January/February 2013

VOL. 86 NO. 1 JANUARY/FEBRUARY 2013

ChOOsiNg wisELY

SAN FRANCISCO MEDICINEJOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Reducing Waste in Medicine By Providing Quality Care

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IN THIS ISSUE SAN FRANCISCO MEDICINE January/February 2013 Volume 86, Number 1

CHOOSING WISELY

Reducing Waste in Medicine by Providing Quality Care

Editorial and Advertising Offices:

1003 A O’Reilly Ave.,

San Francisco, CA 94129

Phone: (415) 561-0850

e-mail: [email protected]

Web: www.sfms.org

Advertising information is

available by request.

MONTHLY COLUMNS

4 Membership Matters

4 Classified Ad

7 2012 SFMS Report

8 Introduction: The 2013 SFMS President

9 President’s Message: Good Things Happen When Physicians Lead Shannon Udovic-Constant, MD

11 Editorial: Choosing Real Quality Gordon Fung, MD, PhD, and Steve Heilig, MPH

24 Hospital News

26 New SFMS Members

FEATURE ARTICLES

12 Choosing Wisely: Up Close and Personal Catherine Lucey, MD, FACP

14 Doctor “No”: Sometimes Saying “No” Is More Important than Being Liked Justin Morgan, MD 16 Rational Care: A Better Option than Rationing Care Eric Denys, MD

17 Cultural Comparison: Lessons from Working with Less Allan Treadwell, MD

18 Smart Oncology: Five Practices to Avoid Bertran Tuan, MD

20 Patient-Centered Imaging: Choosing Wisely in Nuclear Cardiology Robert Hendel, FACC, FAHA, FASNC

23 A Learning Health Care System: Recommendations from the Institute of Medicine Mark Smith, MD, MBA

24 Catastrophic Care: A Book Review John Maa, MD

Dr. Paul Abramson Family Medicine - Insured by MIEC

MIEC 6250 Claremont Avenue, Oakland, California 94618

800-227-4527 • www.miec.com SFmedSoc_ad_12.21.12

MIECOwned by the policyholders we protect.

Join the Insurance Company that always puts their policyholders first. MIEC has never lost sight of its original mission, always putting its policyholders (doctors like you) first. For over 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services.

Added value:n No profit motive and low overhead

For more information or to apply: n www.miec.com n Call 800.227.4527 n Email questions to [email protected]

* (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)



Policyholder Dividend Ratio*

0%

10%

20%

30%

40%

50%

2012 201120102009200820072006

2.2%

11.8%6.4%

29.3%25.6%

5.2% 5.2%

31.5%

6.9%

39.4%

7.1% TBA

49.2%

38.1%

MIECMed Mal Industry (PIAA Composite)

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Activities and Actions of interest to sFMs Members

MEMBERSHIP MATTERS

sFMs/CMA Responds to Ninth Circuit Ruling Vacating Preliminary injunction for Reimbursement Rate Cuts

The California Ninth Circuit Court of Appeals issued its opin-ion in CMA et al v. Douglas et al in December. The court reversed the district court’s decision and ruled that California can reduce Medi-Cal payments for health care providers by 10 percent. The rate cuts will significantly impact access to care for Medi-Cal pa-tients. SFMS and CMA plan to meet with other coalition members to evaluate options moving forward, including requesting a re-hearing en banc from the full Ninth Circuit Court of Appeals.

January 31, 2013, Deadline set to File for 2013 Medicare e-Prescribing hardship

Physicians who meet one of the Medicare electronic pre-scribing (e-prescribing) hardship exemptions have until January 31, 2013, to apply.

Pursuant to efforts of organized medicine, CMS has extended the filing deadline for physicians to avoid the e-prescribing penal-ty. Available hardship exemptions include physicians unable to e-prescribe due to state, federal, or local law/regulation; physicians with fewer than 100 prescriptions between January 1 and June 30, 2012; physicians in rural areas without sufficient high-speed Internet access; or physicians in areas without enough pharma-cies available for e-prescribing.

It is important to know that hardships should be filed us-ing the physician’s individual Type I NPI. For more informa-tion, visit http://bit.ly/Y2z1ES.

st. Mary’s Medical Center Receives Top Recognition for Patient safety

St. Mary’s Medical Center was selected as one of eight North-ern California hospitals to receive recognition as a “top perform-er” for reducing two or more types of hospital acquired-infections to zero and maintaining that standard for a full year from April 2011 through June 2012.

St. Mary’s and its physicians are longtime supporters of the San Francisco Medical Society, and make patient safety a top pri-ority at the hospital.

The awards were given by the Hospital Council of Northern and Central California in a ceremony to celebrate the successes of top performers in Patient Safety First, an innovative program that

uses regional peer-to-peer learning to accelerate the adoption of patient safety practices and strategies for improvement.

Medi-Cal Requiring Physician Re-enrollment DHCS will begin notifying physicians that they must reenroll

in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to revalidate provider enrollment information at least every five years, beginning January 2, 2013.

Notices of revalidation will be mailed beginning the second week of January 2013. Notices will be sent to the business loca-tion on file with DHCS. Each notice will include information on which application(s) must be completed. Anyone receiving a notice must complete and return the requested form(s) and required attachments within 35 working days of the date of the notice. Failure to do so may result in payment delays.

sFMs Board Member John Maa, MD, honored by American College of surgeons

John Maa, MD, SFMS board member and UCSF professor, was selected as the 2013 recipient of the Arthur Ellenberger Award by the American College of Surgeons.

The award recognizes physicians for their outstanding lead-ership and commitment to protecting patients’ access to high-quality surgical care through involvement in legislative and policy advocacy.

Dr. Maa has dedicated his work to improving the quality of and access to emergency surgical care. He was instrumental in the passage of AB 1621 to address flaws within a prostate cancer stat-ute as it relates to trauma care.

In 2009, Dr. Maa was named one of the country’s leading ad-vocates for health care reform by HealthLeaders magazine. He will be honored at the 2013 ACS Northern California Chapter Annual Meeting.

Palmetto Posts New 2013 Medicare Fee schedule

California’s Medicare contractor, Palmetto GBA, has now posted the new fee schedule on its website and has begun pro-cessing 2013 claims. The rates reflect a one-year Medicare fee-for-service physician payment freeze, approved by HR 8 (American Taxpayer Relief Act) recently passed by Congress. Although the Centers for Medicare and Medicaid Services gave contractors in-structions to hold claims for up to ten days to allow time to imple-ment the new fee schedule, there shouldn’t be any noticeable im-pact for California physicians.

Physicians should be aware that the 2013 fee schedule may not be exactly the same as the 2012 fee schedule. Although Con-gress stopped the 26.5 percent SGR cut, there were other compo-nents of the fee schedule formula that affect payment that may

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January/February 2013

Editor Gordon Fung, MD, PhD

Managing Editor Amanda Denz, MA

Copy Editor Mary VanClay

EDITORIAL BOARD

Editor Gordon Fung, MD, PhD

Obituarist Nancy Thomson, MD

SFMS OFFICERS

President Shannon Udovic-Constant, MD

President-Elect Lawrence Cheung, MD

Secretary Man-Kit Leung, MD

Treasurer Roger S. Eng, MD

Immediate Past President Peter J. Curran, MD

SFMS STAFF

Executive Director Mary Lou Licwinko, JD, MHSA

Associate Executive Director for Public Health

and Education Steve Heilig, MPH

Associate Executive Director for

Membership Development Jessica Kuo, MBA

Director of Administration Posi Lyon

Membership Coordinator Lauren Estrada

CMA Trustee: Shannon Udovic-Constant, MD

AMA Delegate: H. Hugh Vincent, MD

AMA Alternate: Robert J. Margolin, MD

Stephen Askin, MD

Toni Brayer, MD

Linda Hawes Clever, MD

Peter J. Curran, MD

Erica Goode, MD, MPH

Shieva Khayam-Bashi, MD

Arthur Lyons, MD

BOARD OF DIRECTORS

Term: Jan 2013-Dec 2015

Charles E. Binkley, MD

Gary L. Chan, MD

Katherine E. Herz, MD

David R. Pating, MD

Cynthia A. Point, MD

Lisa W. Tang, MD

Joseph Woo, MD


Andrew F. Calman, MD

John Maa, MD

Edward T. Melkun, MD

Justin V. Morgan, MD

Kimberly L. Newell, MD

Richard A. Podolin, MD

Elizabeth K. Ziemann, MD


Jennifer H. Do, MD

Benjamin C.K. Lau, MD

Keith E. Loring, MD

Ryan Padrez, MD

Terri-Diann Pickering, MD

Adam Schickedanz, MD

Rachel H.C. Shu, MD

Volume 86, Number 1have changed, such as the relative value units (RVUs). Visit http://bit.ly/Wk6xSo to view the new fee schedule.

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

January 30: Keys to Successful Contracting • 12:15 p.m. to 1:15 p.m.February 6: HIPAA Compliance: The Final HITECH Rule • 12:15 p.m. to 1:15 p.m.February 7: Impact of ICD-10 • 12:15 p.m. to 1:15 p.m.February 12-20: E/M Services Review Series • 12:15 p.m. to 1:45 p.m.March 6: Fraud and Abuse: Dangers and Defenses • 12:15 p.m. to 1:15 p.m.

sFMs Policies at Play on state and National issuesA number of the policies your SFMS delegation adopted at the annual

California Medical Association meeting in October (see full report in Decem-ber SFM) have already taken on relevance in legislative debates. In briefest form, here are some updates:

Evidence-Based Utilization of Services: This SFMS resolution has already been adopted by the AMA to: (1) support physician-led, evidence based, efforts to improve appropriate utilization of medical services; and (2) educate member physicians, hospitals, health care leaders and patients about the need for physician-led, evidence based, efforts to improve appropriate uti-lization of medical services.

Generic Medications and Pay for Delay Practices: Also ad-opted by the AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” il-legal in the United States. This debate has heated up with new federal policy proposed to stop this nonscientific profiteering.

The Prescription Drug Abuse Epidemic:Used to identify physi-cians who might be overprescribing painkillers and other drugs, the state’s prescription tracking database, the Controlled Substance Utilization Review and Evaluation System, or CURES, remains chronically underfunded but is getting much more attention, and CMA is now in full support of sustaining CURES due to our resolution.

