having to defend a medical record alteration. There is almost always a price to pay, and the price can be high. Mary-Lynn Ryan works with NORCAL’s risk management department Copyright 2011 NORCAL Mutual Insurance Company. All rights reserved.


2012 Heart Failure Update By george cohen, MD

2012 Heart Failure Update: All the Things You Wanted to Know, But Were Afraid to Ask The hieroglyphs of the Ebers papyrus probably represent the first clinical description of the syndrome of heart failure. They describe a heart that is “over flooded and weakened. The body parts are all together weak.” The best early description of heart failure, however, dates to the Roman writer Aulus Cornelius Celsus (25 B.C.E. – 50 C.E.) (De Medicina). “…….when moderate and without any choking, it is called dyspnoea; when more severe, asthma; but when in addition the patient can hardly draw his breath except with the neck outstretched, orthopnea. Of these, the first can last a long time, while the two following are as a rule acute. …..blood letting is the remedy unless anything prohibits….as the body becomes depleted by the measures the patient begins to draw his breath more easily. Moreover, even in bed the head is to be kept raised.” We’ve come a long since ancient Egypt and Rome. Since the early 1990s, our patients have benefited from clinical studies, which have tested and validated the concept of neurohormonal suppression. In 2012, the use of ACE inhibitors, angiotensin receptor blockers, aldosterone receptor blockers and beta blockers has become accepted therapy and is now class 1A recommendation, the gold standard for the modern treatment of congestive heart failure (CHF). The use of these medications has been supported by multiple randomized control trials dating from

the Studies of Left Ventricular Dysfunction (SOLVD) trial in 1992. All of these trials have focused on patients with “a bad ventricle,” individuals with so called systolic dysfunction. These patients are more likely to be male, have coronary disease and be younger. It is these individuals for whom development of device therapy such as biventricular pacing and defibrillator implantation has been added to our armamentarium of heart failure therapy. It is this group of patients for whom cardiac transplantation and/or the artificial heart are applicable when all else fails. In fact, our medical heart failure therapy has been so successful that the heart transplant waiting list has shrunk significantly over the past decade. That is the good news. The bad news is that with the aging of our population, we are now seeing an increasing number of patients with heart failure who have “a good ventricle.” They have a thick, stiff left ventricle with normal systolic function, but abnormal filling in diastole, so called “diastolic dysfunction.” The common acronym used is HFpEF, Heart Failure with preserved Ejection Fraction. These patients are more likely to be older, female and hypertensive, with multiple co-morbidities. Because they are able to generate sudden increase in left ventricular filling pressure that is transmitted back to their lungs, their presentation is usually that of acute pulmonary edema, giving rise to multiple emergency department visits and subsequent hospital admissions.

This latter group of patients can be more difficult to manage than patients with systolic dysfunction. The same interventions of neurohormonal suppression are employed, but randomized trial data have not shown similar survival benefits. Critical to the management of these patients is effective control of blood pressure with appropriate antihypertensives and careful control of volume status with loop diuretics, such as furosemide. In the case of a heart that is stiff, small increases in volume produce large increases in filling pressure, resulting in acute pulmonary edema. Conversely, even mild overdiuresis can lead to under filling of the ventricle and prerenal azotemia. Home based monitoring of blood pressure and weight with specialty focused nursing intervention can help balance volume status and prevent multiple hospital admissions. Finally, the end must come to all things. Whether CHF is systolic or diastolic in origin, some patients with truly end-stage heart failure become refractory to medical management. If it is decided that neither transplantation nor device therapy is appropriate, redefinition of the goals of therapy is important. Patient and family education regarding the role of palliative and hospice care services is of the utmost importance. With the ultimate goal of patient comfort, the array of options for end-of-life care and defibrillator inactivation should be discussed with the patient and the family. In this we show that we truly “care” for our heart failure patients. Dr. Cohen is board certified in cardiology and practices in Burlingame.