Cannabis Policy: Just after the CMA meeting, more states decriminal-ized cannabis use, for medical or even general use. This debate continues, but evidence-based policy is gaining ground, with our CMA “white paper” from the previous year now being considered by the AMA regarding rescheduling of cannabis for research, and other policy advances.

POLST Orders: The SFMS resolution to increase use of POLST via authorizing advance practice nurses to complete the forms, for physician con-firmation, was the most narrowly-decided vote of the year – we lost that one. But our coalition to increase POLST use locally continues, with evident suc-cess in hospital and long-term care settings.

Medication “Take-Back” Programs: These efforts to decrease diversion and pollution due to unused medications are increasing, despite some opposition to having pharmaceutical companies help fund them. The local program is running out of funding but support for it is growing, and CMA will support such programs statewide.

Cell Phones in Cars: A retrogressive policy allowing texting while driving snuck through the state legislature, with no accounting for hazardous consequences. While we were unable to get a more strict prohibition of such use adopted by CMA this time, they did commit to a public education effort on the increased risk of accidents when drivers use phones. The evidence here mounts yearly and convenience must not be allowed to trump health.

Thus it seems that, for better or worse, the SFMS delegation’s choice of ‘issues” this past year was perhaps more timely than ever.

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In the midst of economic and policy challenges in the health care environment, physicians are look-ing to medical societies for guidance and support. SFMS was able to establish itself as a reliable source and cen-tral hub of information, advocacy, training, and policy making for our physicians and prospective members—in person, on-line, and in our publications. Your membership and participa-tion enabled us to accomplish so much in 2012.

SFMS physicians participated in CMA Legislative Lead-ership Day in Sacramento and met with all the local Senate and Assembly members or their staffs on issues affecting phy-sicians and the practice of medicine in California.

Our SFMS delegation to the CMA had as successful a year as ever, taking a dozen resolutions to the annual House of Delegates, with most adopted. Two have already been adopted by the AMA, with more to be considered, and our resolutions on efficiency in health care, “pay for delay” tactics by the phar-maceutical industry, cell phone use while driving, reviving the medication-tracking CURES program, and more are already in play in legislative proposals and public debate.

The SFMS PAC held an extremely successful candidate’s night to interview eight leading candidates for the San Fran-cisco Board of Supervisors. Eighty-five percent of the candi-dates that the PAC financially supported were elected to office.

SFMS leadership met a number of times with Assembly candidate Phil Ting to discuss issues facing physicians and their patients. The SFMS PAC supported Ting in his successful bid for the State Assembly seat previously held by Fiona Ma.

The SFMS San Francisco Medicine journal continued to be regarded as one of the very best local medical pub-lications, with theme issues on primary care, pain medicine, infectious diseases, politics, patient education, and more. The biannual “environmental health” issue was used at a national conference in New York and at the American Public Health As-sociation annual meeting in October. We included clinically useful inserts on toxics, partner violence, and POLST. Journal issues now consistently draw more than 500 additional visi-tors online, with some seen by more than 1,000.

SFMS started a new partnership with the Hospital Council of Northern and Central California, the San Fran-cisco Community Clinic Consortium, and the University of San Francisco to present seminars on timely issues regarding health care reform.

The SFMS executive director completed her appoint-ment on the San Francisco Health Care Master Plan Task Force, which was created to find a way to operationalize the health planning ordinance written by Supervisor David Cam-pos. The findings of the Task Force were presented to the San Francisco Health Care Commission earlier in the year, where they were unanimously accepted by the Commission.

Our grant-funded San Francisco-wide efforts to im-prove advance care planning and increase use of POLST forms have continued with regular publication of relevant information and the form itself in San Francisco Medicine, pre-

sentations at hospitals and long-term care facilities and con-ferences, and assessment at long-term care facilities—a key site for POLST applicability, and where use is steadily increas-ing. The statewide POLST coalition coordinators have lauded our efforts and we will continue in 2013 with the final year of funding, but with related work to continue.

We continued our involvement with HealthShare Bay Area (HSBA), which was created under the auspices of the SFMS Community Service Foundation (SFMS CSF) to create a platform for electronically exchanging medical records in the Bay Area. SFMS was instrumental in incorporating HSBA, and the SFMS CSF continues to provide administrative support for the organization. SFMS Executive Director Mary Lou Licwinko sits on the HSBA Board.

We redesigned the SFMS website—sfms.org—with a pa-tient referral service and individual physician practice pages. The new website generates more than 4,000 page views per month, on average. The five most-viewed sections include the SFMS blog (containing up-to-date news, announcements, and member spotlights), San Francisco Medicine, Events, Physi-cian Finder, and Featured Member.

We developed the “Ask the SFMS” campaign to position SFMS as the go-to resource for the local medical community. The launch in September 2012 was well received by our stra-tegic partners as well as by members.

SFMS significantly increased physician and resident membership. Regular physician membership is the highest since 2003, and resident membership increased by one-third.

SFMS secured commitment from the San Francisco Department of Public Health to sponsor a group of its phy-sicians for SFMS membership, effective January 2013. SFMS leaders and staff have met with key leaders and administra-tors at DPH and increased SFMS visibility with DPH physi-cians through presentations at COPC (primary care physician) meetings.

SFMS engaged the local community and promoted its work at the AHA Golden Gate Walk. Our presence at the walk was an opportunity to highlight SFMS and our physicians and to increase our profile with the general public.

Our Career Fair exhibitors increased from 17 in 2011 to 20 in 2012 and generated a profit for the event. Notable additions include all four Sutter Health Bay Area affiliates and John Muir Health. The event also increased SFMS’s visibility among local hospitals and administrators.

These activities were all in addition to our ongoing and daily contacts with patients, the media, legislators, and local leaders, providing patient referrals, conflict resolution, ad-vocacy, and information on a wide array of medical, public health, and related topics.

To be continued in 2013!

2012 SFMS REPORT ACCOMPLishMENTs AND CONTRiBUTiONs


AN INTRodUcTIoN

Shannon Udovic-Constant, MD, is being installed as the 2013 SFMS president at January’s annual dinner. An SFMS member since 2001, Dr. Udovic-Constant is a pediatrician at Kaiser Permanente San Francisco Medical Center.

Dr. Udovic-Constant received her medical degree and pe-diatric residency training from the University of California, San Francisco. She is an assistant clinical professor of pediat-rics at UCSF, a CMA trustee representing San Francisco physi-cians, as well as a board member of the Permanente Medical Group, while maintaining a busy outpatient practice.

With an avid interest in child advocacy, Dr. Udovic-Con-stant has extended herself beyond her job in areas that have directly benefited California children. She is a coauthor of the SFMS Minor Consent for Prevention of STIs resolution that was approved by CMA, AAFP, and AMA and adopted as AB 499, signed by Governor Brown in October 2011. The law allows children ages twelve and older to obtain preventive treatment for sexually transmitted infections without parental consent.

She was honored in 2012 by District IX (California) of the American Academy of Pediatrics for her long-established commitment to advocacy for children.

Dr. Udovic-Constant has worn many hats for SFMS over the years and is looking forward to adding a “presidential hat” to her stack. She sat down with SFMS to share her viewpoints about the medical society and organized medicine.

Why are you a member of SFMS and why is being an active member in organized medicine important for your patient-care philosophy?

Organized medicine allows us to have a strong voice to impact both our profession and our patients’ health. We must continue to have strong leader voices from SFMS in order to bring the issues facing physicians and our patients to the fore-front of both the SFMS and the CMA. Margaret Mead said it well: “Never doubt that a small group of thoughtful, commit-ted citizens can change the world. Indeed, it is the only thing that ever has.”

Can you tell us about any goal(s) you hope to accom-plish in your new position as SFMS president?

My goal this year is to identify future leaders among San Francisco’s physicians and help them learn about SFMS and why being involved can really make a difference. I also want to continue the work of past leaders in having the SFMS at the forefront of all health care issues affecting San Francisco’s phy-sicians and patients. This includes meeting with new Board of Supervisor members, testifying at hearings, and writing let-ters to leaders about our positions.

What are some of the biggest opportuni-ties or challenges you see in health care within the next year?

This is a turbulent time in health care, with Medicare cuts, imminent health care reform implementation, and the start of health insurance exchanges. SFMS and CMA need to have a unified voice to lead these changes in or-der to have the best possible outcome for physicians and patients.

How do you balance your work and personal life, and still manage to find time to participate in SFMS activities? Any advice for new physicians transitioning into practice from residency?

My advice to new physicians is to think about the first few years in practice like a fellowship. You’ll need to spend a lot of time setting up your practice in terms of getting to know your patients and developing systems to best care for them. Then, all of that time will pay off and you’ll start to receive the re-wards of your hard work—seeing the healing that you have directly impacted.

In terms of balance between work and personal life, I have an amazing husband who understands the importance of this work. We eat dinner together as a family whenever one of us isn’t working or at an evening meeting. I talk to my kids about the work that I do and why. In this way, I hope that they are learning about volunteerism.

What about you would surprise our members?I was a cheerleader at Cal. Go, Bears!

If you weren’t a physician, what profession would you most like to try?

Health policy or public health. I am often struck by how much our patients’ health is impacted by the social determi-nants of health. Direct public health or health policy work can have an enormous impact on health outcomes.

Meet the 2013 sFMs President


The Choosing Wisely campaign. I first heard about this project when the National Physician’s Alliance contacted me to ask if I was interested in participating in a project designed to look at regular pediatric practices that do not add value to patient care. Later I read with interest the outcome of this project, called the Choosing Wisely campaign.

good Things happen when Physicians Lead

I understand the concern that best practices can be a way that payors can use to not pay physicians or a way to ration care. The power of the Choosing Wisely campaign is that physicians are leading it—the cost savings are coming from ideas from physicians. The risk of not moving forward is that we will con-tinue to see across-the-board cuts to our reimbursements. We need to continue to lead so that if, in a physician’s judgment, something is done that deviates from a best practice due to a need based on individualized care, it will still be paid for.

The National Physician’s Alliance is a group that was founded by former leaders of the American Medical Student Association (AMSA). As a medical student, I joined AMSA and immediately became active and even joined its board. I eagerly learned about health policy and advocacy. My first meeting with an elected official was in Washington, D.C., with visits arranged by AMSA with my local representative, Ron Dellums, when he served in the House. We were prepared that we would likely meet with staff but were pleasantly surprised to find ourselves meeting with the congressman himself. Our time with him went over schedule because of his interest in hearing from us. I was hooked. Seeing a member of Congress paying attention to what we had to say, I realized the power that we have. As physicians in training, we had the stories about how policy affects the health of our patients.

Flash-forward to this past October. I was at the CMA House of Delegates, listening to the remarkable Elizabeth Mc-Neil, CMA’s lobbyist in D.C., talking about Washington politics. She quoted someone’s remark about Congress that “it’s even worse than it looks.” The sustainable growth rate also came up, and I was prepared to hear the usual—that the SGR would receive a temporary fix and continue to not be fully addressed. Instead I listened with interest about the opportunity for phy-sician leadership. Congress is recognizing that rising health care costs are too big an issue for them to fix. They are now turning to physicians and asking us to develop alternative pay-ment models, and then they will eliminate the Medicare SGR. AMA, CMA, and other organized medicine groups are develop-ing a transition path out of the SGR to new payment models (see http://www.ama-assn.org/ama/pub/about-ama/strate-gic-focus/shaping-delivery-and-payment-models/payment-model-resources.page). We must have a unified plan that re-aligns incentives to provide the best-quality care at a reduced cost. This is our opportunity. Specialty best practices such as the Choosing Wisely campaign are one example, but there are

Shannon Udovic-Constant, MD

PRESIdENT’S MESSAGE

many others, including prevention of chronic conditions, the patient-centered medical home, better management of chron-ic conditions, and care coordination.

As physicians are turned to as the experts in how to de-sign a health care system for more patients while also low-ering costs, I am concerned about a trend that appears to be growing. Physicians are giving up their control around medi-cal decisions. Dr. Francis J. Crosson has been appointed the AMA’s new vice president of professional satisfaction in care delivery and payment, which is one of three strategic areas that will be the focus of the AMA over the next five years. The plan is to survey physicians in six states to see what is hap-pening in their practices, and then prepare a summary with suggestions for how to develop a more robust and sustain-able profession. There is concern that payment models and transformations in the marketplace are leading physicians to choose to give up their autonomy. According to Ian Morrison, a health care consultant from the Institute for the Future, 39 percent of the 2011 residency graduates took positions were they were directly employed by a hospital. A concern that many have is that in this situation physicians may not have a voice in the running of their institution.

During this time of rapid change in health care, it is even more crucial for physicians to be front and center in identify-ing solutions. The risk of not doing this work is that we will find ourselves victims of other people’s solutions. This is ex-actly what organized medicine does best—put physicians out front with a unified voice on what is best for patients. I look forward to this year as your SFMS president. Please join in the dialogue. We need everyone’s input, because good things hap-

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In this edition of our journal, we wade into some possibly treacherous waters, but we really have little choice. It is clear that medicine as a profession is being called upon to cut costs—or, rather, our nation is, whether medicine wants to lead the way or not. The physician’s pen (or, increasingly, keyboard) is the most expensive “tool” in health care, in that medical orders and prescriptions account for the bulk of total expenses.

Choosing Real Quality

That’s as it should be, but there is ever more evidence that much (up to 25 percent overall) of what patients receive is su-perfluous—or, to use a stronger word, wasteful.

A difficult problem—here is the first “treacherous” part—is that such overutilization can be profitable for hospitals, health systems, and, yes, physicians. But the writing is on the wall that the era of such incentives and overuse is coming to an end. If medicine is to truly speak and work for optimal quality, we have to make some difficult decisions—with the best inter-est of patients, and our nation’s convoluted health system, in mind.

We also need to address the “R word”—rationing. As any informed participant in providing care can confirm, rationing is already a reality. It’s inevitable, and it’s becoming more critical and acknowledged. The real issue is who will be in charge of decisions about what interventions and services are beneficial and worth supporting. Most of us would not nominate insurers and health plans (the current leading “rationers”) or politicians to lead the effort. We do not need yet more profit-motivated meddling in clinical decisions, nor more “death panel” scares. Is it self-serving to suggest that clinicians might be both the most informed and the most trustworthy in this regard? We think not, and we expect that most objective people would agree.

To that end, new initiatives are taking on this big issue and providing expert input to guide payment and other policy. We were pleased to see that a leading effort, Choosing Wisely, has strong local ties at UCSF, and even more pleased when UCSF Dean and Choosing Wisely leader Catherine Lucey, MD, heart-ily agreed to join in putting together this special edition of San Francisco Medicine. Working with her, we asked various spe-cialty representatives to reflect on how Choosing Wisely and other such efforts might impact their practices and patients.

For last year’s annual CMA policy-making meeting, your SFMS delegation took the following proposal (originally coau-thored by neurologist Eric Denys, radiologist Roger Eng, and the coauthors of this editorial) for consideration by the state-wide assembly:

REDUCiNg OVERUTiLiZATiON: PhYsiCiAN LEADERshiP

Whereas, overutilization of medical services has long been identified as a significant factor in rising health care costs, with costs in the United States significantly higher than in other developed nations at least in part due to

Gordon Fung, MD, PhD, and Steve Heilig, MPH

EdIToRIAL

significantly higher rates of screening, diagnostic, and treatment procedures, in many cases without demonstrable superior outcomes; and

Whereas, in the new Choosing Wisely initiative sponsored by the Amer-ican Board of Internal Medicine and chaired by a UCSF professor of medicine, nine United States specialty societies representing 374,000 physicians devel-oped lists of “Five Things Physicians and Patients Should Question” in recog-nition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures; and

Whereas, these lists represent specific, evidence-based recommenda-tions physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situations, and each list provides information on when tests and procedures may be appro-priate, as well as the methodology used in its creation; and

Whereas, the American College of Physicians recently published a con-sensus that named 37 commonly overused diagnostic procedures and treat-ments, and has called for physicians to become aware of costs of treatment options and to become more “parsimonious” in treatment decisions where evi-dence indicates costs may not be justified in terms of probable outcomes; and

Whereas, with ever-mounting pressure to control costs, from various health “reforms” and other constraints, it is more important than ever that the medical profession lead the way in ensuring that appropriate guidelines are utilized in utilization- and cost-containment efforts and policies; now be it

RESOLVED: That CMA will support physician-led efforts to reduce over-

utilization of medical services based upon evidence-based criteria; and be it

further

RESOLVED: That CMA educate member physicians, hospitals, and health

care leaders and patients about the need for such efforts; and be it further RESOLVED: That this matter be referred to the AMA for national action.

The CMA’s diverse and often contentious House of hundreds of physi-

cians from all over the state and virtually all specialties and practice settings

endorsed this statement without much dissent. Then, to our further surprise,

CMA leaders prioritized this resolution for submission to the AMA—which also

endorsed it. So the writing is now not only on the wall but in the official posi-

tions of “organized medicine” that the medical profession must lead the way in

reducing overutilization and waste, based upon good evidence of effectiveness.

That won’t be easy, might even be painful—but the time has come.

We hope you find the contents of this issue of interest. Like it or not, we’ll all be hearing much more on this topic, and will keep trying to ensure that medicine leads to where we must go.

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Choosing Wisely


Up Close and Personal

cHooSING wISELy

Catherine Lucey, MD, FACP

A few years ago, I received that phone call that every parent dreads: While riding his bike to school, my teenage son had been hit by a car. Arriving on the scene, I found my son be-ing loaded into an ambulance, strapped onto a backboard, awake, moving all extremities, and apologizing profusely for having been hit. Off to the side was the mangled bike, with the expensive hel-met strapped carefully to the handlebars (so much for years of nagging). At the emergency room, a trusted physician colleague carefully listened to the story, asked key questions (no loss of con-sciousness, no neurologic symptoms), examined my son, and told me that everything looked good. “But you’ll get a CT scan just in case, right?” I asked. He replied no, that the guidelines on scanning in young people recommended against scans in cases like this. To which I responded, “But this is my son! I couldn’t bear it if some-thing was wrong and we missed it.”

When I first heard about the idea for the Choosing Wisely cam-paign, this experience came to mind. Encounters like this happen every day in doctor’s offices and emergency departments across the country. Worried patients bring their concerns to their trusted physicians and ask them to use all that medical science has to offer to reassure them. Those physicians also worry about the patient, often turning to tests and therapeutic trials to be certain that the most dreaded cause of the symptom in front of them is not present. The genesis of this instinct to test early and often and embrace the (deceptively) benign therapeutic trial of an antibiotic, a prescrip-tion pain reliever, or a course of corticosteroids or other drugs has roots within our collective support of the professionalism values of prudence (do no harm), excellence, and altruism. This instinct is often reinforced by grateful patients who believe that more care is better care and by powerful anecdotes about physicians who do less and suffer the consequences in courts of law.

Although the risk and cost of “probably nothing wrong but to be sure” (PNW) tests seems minimal at first blush, this is often not the case. All of us have had the experience of ordering a test “just to be sure” and getting a false positive result that then gener-ates many more diagnostic studies. The tests that follow are often more invasive and more risky. And some of those benign therapeu-tic trials result in drug side effects that can range from annoying diarrhea to life-threatening anaphylaxis or other serious adverse consequences. What’s more, the financial impact to the patient of PNW tests is difficult to ascertain. The easy-to-order MRI scan for chronic headaches may lead to substantial out-of-pocket costs for the patient with less than comprehensive health insurance. On a larger scale, these tests and treatments contribute to the rapidly expanding costs of health care nationally. As much as a 30 percent of the nation’s 2.7 trillion dollar expenditures on health care may be due to waste, with waste due to overuse of tests and treatment equaling the waste related to administrative complexity.1

Since the publication of “Medical Professionalism in the New Millennium: A Physician Charter” in 2002, the ABIM Foundation has sought opportunities to reinforce the foundational values of professionalism for all physicians and to endorse the power of professionalism to address the nation’s health care challenges. 2 This work has supported professionalism initiatives in residency programs with Putting the Charter into Practice grants. The ABM Foundation has partnered with professionalism experts from the Mayo Clinic, the Josiah Macy Foundation, and the Institute of Medicine as a Profession to sponsor meetings on professionalism. Building on this body of work, the ABIM Foundation’s Choosing Wisely Campaign attempts to leverage our collective commitment to prudence (do no harm), excellence, and altruism to address is-sues of stewardship and to tackle the problem of dangerous and wasteful tests and treatments.