SAN MATEO COUNTY PHYSICIAN | page 13


Expert Fees for Treating Doctors By Robert w. olson, Jr., JD Doctors are frequently asked to consult with an attorney or testify on a patient’s diagnosis, treatment and prognosis. Unfortunately, once the doctor becomes involved, attorneys on both sides will try to obtain this consulting and testimony without offering to pay proper expert fees. This article (in 2 parts) will help doctors receive their deserved expert fees before providing that consultation or testimony. Part 1 concerns requests from the patient’s attorney and setting expert fees. Part 2, concerning depositions and court ordered testimony, will continue in the next publication. Informal Attorney Request: The patient’s attorney usually will ask the doctor to discuss the patient’s case voluntarily. There is no need to be intimidated by the attorney’s request; although it is a necessary part of the pre-lawsuit process the doctor is not required to cooperate at this point. If the doctor wants to cooperate, two things should be in place before the doctor speaks with the attorney: a patient release authorization and an expert retainer agreement. Before providing any information about a patient to the attorney, the doctor legally must have prior written patient authorization to do so. When the patient’s attorney requests information, the doctor should inform that attorney that a signed release authorization is required before providing information about any patient, and the doctor cannot even acknowledge that someone is the doctor’s patient without that authorization. The authorization should include language that the doctor is authorized to “provide records, diagnoses, prognoses, and all other aspects of patient’s past and

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prospective care, with [law firm] and its principals, employees, agents and representatives,” but should not include the patient’s name. Expert Retainer Agreement: The doctor has no obligation whatsoever to discuss the patient’s case with the attorney unless and until the attorney agrees to pay your “Reasonable and Customary Fee” (see below) to discuss the case. The attorney is unlikely to suggest this, so the doctor must make it clear that all time and expenses discussing the case must be paid by the attorney. The doctor can even require payment in full before talking to the attorney. Here is a sample letter setting forth this agreement: “You have told me that a patient of mine has a pending lawsuit and as part of your investigation you want to discuss my treatment of that patient. Before I discuss any matter regarding any of my patients, I require the following: a signed patient release authorization (see attached); and your agreement to pay my $____ per hour fee for my time commitment (includes telephone, email, meetings, preparation, travel time, and meetings or testimony cancelled on less than 2 full business days notice) plus any out of pocket expenses. Payment in full for my preparation and estimated meeting time must be tendered at the start of the meeting, with any cancellation, excess time and expenses to be paid within 5 days after I provide you an itemized statement. Once I receive your written agreement to these terms and the signed release authorization, we can schedule our first meeting.” Patient’s Attorney Responsible for Fees: At this stage, the patient’s attorney is primarily responsible for

all the doctor’s time and expenses. If the doctor has the attorney’s written agreement on the rate and terms of payment, preferably under an Expert Retainer Agreement as suggested above, that agreement will control how and when these payments are made. Expert witness fees and expenses are generally not recoverable as part of the lawsuit, and although it is the patient’s attorney who contracts for the doctor’s services, the patient is legally required to repay the attorney for those fees, regardless of the outcome of the lawsuit. Reasonable and Customary Fees: “A reasonable and customary fee” is not set by law. The doctor’s average hourly fee charged to patients certainly would qualify, but expert witness fees can go much higher depending on the doctor’s expert experience and fees charged by other medical experts in the community. When setting an expert fee, the doctor should consider the doctor’s average hourly fee to patients, what expert fees the doctor has charged and received in other lawsuits, the number of times the doctor has charged and received that fee (particularly in the last 2 years), and the fees charged by experts for similar services in the community. Local expert fees range from $250 to $850 per hour, depending on specialization, type of work and experience. If the doctor is subpoenaed to testify (discussed in Part 2), and the attorney who subpoenas the doctor does not accept the doctor’s fee demand, the doctor and attorney should meet informally to set an agreed fee. Failing resolution, the attorney can ask the court to determine the proper