The Choosing Wisely Campaign has its origins in Howard Brody’s 2010 New England Journal of Medicine article, in which he called upon each medical specialty society to appoint a blue-rib-bon panel to identify the five most frequently used medical tests or treatments that current evidence suggests do not provide benefit for most patients for whom they are ordered.3 Subsequently, the National Physicians Alliance (NPA), supported by a grant from the ABIM Foundation, launched the Good Stewardship Working Group and created “top 5” lists in internal medicine, family medicine, and pediatrics. Research published in Archives of Internal Medicine es-timated that cutting back on the tests in the top five lists in primary care alone would lead to savings on the order of $5 billion per year.4

In 2011, building on the work of NPA, the ABIM Foundation recruited nine additional physician organizations to create lists of tests and treatments that are at times overused by physicians in their specialties (Table 1). The campaign was carefully constructed to reinforce the trusted role of physicians in society. Physicians (not administrators or payors), embracing the professionalism values of excellence and prudence, used scientific evidence to de-velop lists of tests and treatments that are often given to patients unlikely to benefit from them. Using these lists, the ABIM Founda-tion launched the Choosing Wisely campaign in April 2012. The campaign reinforces the shared decision making that underpins successful doctor-patient relationships. It encourages physicians to discuss the limitations and risks of the tests and treatments on the list with their patients and help them understand the problems of overtesting and overtreatment. Careful focus on the importance of conversations has helped differentiate the Choosing Wisely campaign, which encourages physicians and patients to talk about tests that do not help and can sometimes cause harm, from ration-ing, where needed care is restricted to save costs. The campaign also recognizes that changing the culture of U.S. health care—from one in which “more” care is better to one in which “right” care is


better—requires addressing public expectations. Consumer Re-ports has launched an educational series to help patients under-stand the problems with overused tests and treatments so they can engage in conversations with their physicians about what care is best for them. Through a coalition of fourteen employer and consumer groups including AARP, the National Business Group on Health, SEIU, and Union Plus, Consumer Reports will disseminate this information to millions of consumers (Table 2).

Since the launch in April 2012, more than fifty-five articles citing Choosing Wisely have already been published in peer-reviewed journals, demonstrating the impact this concept has had among physicians and other health care stakeholders. Medscape worked with the original nine specialty societies to create a series of fourteen articles throughout 2012, reaching nearly 100,000 physicians; an article developed in conjunction with the American Academy of Allergy, Asthma, and Immunology was the most-read feature article among allergists in 2012. This edition of the San Francisco Medicine joins the ranks of journals committed to helping their physician readers understand and embrace the principles embedded in the Choosing Wisely campaign. Additional specialty societies are coming on board with more lists (Table 3).

The work on Choosing Wisely is not done yet, however. De-veloping and disseminating the lists is a starting point. The impor-tant work must be done by physicians in the exam room, in the emergency room, and on hospital wards. Campbell and colleagues remind us how difficult it is to say no to a patient who requests a test that is of no or marginal benefit. In a 2011 study of physicians across the country, they documented that more than one-third of physicians would accommodate a patient who asked for a test even if that test was not indicated.5 The frequently used argument that patient autonomy demands that physicians acquiesce is a misuse of the concept of autonomy and ignores our commitment to excellence and prudence.6 Next steps in this work include for-mulating strategies to help physicians in practice and physicians in training master the skills necessary to communicate the risk of unnecessary tests and treatment and to offer other forms of reas-surance to worried patients. Medical students and residents need to learn when to watch and wait rather than prescribe unneces-sary tests and treatments. It is also critically important to support physician decision making that uses the tests and treatments on the lists when they are indicated. More outreach to community or-ganizations, patient advocacy groups, and educators responsible for health education in our schools will lead to patients who are willing to engage with us in meaningful conversations that focus on getting the right care at the right time.

And what about my son? The physician took me aside, ex-plained that new studies have documented the risks of radiation on growing brains, and showed me the practice guidelines that outlined when CT scans were indicated following accidents. He then reassured me that I could call him personally if new symp-toms emerged. All in all, it took more time, empathy, and skill than simply ordering the CT scan—and considering I was a physician myself, it also took a certain amount of courage. But our conversa-tion gave me confidence that the decision not to test was based on our doctor’s willingness to put my son’s best interests at the forefront of his decision-making process—the true definition of professionalism. All is well.

Catherine Reinis Lucey, MD, is UCSF vice dean of educa-tion. She directs the undergraduate, graduate, and continuing medical education programs of the chool of Medicine and the Office of Medical Education. Dr. Lucey completed her residency in internal medicine, including service as chief resident, at the UCSF-affiliated San Francisco General Hospital after earning her medical degree from the Northwestern University School of Medicine. A full list of references is available on www.sfms.org.

Table 1: Original specialty societies Joining the Choosing wisely Campaign

American Academy of Allergy, Asthma, and ImmunologyAmerican Academy of Family Physicians American College of Cardiology American College of PhysiciansAmerican College of RadiologyAmerican Gastroenterological AssociationAmerican Society of Clinical OncologyAmerican Society of NephrologyAmerican Society of Nuclear Cardiology

Table 2: Consumer Organizations Endorsing Choosing wisely

AARPAlliance HealthThe Leapfrog GroupMidwest Business Group on HealthMinnesota Health Action GroupNational Business Coalition on HealthNational Business Group on HealthNational Center for Farmworker HealthNational Hospice and Palliative Care OrganizationNational Partnership for Women and FamiliesPacific Business Group on HealthSEIUUnion PlusWikipedia

Table 3: New specialties Joining the Campaign

American Academy of Family PhysiciansAmerican Academy of Hospice and Palliative MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Otolaryngology–Head and Neck SurgeryAmerican Academy of PediatricsAmerican College of Obstetricians and GynecologistsAmerican College of RheumatologyAmerican Geriatrics SocietyAmerican Society for Clinical PathologyAmerican Society of EchocardiographyAmerican Urological AssociationSociety of Cardiovascular Computed TomographySociety of Hospital MedicineSociety of Nuclear Medicine and Molecular ImagingSociety of Thoracic SurgeonsSociety for Vascular Medicine

see www.Choosingwisely.org for more!


Choosing Wisely


Even when the answer to a request should be “No,” saying “Yes” is often times so much easier. Yes to an MRI to screen for “everything.” Yes to antibiotics . . . just in case. Yes to a chest X-rays to evaluate heartburn after meals. Yes to your pager number.

The precautionary “Yes” usually seems less costly for ev-eryone, even if “No” is the best answer. “Yes” makes everyone happy. “Yes” solves the problem. No one wants to be “Dr. No,” serving up the disappointments that come along with that role.

That is until you get the incidental, inexplicable MRI or chest X-ray finding, the call for antibiotics with every viral ill-ness, and the patient who pages you at home to request an earlier appointment. The tests and procedures that make all the “Yeses” add up to hundreds of millions of dollars overuti-lization and skyrocketing cost of health care in this country.

As a primary care physician in a public health care sys-tem committed to universal health care access for everyone in San Francisco, I’m often in a position where I’m being asked to use services that I know are limited, and it is part of my re-sponsibility to make sure they are used wisely. Part of my re-sponsibility, as Dr. No, is not just to say “No” to overutilization but to help people better understand how to make our system both caring and efficient, while addressing my patients’ needs at the same time.

After years of practice, learning from others and telling some patients, “Please do not call me at this number again,”

here are some tips I’ve put together in my stepwise approach to saying “No.”

step 1: Don’t say, “No.” Listen.

Before you pounce on the patient and smack down their feeble attempt to practice medicine based on a forty-five- to fifty-minute Internet search, acknowledge the patient’s re-quests in a way that lets them know they are being heard and that you are interested in helping them. For example:

“It sounds like you’re worried about your risk of having cancer and would like an MRI to find cancer early. Did I get that right? What more can you tell me about that?”

step 2: Don’t say, “No.” Acknowledge.

When your patients need something from you, they may ask for your help in a specific way. They may not know the details of medicine like you do, but their need for your help is what they are actually asking for. Saying “No” to that specific request may translate into not helping at all. Instead, focus on learning what their concerns are and what you can do to help. For example:

“An MRI is a good test, and it looks like you’ve done a lot of research on it. Is there a specific type of cancer you are wor-ried about? Because I may be able to help you get a better test for finding specific types of cancers, some we can offer you right here in the office.”

sometimes saying “No” is More important than Being Liked

docToR “No”

Justin Morgan, MD


step 3: Don’t say, “No.” Explain. Explain how you are going to help, and be specific. Some-

times we do the opposite and try to explain why we can’t help. “We don’t do MRIs for stuff like that” or “Do you know how expensive an MRI is?” or even, “We’re short-staffed, so you’ll have to wait to get an MRI.” Such responses give little comfort to the patient and they’ll see you as an obstacle, not a partner in delivering good care.

Explaining what you can do to help, with some specifics, goes a long way in reassuring patients that you’re on their side. For example:

“We have a test that can find colon cancer before it shows up on the MRI, by looking for small amounts of blood mixed in the stool. You can have the results of this test in less than a week.”

step 4: Don’t say, “No.” Offer more help.

By now, your patient might be willing to go along with your plan. This is a good time to find out if there’s anything else they need help with.

But what if, despite steps 1 through 3, you find yourself in a position where you are still thinking of saying “No”? The patient is convinced that the MRI will save them from cancer; the antibiotics will cure their asthma; and if they could just call you at home, they wouldn’t have to bother you as much. Don’t say it! Don’t close the door with a “No.” As with the pa-tient who agrees to do the stool cards, with this patient you should also end with an invitation to help:

“I would like to help you find cancer early, so here’s some

information about the test I have available; if you change your mind and decide to do the test we have, please let me know. Is there anything else I can help you with today?”

step 5: Don’t say, “No.” Reconnect.

If you approached all patients with steps 1 through 4, don’t do so with the expectation that they or any patient should surrender or do what you say. Even the patient who seems to agree with you in the office may still walk out the door worried or thinking of who they really need to talk to in order to get that MRI done. I’ve found that reconnecting with patients after a visit with Dr. No is often more appreciated than a “Yes” to the MRI.

Receiving a phone call from their provider to say that you did read the Internet article they gave you on how anti-biotics cure asthma or that you asked another provider about their request, and hearing what you learned and would like to share, often leaves in the mind of many the idea that their con-cerns are your concerns. When they leave your office, think-ing about their health problems, they know you are thinking about them, too.

Saying “No” is sometimes the best thing you can do for your patients and the larger health care system.

Dr. Justin Morgan is a family physician with the San Fran-cisco Department of Public Health in their outpatient clinics and juvenile hall. He is president of the National Medical Associa-tion’s San Francisco chapter, the John Hale Medical Society, and a board member of the San Francisco Medical Society.


Choosing Wisely


On the first day of a clinical rotation through neurology, a third-year medical student listened to the patient’s history in my consultation room. Thereafter, while the patient undressed in the examination room, I turned to the student, asking his opinion as to what we should do next. After a pensive moment, the student said, “How about doing an MRI scan?” I pointed out that we had not even examined the patient. His reply was that he had thus far mostly observed physicians ordering tests and looking at the results. I hope that this was not true.

No doubt, the hierarchy of taking a history followed by an examination and then ancillary testing based on that exam is being turned on its head. Neurology, I like to believe, still remains a specialty in which the history and the examination of the patient play a crucial role. Just as with real estate, much depends on “location, location, location.” Neurology was also the first beneficiary of technology with the arrival of CT scans, which could look through the skull and for the first time amaze us with the anatomical detail inside. This was followed by MRI scanning. These techniques were tempting, because they showed that, despite great clinical acumen, the neurolo-gist was sometimes proven wrong. The medicolegal climate did the rest. Thus, neurology has not escaped the overuse of imaging techniques. Lest I be perceived as being antitechnol-ogy, let me remind the reader that I more than welcomed the arrival of CT scans so I could stop doing pneumoencephalo-grams.

After all, neurology is still a specialty with relatively few technical procedures. Nerve conduction studies and electro-myography are the most common in-office tests. They have recently come under scrutiny, followed by heavy reductions in reimbursement by CMS as of January 1, 2013—so much so that it will affect conscientious physicians much more than al-ready over-testing diagnostic mills. Electrodiagnostic testing should, in my opinion, never be done without sound clinical information and a competent examination. But even among neurologists, we see an excessive number of nerve conduc-tions or needle electrode examinations done inappropriately. It is rare that a patient presenting with a distal sensory poly-neuropathy in the toes needs studies in the arms in the ab-sence of other symptoms, or that a clear-cut radiculopathy due to a disk needs nerve conduction studies. A clinical pre-sentation of a median nerve carpal tunnel syndrome in one hand does not need a full battery of ulnar nerve conduction studies on both sides.

The reasons for unnecessary testing are many. Lack of education or experience play a significant role. A recent study in Health Affairs (2012; 31:2453-2463) entitled “Less Experi-

enced Physicians Reportedly Incur Higher Costs” points out that costs are 13.2 percent higher for physicians in the first 10 years of practice, 10 percent for 10 to 19 years, and 6 percent for 20 to 29 years of practice. Unfortunately, personal finan-cial gain cannot be dismissed as a factor, just as fear of litiga-tion remains an issue. Nevertheless, doing what’s right is the right thing to do.

What we are witnessing in neurology with the drastic reduction in reimbursement for electromyography is nothing less than a form of rationing without regard for quality of care.

By focusing on the rational use of medical technology, we will keep the financial resources available for those patients who need more complex or multiple procedures, such as in the acute treatment of stroke, where combinations of imag-ing using CT angiography, perfusion, and blood flow scans can greatly expand the beneficial treatment window and avoid fu-ture costs and neurological impairment of the patient.

Eric H. Denys, MD is with the department of neuroscience at California Pacific Medical Center and associate clinical pro-fessor of neurology at UCSF. He was awarded both the Royer Award and the Charlotte Baer Memorial Award, two of UCSF’s most prestigious honors, and was a coauthor of the CMA/AMA’s new policy on the topic of this essay. He is a member of the SFMS.

Eric Denys, MD

A Better Option than Rationing Care

RATIoNAL cARE


Choosing Wisely

Allan Treadwell, MD

Lessons from working with Less

cULTRAL coMPARISoN

In the past few years the national discussion about health care costs has been brought into sharp focus, but when I was a fourth-year medical student in the early 1990s, the national dialogue about health care costs and overutilization was still largely academic. Although there were editorials railing against the fact that 12 percent of our gross domestic product (GDP) was spent on health care (remember the days of 12 per-cent?), on the medicine wards the concern of overutilization was largely drowned out by the burgeoning AIDS epidemic and the looming senescence of the baby boomers. On hospital rounds cost was never discussed, and even when of questionable medi-cal utility, studies were often justified with the argument that we were in an academic setting and would be able to learn more the more tests we ordered.

It was against this backdrop that I served an eight-week rotation in Micronesia at the Chuuk State Hospital. Having come from a large, academic medical center in the U.S., it was both terrifying and foreign to suddenly find myself in a setting where the most advanced tests we had included an I-Stat and an outdated X-ray machine. But it was also there where I first found myself acting truly as a physician. With limited testing available, I was forced to treat patients almost exclusively based on my history and physical exam. I listened to patients more closely, examined them more closely, and spent more time observing them and their illnesses.

I became more adept at recognizing Janeway lesions, the machinery murmur of a patent ductus arteriosus, and the sub-tle denervated skin lesions of Hansen’s disease. To my surprise I found that I could actually diagnose most patients correctly, and as I became more confident in my skills I wondered why in the U.S. we relied so heavily on expensive testing. Ancillary testing had in many ways replaced the art of medicine in the U.S. Of course, I’m not confident enough to believe that we were 100 percent correct in our diagnoses, but it was clear that the vast majority of these patients did not need the extensive and expensive testing they would have received in the U.S. My grow-ing skepticism of high-tech medicine was further heightened by the treatment I witnessed of patients at the end of life. These patients, who themselves knew that their time left was short, were treated with empathy and dignity because those were the only treatments we had to offer. Their deaths were marked by a simple pronouncement, often with family at the bedside, rather than the rattling crash cart, beeping monitor, chest compres-sions, ventilator, and other medical paraphernalia to which I had become accustomed in the U.S.

Despite these misgivings, it was also obvious that there were patients whose lives clearly could have been saved with modern medical procedures—patients such as the twenty-sev-

en-year-old father of three who died of a probable pulmonary embolism because his chest X-ray—our only available test—was normal. Would a CT, V/Q scan, D-dimer, or even a pulse oximeter have helped us save his life? And although patients like him rep-resented a small minority, they are the ones who will affect my practice most profoundly because they illustrated the disparity between the two standards of care. It is a hugely frustrating feel-ing to know what to do but not have the resources to do it, espe-cially when a young and potentially healthy life is at stake.

On returning to the U.S., I was left with a deep ambivalence regarding the use of expensive technology. I obviously don’t order a spiral CT with pulmonary embolism protocol for every young patient who comes in with pleuritic chest pain, but I’m certainly glad to know that it is available to me if needed. Living in the U.S., I cannot and do not want to practice medicine as though I were in a third-world country, and obviously my patients don’t want me to, either. But it is increasingly apparent that the choice is not between these two extremes. There is a reasonable balance that can be obtained. Last year, for example, the American Board of Internal Medicine Foundation launched its widely publicized Choosing Wisely campaign (www.choosingwisely.org), which includes lists from a number of medical specialty societies iden-tifying practices that “physicians and patients should question.” On the American College of Radiology’s short list: “Don’t image for suspected pulmonary embolism without moderate or high pretest probability.”

In addition, the recently released Institute of Medicine re-port outlines approximately $750 billion annually in health care waste, calling on physicians to strive for “best care at lower cost.” It recognizes that overutilization is due to a number of compli-cating factors, including an array of economic, cultural, and so-cial pressures. Another important driving force that deserves to be acknowledged is the fact that ordering a test is simply much easier and quicker than sitting with a patient to explain in detail why the test they want isn’t actually necessary.

And that brings up my final point. Although the medical care in Micronesia was clearly technology-poor, it was rich in one re-source that we desperately lack right now in the U.S.: time. Time to spend assessing the patient, time to explain the risks and ben-efits of diagnostic and treatment protocols, time to reflect on dif-ferential diagnoses. More time may lead to more thoughtful care and ultimately to more efficient use of our increasingly scarce resources. In some ways, perhaps, overutilization is a sign of a deeper problem with our health care system—but I don’t really have time to get into that right now.

Dr. Treadwell practices internal medicine at UCSF and is a member of the SFMS. Dr. Christopher Moriates (UCSF) contrib-uted to and edited a draft of this manuscript.


Choosing Wisely


Bertran Tuan, MD

Five Practices to Avoid

SMART oNcoLoGy

United States health care spending is growing at a rapid pace, with a projected cost in 2019 of $4.3 tril-lion, accounting for 19 percent of the national GDP. Cancer costs are expected to rise from $100 billion in 2006 to $173 billion in 2020. Expenditures for cancer patients include the costs of diag-nosis, treatment, hospitalizations, posttreatment surveillance, and, ultimately, costs for end-of-life care. The American Society of Clinical Oncology, the preeminent society for medical oncolo-gists, established a Cost of Care Task Force in 2007 to address the rapidly rising costs of cancer care. In response to the Choosing Wisely campaign, this task force published, in May, “Five Key Op-portunities to Improve Care and Reduce Costs: The Top Five List for Oncology.”

“Practices or interventions that are costly, widely used, and not supported by high-level clinical evidence” include the routine use of imaging for the staging of patients diagnosed with early breast and prostate cancer, surveillance tumor markers and scans for breast cancer patients treated for cure, WBC growth factors following chemotherapy for patients at low risk for febrile neu-tropenia, and, most importantly, the use of chemotherapy for in-curable patients who are declining and have not received benefit from prior chemotherapy.

1. “Do not use cancer-directed therapy for patients with solid tumors who have the following characteristics: low per-formance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and with no strong evidence supporting the clinical value of further anticancer treat-ment.”

A criticism of medical oncologists is that we continue to give chemotherapy to patients with weeks to live. We need to rethink giving nonbeneficial therapy to patients who are bedbound more than 50 percent of the time (PS3) due to their cancer; there is no evidence this therapy will meaningfully prolong survival. I fre-quently tell house staff and referring physicians that palliative chemotherapy for an incurable cancer patient is only advisable if the patient can walk into my office.

A recent trial of targeted therapy for lung cancer combined with standard chemotherapy prolonged median survival by al-most three months; companies would make millions if this were a drug. This therapy turns out to be early palliative care introduced shortly after diagnosis, and the targets are patients and their caregivers. Several studies show that early palliative care inter-vention/hospice enrollment combined with chemotherapy for advanced and incurable patients prolongs survival, provides for more patient comfort and satisfaction, and decreases hospitaliza-tions and reduces cancer costs.