fee, considering the same factors described above. The loser at the hearing will be fined for misuse of the court system, so it is important to keep expert fee demands within reason. Subpoenas: A request to discuss the patient’s care becomes mandatory when in the form of a subpoena. This subpoena is a court order requiring the doctor to personally appear and testify about the patient, which can only issued after a lawsuit is filed. The doctor is entitled to be paid for that testimony, with the amount determined by the type of testimony provided. Anyone with personal knowledge of facts that don’t require special knowledge to understand or report can be required to testify on those facts. If the doctor hasn’t already been formally designated as an “expert witness” by either attorney and is only asked questions that could be answered by a non-expert, the doctor is only entitled to mileage at standard IRS rates and a $35 witness fee. Such questions would include “what day did the patient first visit you,” and “what is this illegible word in the chart.” It is unlikely the attorney will limit the questioning this way, but will probably treat the doctor as an “expert witness,” defined (in part) by California law as a “treating health care practitioner who is to be asked to express opinion testimony, including opinion or factual testimony regarding the past or present diagnosis or prognosis made by the practitioner or the reasons for the particular treatment decision made ....” Confirming Expert Status: If the doctor hasn’t already been designated as an expert witness, the doctor may not know in advance whether expert testimony will be required. In either case, the doctor should inform the attorney issuing the subpoena, immediately by certified letter return receipt

requested with a copy to the patient’s attorney, as follows: “You have subpoenaed me to testify about my care of [patient]. Under California Code of Civil Procedure Section 2034 and following, if you request any opinion testimony, such as factual or opinion testimony regarding my past or present diagnoses or prognoses or the reasons for my particular treatment decisions, my entire appearance will be considered expert testimony. You are hereby notified that if you request expert testimony, your office will be responsible for my billings, as described below. I charge $___ per hour for expert testimony, with a 4 hour minimum per day. If I am required to be available for the full day, an 8 hour minimum will apply. My fee is payable at least 2 business days in advance. If not paid in advance, no expert testimony will be given. If my testimony is canceled on less than 2 full business days notice, you will be billed for the full time scheduled, because you will have forced me to forego business I could have scheduled and conducted in that time.” Amount/Payment of Fees: Unfortunately, the attorney issuing the subpoena can’t be charged for the doctor’s preparation, travel or expenses unless that attorney has already designated you as an expert or agreed to pay those extra charges. Also, there is no authority under California law to demand payment for cancelled testimony or until the day of testimony (although you should ask anyway). Otherwise, this letter tracks California law that requires the attorney who subpoenas an expert witness must “pay the expert’s reasonable and customary hourly or daily fee for any time spent ....”

of payment, preferably under an Expert Retainer Agreement described in Part 1, that agreement will control how and when payment is made. If payment isn’t made in full before testimony starts, the doctor shouldn’t provide any “expert” testimony whatsoever. If testimony runs longer than anticipated, the attorney issuing the subpoena must pay the balance due either to the patient’s attorney or directly to the doctor) within 5 days of receipt of the doctor’s itemized statement. Day of Testimony: The doctor should bring 4 copies of the certified letter and proof of receipt, and upon starting testimony ask the attorney issuing the subpoena “on the record, do you accept the terms of this certified letter I sent you?” If the attorney denies receipt of the letter or doesn’t accept its terms, the doctor should ask “do you promise to pay my expert witness fee of $___ per hour within 5 days of receiving my itemized statement for my testimony?” If the answer is no and the fee the doctor demands is reasonable (see Part 1), the doctor may legally refuse to answer any questions that ask for expert opinion. This article has been reprinted with permission from the Santa Barbara County Modical Society. © 2009-2012 by Robert W. Olson, Jr., JD. Robert W. Olson, Jr., is the former Chairman of the Santa Barbara County Medical Legal Committee and an attorney specializing in medical and dental practice transitions.

The attorney who designates the doctor as an expert, usually the patient’s attorney, is primarily responsible for the doctor’s expert fees for testifying. If the doctor has an agreement on the rate and terms

SAN MATEO COUNTY PHYSICIAN | page 15


2012 Physician Art Exhibit: May 3 -10 San Mateo County Medical Association PRESENTS AN

EXHIBITION OF THE WORK OF PHYSICIAN ARTISTS You and your spouse/guest are invited to a reception to view the works of physicians who have demonstrated mastery beyond the practice of medicine.