2. “Do not perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metas-tasis. Evidence does not support the use of these scans for staging of newly diagnosed low-grade carcinoma of the prostate (stage T1c/T2a, PSA<10, Gleason score <=6). Because low-risk prostate cancer has a small propensity to metastasize, aggressive clinical staging provides no clinical benefit, despite considerable cost.”

Of the men with low-grade prostate cancer diagnosed only because of PSA elevations without palpable tumor (T1c), or pal-pable in less than one half of one lobe (T2a), less than 1 percent will have positive scans that could preclude curative radiation therapy or surgery. In 2004, 36 percent of 6,444 low-risk men studied through SEER data underwent scans.

3.”Do not perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metas-tasis. Imaging can lead to harm through unnecessary invasive procedures, overtreatment, unnecessary radiation exposure, and misdiagnosis.”

Patients with early breast cancer are highly curable with sur-gery, radiation, and adjuvant chemo/hormonal/targeted thera-pies. Abnormal scan results (in patients with normal labs and physical exams) are almost always false positives, and no data exists to indicate clinical benefit from routine use of these scans.

4. “Do not perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for as-ymptomatic patients who have been treated for breast can-cer with curative intent. . . . To date, there is no evidence from randomized trials that earlier detection of asymptomatic breast cancer recurrence improves survival. . . . [M]ost breast cancer re-currence is detected through clinical symptoms and not through screening.”

Patients with colon cancer benefit from routine postopera-tive CEA surveillance; some patients who develop isolated liver or lung metastases can be cured. There are no studies to show com-parable benefit to patients with breast cancer. What is indicated for breast cancer patients is routine mammography to detect lo-cally recurrent and new primary breast cancers.

5. “Do not use white cell-stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.”

The myeloid growth factors (ten days of subcutaneous fil-grastim or one dose of pegfilgrastim for each cycle of chemothera-py) cost several thousand dollars per cycle and frequently prevent the life-threatening complication of febrile neutropenia necessi-tating hospitalization. Certain regimens for breast cancer and


More information on The Choosing wisely Program

Nine United States specialty societies representing 374,000 physicians developed lists of Five Things Physicians and Pa-tients Should Question in recognition of the importance of phy-sician and patient conversations to improve care and eliminate unnecessary tests and procedures. These lists represent spe-cific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most ap-propriate care based on their individual situation. Each list pro-vides information on when tests and procedures may be appro-priate, as well as the methodology used in its creation.

Read the lists: http://choosingwisely.org/?page_id=13

Specialties Currently Participating: American Academy of Allergy, Asthma & ImmunologyAmerican Academy of Family PhysiciansAmerican College of CardiologyAmerican College of PhysiciansAmerican College of RadiologyAmerican Gastroenterological AssociationAmerican Society of Clinical OncologyAmerican Society of NephrologyAmerican Society of Nuclear Cardiology

More specialties to join in 2013!

lymphoma carry a high risk of causing febrile neutropenia, and growth factors are indicated when starting chemotherapy. Older and medically frail patients who may develop febrile neutropenia from less intense chemotherapy may be offered these factors for primary prevention. These factors should not be used prophylac-tically when chemotherapy is initiated for low-risk patients.

In the spirit of Choosing Wisely, we should reconsider our use of technology and costly medicines and push for the early implementation of palliative care services that can improve the lives of our patients.

Dr. Tuan is an attending physician in the department of medi-cine at California Pacific Medical Center and has been in the private practice of medical oncology and hematology for the past 19 years at Pacific Hematology-Oncology Associates. He is also a member of the SFMS.

References1. Schnipper L et al. American Society of Clinical Oncol-

ogy identifies five key opportunities to improve care and reduce costs: The top five list for oncology. Journal of Clinical Oncology. 2012; 30:1715-1724.

2. Smith TJ, Hillner BE. Bending the cost curve in cancer care. New England Journal of Medicine. 2011; 364:2060-2065.

3. Temel JS et al. Early palliative care for patients with meta-static non-small-cell lung cancer. New England Journal of Medi-cine. 2010; 363:733-742.

Matt Dickstein Business Attorney

RepresentingMedical Practices Since 1994

* Medical Corporations * Stark & Kickback / Regulatory Compliance * Employment & Contractor Agreements * Breakaway Physician Competition * Buying & Selling a Practice * Hospital – Group Contracts * Leases for Medical Offices * Multi-Discipline Practices Idea of the Month: Why does man kill? He kills for food. And not only food: frequently there must be a beverage. – Woody Allen

39488 Stevenson Pl. #100 Fremont, CA 94539 510-796-9144 [email protected]

mattdickstein.com

CLiNiCAL REsOURCEsDrUg ABUsE AND ADDICTIoN

The National Institute on Drug Abuse (NIDA) is in-terested in improving clinical outcomes by providing science-based resources to clinicians about drug abuse and addiction. To help achieve that goal, NIDA developed NIDAMED, a portfolio of resources for clinicians that in-cludes drug abuse and addiction related screening tools, CME courses, patient materials, and curriculum resourc-es. To access these tools, see: http://www.drugabuse.gov/nidamed-medical-health-professionals.

12th Annual Developmental Disabilities An Update for Health Professionals

March 7-8, 2013 UCSF Laurel Heights Conference Center. This interdisciplinary, interprofessional confer-ence provides a practical and useful update for primary care and subspecialty health care professionals who care for children, youth, and adults with complex health care needs and developmental disabilities. Chairs: Lucy Crain MD, MPH, FAAP, and Geraldine Collins-Bride RN, MS, ANP. For more information visit https://www.cme.ucsf.edu/cme/Index.aspx.

Choosing Wisely

Robert Hendel, FACC, FAHA, FASNC

Choosing wisely in Nuclear Cardiology

PATIENT-cENTEREd IMAGING

Choosing Wisely is an initiative of the ABIM Foun-dation focused on encouraging physicians, patients, and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.

To spark these conversations, the American Society of Nuclear Cardiology (ASNC) and eight other specialty societies created lists called “Five Things Physicians and Patients Should Question”—evidence-based recommendations that should be discussed to help make informed decisions about the most ap-propriate care based on each patient’s individual situation. ASNC developed the following list for cardiac imaging, especially as these situations relate to radionuclide procedures:

1: Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.

Development of this item was based on a wealth of medical literature, as well as the Appropriate Use Criteria for radionu-clide imaging, cardiac CT, and echocardiology (1-3). Additional support may also be found in the 2010 ACCF/AHA Guidelines for the Assessment of Cardiovascular Risk in Asymptomatic Adults (4), as these specifically address the use of myocardial perfusion imaging (MPI): Stress MPI may be considered for advanced car-diovascular risk assessment in asymptomatic adults with diabe-tes, with a strong family history of coronary heart disease (CHD), or when previous risk assessment testing suggests high risk of CHD, such as a coronary artery calcium score of 400 or greater, as these are high-risk markers. Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk as-ymptomatic adults.

Recent studies examining the use of CV testing have shown that performing testing in symptomatic, low-risk patients ac-counts for up to 45 percent of inappropriate stress imaging (5).

2: Don’t perform cardiac imaging for patients who are at low risk.

This is a similar item to the preceding one. Chest pain patients at low risk of cardiac death and myocardial infarction (based on history, physical exam, electrocardiograms, and cardiac biomark-ers) do not require stress radionuclide myocardial perfusion im-aging, stress echocardiography, or cardiac CT angiography as an initial testing strategy if they have a normal electrocardiogram (without baseline ST-abnormalities, left ventricular hypertrophy, preexcitation, bundle branch block, intraventricular conduction delay, or paced rhythm; or if they are on digoxin therapy) and are able to exercise (1-3,6). The assumption is that if any test is need-ed, a standard ECG exercise test will suffice.

3: Don’t perform radionuclide imaging as part of rou-tine follow-up in asymptomatic patients.

Performing stress radionuclide imaging in patients with-out symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may lead to unnecessary invasive procedures and excess radia-tion exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation or at least two years after PCI (1). However, if symptoms recur or there are concerns about incom-plete revascularization, then stress imaging may be reasonable. Additionally, repeat testing, even among patients who have not undergone coronary revascularization, is not indicated unless there is a change in symptomatology.

4: Don’t perform cardiac imaging as a preoperative as-sessment in patients scheduled to undergo low- or interme-diate-risk noncardiac surgery.

Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery or with no cardiac symptoms or clinical risk factors undergoing intermediate-risk noncardiac surgery. Low-risk surgery would include minor procedures such as breast biopsies or eye surgery. Clinical practice guidelines have been clear that this practice should not occur and there are no data to support the use of stress MPI or stress echo in these settings. (See JACC published guidelines for periop risk.) These types of testing do not change the patient’s clinical management or outcomes and will result in increased costs—both direct and downstream expenses. Additionally, there is no evidence to dem-onstrate that patient outcome will be altered by testing preop-eratively, except in high-risk patients and those with multiple risk factors who are functionally limited. Therefore, it is not ap-propriate to perform cardiac imaging procedures for noncardiac surgery risk assessment in patients with no cardiac symptoms or few clinical risk factors, or for those who have moderate-to-good functional capacity (1-3,7).

5: Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

The most critical step to reduce or eliminate radiation expo-sure is appropriate selection of any test or procedure for a spe-cific person, in keeping with medical society recommendations, such as appropriate use criteria. However, when testing is to be done, imagers must incorporate new methodologies to reduce patient exposure to radiation while maintaining high-quality test results (2,5,7,8). This may be accomplished by dose modulation


www.sfms.org jaNuarY/FEbruarY 2013 SaN FraNCISCO MEdICINE 2120 SaN FraNCISCO MEdICINE jaNuarY/FEbruarY 2013 www.sfms.org

and prospective gating techniques in cardiac CT, as well as the use of high-sensitivity gamma cameras and stress-only protocols in nuclear cardiology.

ASNC is dedicated to continuous quality improvement and patient-centered imaging. Campaigns such as Choosing Wisely help make patients informed health care consumers. It is the responsibility of the clinician to educate patients about ap-propriate use and its relationship to their safety. The Choos-ing Wisely campaign has encouraged dialogue about care be-tween patients and clinicians, weighing risks and benefits, with a discussion of supporting literature. Most patients simply want to be part of the conversation.

These conversations must be put into the context of both patient-centeredness and what medical literature and expert consensus support. It is sometimes challenging to explain to a patient that not doing a test is often the best (and most appropri-ate) approach. It all begins with a diagnostic evaluation, which usually involves a low-risk, low-cost test. However, performing such a test may lead to additional testing or even treatment, even in the absence of clear benefit. This may cause both risk and ad-ditional cost for the patient. A screening test, when abnormal, may lead to a confirmatory test, often with increased risks to the patient (undergoing stress testing, adverse effects to medi-cations, exposure to radiation) and additional costs to society. However, though a high-risk population may greatly benefit from the early detection of disease, such testing should not be indis-criminately used for all patients, especially those at low risk for cardiovascular events.

Nuclear cardiology techniques remain among the most reli-able tests to evaluate heart disease, especially for patients with a high risk of coronary artery disease. Testing is and will remain a critical tool for cardiologists. However, a key concept behind many quality initiatives and appropriate-use criteria must be kept in mind: the right test for the right patient at the right time. Quality assurance and patient-centered imaging must be at the forefront of nuclear cardiovascular education campaigns such as Choosing Wisely, which help promote best practices within the medical community.

Dr. Robert Hendel, FACC, FAHA, FASNC, associate chief, Clini-cal Cardiology at University of Miami Miller School of Medicine, is a past president of the American Society of Nuclear Cardiology (ASNC). ASNC is the leader in education, advocacy, and quality for the field of nuclear cardiology. Serving more than 4,500 individuals in more than 50 countries, ASNC is the only professional associa-tion dedicated to the dynamic subspecialty of nuclear cardiology. Visit www.asnc.org to learn more.

References 1. Hendel RC, Berman DS, Di Carli MF et al. ACCF/ASNC/ACR/

AHA/ASE/SCCT/SCMR/SNM 2009. Appropriate use criteria for cardiac radionuclide imaging: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomog-raphy, the Society for Cardiovascular Magnetic Resonance, and the

Society of Nuclear Medicine. Journal of the American College of Car-diology. 2009; 53:2201-29.

2. Taylor AJ, Cerqueira M, Hodgson JM et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the Ameri-can Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology. 2010; 56:1864-94.

3. Douglas PA, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Ameri-can Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiog-raphy and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardio-vascular Magnetic Resonance. Endorsed by the American College of Chest Physicians. J Am Coll Cardiol. 2011; 57(9):1126-1166.

4. Greenland P, Alpert JS, Beller GA et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010; 122:2748-64.

5. Hendel RC, Cerqueira M, Douglas PS et al. A multicenter as-sessment of the use of single-photon emission computed tomogra-phy myocardial perfusion imaging with appropriateness criteria. J Am Coll Cardiol. 2010; 55:156-62.

6. Hendel RC, Abbott BG, Bateman TM et al. The role of radio-nuclide myocardial perfusion imaging for asymptomatic individu-als. Journal of Nuclear Cardiology: Official Publication of the American Society of Nuclear Cardiology. 2011; 18:3-15.

7. Fleisher LA, Beckman JA, Brown KA et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009; 54(22):e13-e118.

8. Cerqueira MD, Allman KC, Ficaro EP et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. Journal of Nuclear Cardiology: Official Publication of the American Society of Nuclear Cardiology. 2010; 17:709-18.

9. Douglas PS, Carr JJ, Cerqueira MD et al. Developing an action plan for patient radiation safety in adult cardiovascular medicine: Proceedings from the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Asso-ciation Think Tank held on February 28, 2011. Journal of the Ameri-can College of Cardiology. 2012; 59:1833-47.

10. Depuey EG, Mahmarian JJ, Miller TD et al. Patient-centered imaging. Journal of Nuclear Cardiology: Official Publication of the American Society of Nuclear Cardiology. 2012; 19:185-215.


Choosing Wisely


Mark Smith, MD, MBA

Recommendations from the institute of Medicine

A LEARNING HEALTH cARE SySTEM

In the United States, we provide world-class servic-es to some, while others receive substandard care and experience unnecessary harms. Spiraling costs strain national, state, and local government, corporate, and fam-ily budgets. Equally troubling, far too much of the nation’s invest-ment in health care is wasted on care that does little to improve patients’ health or quality of life. Approximately 30 percent of health spending in 2009, roughly $750 to $765 billion, was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Yet available knowledge is too rarely applied to improve care. Medical care delivery is frequently not guided by evidence, with Americans receiving only about half of the preventive, acute, and long-term care recommended by cur-rent research and evidence-based guidelines.

Deficiencies in care quality are not due to constraints on ex-penses. Costs have increased at a greater rate than the economy as a whole for thirty-one of the past forty years. In fact, this in-crease in health care costs has contributed to stagnation in real income for U.S. families. Although average income has increased by 30 percent over the past decade, these gains have effectively been eliminated by a 76 percent increase in health care costs.

Beyond the increasing stores of biomedical and clinical knowledge, changes in disease prevalence and patient demo-graphics have altered care delivery. For example, in 2000, 125 million people were affected by chronic conditions; by 2020, the number is projected to increase to an estimated 157 million. It would take an estimated twenty-one hours a day for individual primary care physicians to provide all of the care recommended to meet their patients’ acute, preventive, and chronic disease management needs. Clinicians in intensive care units must man-age in the range of 180 activities per patient per day. Medicare patients now see an average of seven physicians, including five specialists, split among four different practices, for their health care. In a single year, a typical primary care physician coordi-nates with an average of 229 other physicians in 117 different practices just for that physician’s Medicare patient population.

What’s needed is a care system that consistently delivers reliable performance and constantly improves with each care experience—in short, a system with an ability to learn. The good news is that opportunities exist to build one. In 2012 the Insti-tute of Medicine (IOM) issued a report, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”1, which addresses a number of these issues.

A Learning system Among the Recommendations of the IOM Committee

• Health care organizations should embrace new tools, such as online patient portals, to gather and assess patients’ perspec-tives and use the information to improve their care delivery.

• Increased transparency about costs and outcomes should be a hallmark of institutions’ organizational cultures.

• Linking clinicians’ performance to patient outcomes and measuring performance against internal and external bench-marks allow organizations to enhance their quality and become better stewards of limited resources. In addition, managers should ensure that their institutions foster teamwork, staff em-powerment, and open communication.

• Data generated while delivering care—whether clinical, delivery process, or financial—should be collected in digital formats, compiled, and used for managing care, improving pro-cesses, strengthening public health, and generating knowledge.

• Patients should participate in developing robust data util-ity; use new tools, such as personal portals, to better manage their own care; and be involved in building new knowledge, such as through patient-reported outcomes.

• Decision-making support tools and knowledge manage-ment systems should be included routinely in health care deliv-ery to ensure that decisions made by clinicians and patients are informed by the best evidence.

• Among possible actions, clinicians and health care orga-nizations should adopt tools that deliver reliable clinical knowl-edge to patients. Research organizations, advocacy organizations, professional specialty societies, and care delivery organizations should facilitate the development, accessibility, and use of evi-dence-based and harmonized clinical practice guidelines.

Implementing these recommendations will be highly dis-ruptive—and absolutely necessary. The choice is not whether or when to begin the overdue transformation, but how.

Mark Smith, MD, MBA, is president and chief executive officer of the California HealthCare Foundation. This essay is based on a viewpoint that appeared in JAMA, Oct. 23, 2012, coauthored with George Halvorson and Gary Kaplan, MD.

Reference

1. Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best care at lower cost: The path to continuously learning health care in America. Committee on the Learning Health Care System in America, Institute of Medicine. September 2012. http://www.nap.edu/catalog.php?record_id=13444.


Choosing Wisely

unavailable, so she was “boarded” and spent the entire night sleeping on a gurney in the emergency room.

Only when other patients had been discharged from the hospital on Friday was my mother admitted to a regular hos-pital bed. Because of the delay, her planned procedures were postponed until Monday. On Saturday, she suffered a severe stroke that would claim her life. She had not received the blood thinners as planned while she spent the night in the emergen-cy room. Key treatments are often missed while patients are boarded this way.

My mother’s story highlights how perverse business incen-tives lead to undesirable compromises in the quality of care, for it is business forces that lead hospitals to allocate precious beds and resources in this illogical manner, and to board patients in the emergency department.

The primary limitation of Goldhill’s solution is that busi-ness itself also needs to be reformed, as greed and profiteering plague both our financial sector and its intrusion into medicine. Goldhill fails to recognize that blind adherence to business principles helped lead America into this modern health care mess to begin with and that the current construct of health care finance has enormously benefited businesses since the 1940s.

He does not discuss the business factors that spurred the development of modern financing, and how business has prof-ited enormously over the decades in perpetuating this flawed construct. He falls into the trap of using failed business argu-ments to justify repeating the mistakes of the past, applying the same arcane arguments used in the 1940s to expand an employer-based health care system, and in 1965 to introduce Medicare and Medicaid. To simply reuse these failed business principles and arguments to reform health care in 2012 is to repeat the mistakes of the past.

Goldhill comes close to the real solution when he raises the topic of rationing, but he stops short. Business forces contribut-ed to my mother’s death, and business forces are what need to be dismantled in health care as they drive the flawed system. It is unclear to me how the changes Goldhill suggests would have prevented the deaths of either of our parents.

The beast of American health care, as Goldhill refers to it, needs to be attacked directly. The answer is to design a fair sys-tem where everyone receives an adequate—and sufficient— amount of health care. Better solutions to allocate our precious medical resources will be revealed after our nation ceases to regard health as a commodity, and comes to understand the key principle that health care is a public good.

John Maa, MD, is an assistant professor of surgery at UCSF and a member of the SFMS. This article originally appeared in the San Francisco Chronicle.

Catastrophic Care: How American Health Care Killed My Father and How We Can Fix ItBy David Goldhill (Knopf; 369 pages; 25.95)

The latest salvo in a series of books seeking solu-tions to reform health care comes from American businessman David Goldhill, president and chief executive officer of the cable network GSN. In 2009, Goldhill’s acclaimed article in the Atlantic magazine chron-icled the death of his father from an infection acquired after five weeks of hospitalization in the intensive-care unit of one of New York City’s leading hospitals. Frustrated by this tragic death, Goldhill was inspired to carefully research and trace the evolution of the daunting problems plaguing both the financing and delivery of care in our modern American health industry.

Applying his business background, Goldhill deftly dissects the peculiar origins of health care financing in America. In do-ing so he draws an analogy between our American system and the Galapagos Islands. American health care, he says, is discon-nected from reality (as opposed to a mainland) by the lack of natural-selection pressures to evolve, particularly from a lack of consumer input into the pricing and assessment of the qual-ity of care delivered.