Opening Reception - Thursday, May 3, 2012 6:00 - 8:00 pm Hillsdale Mall

Daniel Switky, MD is a past SMCMA art exhibitor. Here is his piece, Blue Quilt (acrylic on canvas) that was completed in November 2006.

Physician Exhibitors: Peter Benson, Bella Berzin, Robert Gamburd, David Jacoby, Edward Koo, Alan Lash, Frank Lee, Steven Machtinger, Stephen Marks, John Quilici, Lorne Rosenfield, Donald Stone, Dan Switky, Bernhard Votteri, Christopher White. TO RSVP, email gcromosini@smcma.org or call (650) 312-1663

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President’s Message

Hot Topics

continued from page 5

continued from page 11

age 30 who cannot otherwise afford one of the four levels. The Health Benefits Exchange would then provide a marketplace where plans are standardized and offered so that individuals can make comparisons based upon price, quality and provider networks and access. It is hoped that this will then lead to greater competition in the marketplace and, the thought is, bring the price of health care down.

important role in limiting disease and death from influenza, and all clinicians should be vaccinated against influenza each year and should be strong advocates of influenza vaccination for all members of our society.

Regardless of what the Supreme Court decides this summer regarding the individual mandate, the Health Benefits Exchange may survive as it is looked at as a way of increasing access to care for patients and potentially helping to limit the ever increasing costs of medical care. A number of potential problems are possible. From a patient standpoint, there is a risk that plans may try to cherry pick healthy patients outside the Health Benefits Exchange, leaving only sicker patients to participate within the Exchange and thus leading to a lack of affordability for those patients remaining within the Exchange. In addition, patients may “churn” between the private insurance market and Health Benefits Exchange as their income varies leading to both poor continuity and quality of care from a patient standpoint and loss of timely reimbursement for physicians as patients switch in and out of plans with which the individual physician participates. Whether the Exchange achieves its goals of increased access and cost savings will depend upon the final details and regulations which have yet to be established. Because of the Exchange Board’s independence and its prohibitions around the appointment or employment of a practicing physician, organized medicine faces significant challenges to having an impact on the Board’s decisions.

HIV and AIDS Steady progress continues to be made in the fight against HIV/AIDS. However, there are still over 30 million people who are HIV infected worldwide, approximately 1.2 million people living with HIV in the US, and over 40,000 new HIV infections occurring in the US each year. Roughly one-quarter of those infected in the US are unaware of their infection, and these individuals are responsible for at least half of all new infections. To identify those individuals who are infected unknowingly, all adults should have at least one HIV test, repeated as needed if there are HIV risk factors. All clinicians should ask their patients about their HIV status, and should routinely order an HIV screening antibody test when appropriate. No special consent or pre-test counseling is required. Treatment of HIV infection is extremely effective with currently available regimens, and the majority of patients who begin effective combination therapy and who remain fully compliant with their treatment regimen have excellent clinical and virologic results. Newer anti-HIV medications are safer and better tolerated than earlier medications, and the development of combination pills has allowed many patients to take very few pills daily - in many instances, patients achieve full virologic suppression by taking only one pill once a day!. It is recognized that individuals with a good virologic response are markedly less likely to transmit HIV to others; raising the concept of “HIV treatment as HIV prevention”. In addition, it is recognized that male circumcision reduces the risk of HIV transmission. Despite these advances, there remain enormous worldwide challenges to providing effective HIV