In the remainder of the book, Goldhill dismantles myths, challenges assumptions, explains the unintended consequenc-es of policy mandates over the decades, and searches for solu-tions to tow our health care system back into the “mainland” of sanity.

Goldhill believes the solution is a balance of health ac-counts, health loans, and a mandatory high-deductible cata-strophic insurance program. He doubts the Affordable Care Act will solve our problems, speculating extensively throughout the book that Obamacare may actually only worsen the crisis by simply propping up a collapsing system.

Ultimately, the book suffers from blind spots similar to those of many previous books on this topic. It works around the edges, seeking indirect solutions without fully attacking the central challenges of the health care delivery system. Goldhill’s father’s bills were paid for by the same Medicare system that he criticizes, referring to it, along with Medicaid and the private insurance industry, as the surrogates that are fueling the crisis in health care.

I understand how Goldhill feels. Four years ago, my six-ty-nine-year-old mother was admitted to a hospital through the emergency room. The plan was for her to start receiving blood-thinning medications to prevent a blood clot that might cause a stroke, and to undergo procedures the next day (a Fri-day), to correct her abnormal heart rhythm. A hospital bed was

John Maa, MD

A Book Review

cATASTRoPHIc cARE


SFVAMCDiana Nicoll, MD, PhD, MPA

The Department of Veterans Affairs (VA) has been a leader in the use of telehealth—as has the San Francisco VA Medical Center (SF-VAMC), which, since 2005, has been one of the earliest in the VA to offer telehealth programs. The clear advantage of telehealth is that it re-duces the overuse of medicine by providing efficient, cost-effective care, and it eliminates or decreases the incidences in which patients must travel—sometimes great distances—to receive care. It also enables patients to choose wisely instead of using an emergency depart-ment for nonurgent visits. For the patient, it results in a substantial savings of time and medical costs to be able to connect with a pri-mary provider (or specialist) at home or at a nearby VA outpatient clinic.

Home telehealth permits veterans, in the convenience of their homes, to communicate with a primary care physician by using a por-table device that transmits vital signs and an-swers to preprogrammed questions that help assess and manage their health needs. Clini-cal video telehealth allows veterans to talk to specialists by videoconferencing into our Medical Center from community-based out-patient clinics. Store-and-forward telehealth, commonly used in dermatology, captures and stores images, which are sent for expert inter-pretation.

SFVAMC has the strongest VA telehealth program in the nation. Excellent patient sat-isfaction scores confirm that patients are pleased with telehealth services. Our patients in our Eureka clinic can use telemedicine to avoid the six-hour commute (each way) to see a specialist.

KAISERRobert Mithun, MD

HoSPITAL NEwS

The Patient Protection and Affordable Care Act (aka ACA) provides physicians with a chance to change an unsustainable system and chart a new course for the future. How-ever, major culture changes in health care delivery for the country won’t come easily. At Kaiser Permanente, we feel fortunate that one of the central tenets of the ACA, shifting from a model in which quantity is rewarded over quality, has been our focus for years.

The Permanente Medical Group is com-prised of a closed network of more than 15,000 physicians, and this has allowed us to choose an alternative path to deliver health care for years. As providers, we freely com-municate with one another and our patients via phone, e-mail, or other simple and im-mediate modalities because we have no in-centive not to do so. Our communications are enhanced by a state-of-the-art electronic medical record (EMR), where all medical in-formation about a patient is efficiently stored and available for those who need access, in-cluding providers and patients.

How does the EMR enable us to make wise choices? Information is available in real time so decisions can be made accurately; physicians freely consult with one another with immediacy so that they order the most appropriate tests; and redundant tests are or-dered infrequently, saving patients from such risks as radiation exposure.

Decision-making tools are also impor-tant to help providers deliver the best evi-dence-based care for their patients. For ex-ample, our EMR includes links to calculators that allow a provider to decide whether to initiate warfarin in atrial fibrillation or start a statin for hypercholesterolemia.

We have challenges ahead, but learn-ing from past experience and aiming toward high-quality and efficiently delivered care in an environment that supports both provider and patient decision making, we will continue to lead the way toward excellent care and sus-tainable medical practice.

Saint FrancisPatricia Galamba, MD

As the world of health care grows in-creasingly complex, the role of the primary care physician is becoming more important. Moving into the year 2013 and beyond, and with the health care landscape changing so dramatically, it’s a good time to remember the role of the primary care physician in a pa-tient’s life and from their perspective.

I’ve always viewed my responsibility as a primary care physician as being some-one who is a not only a patient’s navigator of care through illnesses and treatment but also through a complicated health care system. While specialists look at patients through their lens of expertise, primary care physi-cians help negotiate care and view patients as the whole person. It’s crucial in this new arena of “more for less” medicine that PCPs are treated with fairness and equity, because we are stewards for the patients, offering per-sonalized, comprehensive treatment plans.

So it is within this role, as the entry points into the complexities of the health care world, that PCPs should view themselves as advocates for their patients and their total health. That’s why I have always stressed the importance of a strong patient-physician re-lationship based on mutual respect and un-derstanding.

As time passes and we gain more experi-ence in dealing with the Affordable Care Act, it’s likely we’ll see more prospective patients searching for the right primary care physi-cian. I see this as an opportunity for us to help educate patients on some of the important aspects of choosing a new PCP. For instance, I often find myself advising patients to select an insurance plan that will give them the most op-tions within their budget. Or a medical group that includes a large network of specialists and linkage to hospitals. We understand the im-portance of these initial steps, but to a patient, these choices can seem daunting and complex. Now more than ever, it’s vital that we work to-gether to respect the needs of our patients so they may be empowered to choose wisely in their own health care.


St. Mary’sPeter Curran, MD

On the surface, the subject of appropri-ateness in physician treatment decisions may cause some in our noble profession to squirm. Have not years spent in education and training provided us the benefit of the doubt when it comes to deciding what is best for our patients? Besides, medicine is described as both science and art—there often is no one correct answer to a differential diagnosis or treatment plan, and the overused catchphrase “evidence-based medicine” does not trump caring for the indi-vidual patient. Using good judgment in medical decision making is not a new concept. The hos-pital ethics committee, a medical staff creation, helps with the more difficult questions related not to “Can we do something for our patient?” but rather “Should we, and why?” From a hos-pital administration standpoint, utilization re-view has been nudging doctors since the 1990s to watch our patients’ length of stay. Insurance companies and managed care organizations ask us to justify the tests we order and the pro-cedures we perform. Despite these measures, health care costs are too high for the outcomes we get in this country. Health care reform will make some choices for us, regardless of how wise they may be. While we come to grips with what parts of Obamacare work and what parts ultimately get changed or discarded altogether, it may look at times like treating a leaky faucet by simply turning off the water. The real fix must go back further to how we train doctors in the first place, to becoming more transparent with our patients regarding the actual costs of medical care, and to meaningful tort reform for medical malpractice. Gone are the days when physicians can go through training without knowing what their prescribed treatment costs, having our patients accept our decisions with-out discussing the medical and economic impli-cations, or going through a medical career fol-lowing the trial attorney’s mantra that lawsuits are simply “the cost of doing business.” Maybe Napoleon said it best about the value of using good judgment when he said, “I have plenty of clever generals, but just give me one lucky one.” Choose wisely, fellow colleagues!

CPMCMichael Rokeach, MD

In late December, a memorial service was held to honor the life of Dr. Stephen Hufford. The event was attended by family, friends, and CPMC colleagues and staff who celebrated the life and work of this extraor-dinary physician. For those wishing to honor Dr. Hufford, a memorial fund has been es-tablished and will be used to install a bench in one of our local parks to honor his love of nature. The Stephen T. Hufford Memorial Fund is being administered through First Re-public Bank. For more information, you may contact Sudarat Smith at (415) 831-6688 or [email protected].

Thank you to everyone who attended the Community Health Resource Center’s open house celebration this past November. The event was held to honor the life and achieve-ments of the late Dr. Damian Augustyn. Dr. Eliza McCaw was also honored for her con-tinued support. Both have contributed to success of the Center, which offers affordable disease prevention and wellness services.

Congratulations to Dr. Michael Abel, who was recently appointed chair of the De-partment of Surgery for a five-year term that began January 2013. Dr. Ari Baron was also appointed chief of the Division of Hematol-ogy/Oncology. Dr. Baron assumed the role formerly held by the late Dr. Stephen Hufford.

Medical staff members recently elected Medical Executive Committee (MEC) Mem-bers-at-Large for the term January 1, 2013, through December 31, 2014. Drs. Oded Herbsman and Ovidiu Dumitrescu were elected for a second term as MEC Members-at-Large, along with two new Members-at-Large: Drs. Benson Chen and Aaron Rang.

The Continuing Medical Education pro-gram at CPMC was recently awarded a four-year reaccreditation by the Institute for Medi-cal Quality. A special thanks to CME committee members and our physician leaders for their continued commitment to provide quality ed-ucation to our medical staff members.

The rapidly escalating costs encountered in the development of new therapies and di-agnostics, as well as in the delivery of health care, are unsustainable. Drug development costs now exceed $1 billion for an approved therapy, greatly limiting development of new therapies and outstripping the capabilities of biotech venture capital to fund high-risk development. Overall health care costs now consume about 17 percent of the U.S. gross domestic product, a rate that burdens the economy as a whole, reduces U.S. competi-tiveness on the global market, and limits our ability to improve health overall.

The new UCSF Center for Healthcare Value (CHV) has been created to promote and support initiatives that address these issues and ultimately deliver high-quality health care at lower cost. The CHV also aims to de-velop a national model to harness the unique strengths of academic medical centers to in-crease health care value and bring UCSF to the forefront in addressing these unsustain-able costs.

The CHV brings together expertise in clinical care, research methods, implemen-tation sciences, health policy, health care delivery, law, information technology, entre-preneurship, and business to address the bar-riers to providing high-quality, efficient, and cost-effective health care and innovation.

The CHV is already engaged in key partnerships and intends to collaborate with organizations involved in the financing of health services, such as medical centers and insurers. Partner-identified priorities for improvement will be matched with experts in care delivery and outcomes assessment, with the center soliciting, fostering, and vetting interventions that deliver high-value health care. In tandem, longer-term interventions in training, education, and cultural change will pave the way for broader impact. For more on the center and its work, visit http://healthvalue.ucsf.edu.

UCSFMichael Gropper, MD


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January/February 2013

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