therapies to impoverished populations, but with each passing year we see increased global resources being directed towards this goal. With these concepts in mind, it may no longer be unthinkable to start imagining a world without AIDS. All clinicians should feel comfortable talking about HIV with their patients, and should be sure that every adult patient in their practice has been tested for HIV. “Bedbugs, and skeeters, and flies, oh my!“ Increased global populations, human migration, poverty, and pesticide resistance has resulted in continued vector transmission of many infectious agents, including malaria, dengue fever, plague and West Nile Virus. Vaccines to protect against many of the most important vector transmitted pathogens (such as dengue fever and malaria) remain elusive, but some progress is being made. Proper use of prophylactic antibiotics for travelers, drainage of standing water where mosquitoes breed, use of topical insect repellents, and distribution of bed-nets and screens to prevent contact between insects and humans has had positive results and should be encouraged. Although we do not see malaria or dengue fever in the US (except in returning travelers), other insects remain an increasing problem. Bedbugs are increasingly prevalent in cities throughout the United States. Although they do not transmit diseases, they create a great deal of misery from their pruritic bites, and can be difficult to eradicate. “ Close the book” on Infectious Diseases? I think not! There are still many chapters waiting to be written. Note: this article was distributed in the “Mills Peninsula Infection Control Newsletter - Spring 2012” Dr. Erlich is board certified in internal medicine and infectious disease and practices in Daly City.

SAN MATEO COUNTY PHYSICIAN | page 17


Membership Update

Editorial Committee

New Members

Barry B. Sheppard, M.D., Chair Russ Granich, M.D. Edward G. Morhauser, M.D.

Minal Patel/ *IM Redwood City John Rosoff/ *AN Redwood City Sergio Sapetto/ *IM Redwood City Cam Tran/ *DR, *NR Redwood City Chun Kee Victor Tse/ *NS Redwood City Marina White/ *U Redwood City Denise Woo/ *D Redwood City Samuel Yu/ *OBG Redwood City Qinghua Zhu/ *IM Redwood City

Classified Ads Burlingame Medical Building Location on El Camino, Burlingame; across from MillsPeninsula Hospital. Two office suites: 800+ square feet and 1700+square feet. Call Alipate Sanft, SC Properties, 650342-3030 x212. Medical Office Space Available for Sublet Four exam rooms with running water and one MD office available for up to four days weekly. May be able to provide office staff if needed. Excellent location, opposite Peninsula Hospital. For details please contact Bonnie McGuire: Bonnilee@aol.com or 650-259-1480. Medical Office Space to Share Downtown San Carlos Dermatology office. Private rooms with shared reception area and waiting room. Ideal location for Medical/Paramedical practitioner. Ground floor with direct street access. Excellent visibility to a passer-by! Call Darlene (650) 591-8501 Place a classified ad for $40 for up to five lines for members and $75 for up to five lines for non-members. Contact SMCMA at (650) 312-1663 or smcma@smcma.org.

Sharon Clark, M.D. Gurpreet K. Padam, M.D. Michael Stevens, M.D

Sue U. Malone.............................................Executive Director Reina O’Beck..................................................Managing Editor

2011-2012 Officers & Board of Directors Gregory C. Lukaszewicz, M.D...................................President Mary Giammona, M.D......................................President-Elect Amita Saxena, M.D...................................Secretary-Treasurer John D. Hoff, M.D...........................Immediate Past President Alberto Bolanos, M.D. Russ Granich, M.D. Edward Koo, M.D. Vincent Mason, M.D. Kristen Willison, M.D.

Raymond Gaeta, M.D. Robert Jasmer, M.D. C.J. Kunnappilly, M.D. Michael Norris, M.D.

David Goldschmid, M.D. ......................................CMA Trustee Scott A. Morrow........................Health Officer, San Mateo Co. Barry B. Sheppard, M.D. ..................AMA Alternate Delegate

Article Submission Members are always encouraged to submit articles, commentary and Letters to the Editor. Email your submission to the SMCMA Editorial Committee at smcma@smcma.org for consideration for publication in San Mateo County Physician. For editorial or advertising inquiries, please use the contact information provided below.

Editorial and Advertising Offices 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404 Tel (650) 312-1663 Fax (650) 312-1664 smcma@smcma.org www.smcma.org Acceptance and publication of advertising in San Mateo County Physician does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. SMCMA reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted.

Š Copyright 2012 San Mateo County Medical Association

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SAN MATEO COUNTY PHYSICIAN | page 19


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April 2012