San Francisco Medical Society Blog

Medical Volunteerism: Helping Out in Your Own Backyard

Tue, 19 Mar 2013 16:55:12 GMT

This article was originally posted on The Turek Clinic Blog on March 18, 2013. Dr. Paul Turek is a SFMS member and an internationally known thought leader in men’s reproductive and sexual health care and research.

By Paul Turek, MD, FACS, FRSM

What makes you feel like a good citizen? Is it giving blood? Coaching your kid’s team? Volunteering at a school or shelter? Church work? Voting? Recycling? What is it that makes you feel part and parcel of the wide, wide world around us?

I asked this question of myself recently. As a doctor, quite naturally I thought of helping people. I am a big fan of the “smallest things make the biggest difference:” opening doors for others and helping the elderly cross the street. But what struck the most resonant chord with me was my commitment to the little free clinic that could right here in San Francisco.

It Stole My Heart

The full story behind my devotion to Clinic by the Bay is published in this month's San Francisco Medicine journal. It’s funny how such large commitments begin so innocently.

It was during a busy cystoscopy clinic at the Veterans Affairs Hospital. Vets in half buttoned medical gowns were meandering all around. And there was Janet Reilly, oblivious yet focused: “Hi, Paul… I really need you to help me get medical professionals, especially retired ones, to volunteer in a free clinic.”

The wall went up. How could I possibly add any more to my schedule? My days at UCSF were chock full of teaching, research, grants, clinics, committees and travel. And then there was the young family. As an academic surgeon, I was spinning at tortuously high rpm, barely holding things together and here was yet another demand on my time.

But her dream was clear. She wanted to start a volunteer-powered, free clinic for the working uninsured in San Francisco, a population of about 63,000 at the time. I emailed her back later that same day and said “Count me in.”

Why I Said Yes

I have always been interested in medical volunteerism, but this was not exactly how I pictured myself getting involved as a professional. During training, I had volunteered in fantastically needy and faraway places like Dakar, Senegal and always imagined going back to the Third World again, when I could offer more expertise and wisdom. But this proposal was different: it awakened me to the opportunities to help in my own backyard. And that’s why her offer was so compelling to me. I didn’t have to fly 16 hours to another continent and leave my family for weeks at a time to help others.

Volunteering is really quite possible in smaller, less disruptive, doses and nearer to home, where I live. It’s really the same giving feeling, just spread evenly over everyday life.

Looking Back

Since I became involved during the Clinic’s planning stages 7 years ago, I have never looked back. As a Founding Board member and Chair of the Medical Advisory Board, my involvement has only deepened with time. Why did I become, and why do I remain, involved with Clinic by the Bay? Honestly, because it feels good to give back in an understated, everyday way. And every single one of the following matters deeply to me:

Providing the gift of better health
Giving back in your own backyard.
Helping fellow citizens in an incredibly fundamental way
Making the community a better place
Doing what you love to do
Coming home to your family with a big smile on your face

I know I keep repeating the words attributed to that dotty-old-cigar-smoking-Brit Winston Churchill, but they still ring true for me: “You make a living by what you get; you make a life by what you give.”

So, I offer you, right here and now, an opportunity to share in this historical experience, one that is unfolding as you read this. Our history is being made every day; help us shape it.

Volunteer Opportunities

Physicians--retired or currently in practice--can make a difference at Clinic by the Bay with minimal time commitment.

Volunteer at least 4 hours/ month during evening clinic; or,
Participate in the Physician Advisory Panel to dispense real-time medical advice over the phone to Clinic by the Bay clinicians once or twice a month.

Click here for detailed information on physician volunteer opportunities or email David Goldschmid, MD, Medical Director of Clinic By the Bay.

Click here to view the March 2013 issue of San Francisco Medicine and other physicians' perspectives on medical philanthropy.

Choosing Wisely: Up Close and Personal

Tue, 19 Feb 2013 16:22:13 GMT

This article was originally published in the January/February 2013 issue of San Francisco Medicine.

By 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 being 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 helmet 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 consciousness, 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 something was wrong and we missed it.”

When I first heard about the idea for the Choosing Wisely campaign, 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 prescription 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 generates many more diagnostic studies. The tests that follow are often more invasive and more risky. And some of those benign therapeutic 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

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-ribbon 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.² 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 estimated 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.³

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. 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 develop lists of tests and treatments that are often given to patients unlikely to benefit from them. Using these lists, the ABIM Foundation 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 rationing, 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.

The work on Choosing Wisely is not done yet, however. Developing and disseminating the lists is a starting point. The important 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.⁴ 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.⁵ Next steps in this work include formulating 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 reassurance to worried patients. Medical students and residents need to learn when to watch and wait rather than prescribe unnecessary 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 organizations, 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, explained 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 symptoms 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 conversation 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.

Click here for more information about the Choosing Wisely campaign and partnering organizations.

Click here to access the January/February 2013 issue of San Francisco Medicine focusing on the Choosing Wisely campaign and perspectives from physicians of different specialties about reducing waste in medicine.

Medical Professionalism Project. Medical professionalism in the new millenium: A physician charter. Ann Intern Med. 2002; 136(3): 243-246.
Brody H. Medicine’s ethical responsibility for health care reform—The top five list. New Engl J Med. 2010; 362:283-285.
The Good Stewardship Working Group. The top five lists in primary care: Meeting the responsibilities of professionalism. Arch Intern Med. 2011; 171(20):1858-1859.
Campbell EG et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007; 147:795-802.
Emanuel EJ, Pearson SG. Physician autonomy and health care reform. JAMA. 2012; 307 (4): 367-368.

December SFM Crossword (Cranial Nerves) Puzzle Answers

Mon, 17 Dec 2012 13:50:12 GMT

Answer to the December 2012 San Francisco Medicine crossword puzzle, Cranial Nerves.

SFMS Develops Updated Domestic Violence Guide for Clinicians; Covers Screening, Diagnosis, Documentation, and Reporting Protocols

Wed, 28 Nov 2012 12:23:56 GMT

Back by popular demand! The SFMS has updated and published a short guide on domestic violence screening and intervention for physicians and other clinicians in consultation with some of the most experienced clinicians in this arena.

Published in the December issue of San Francisco Medicine as an insert and also available on the SFMS website, this guide represents a concise and clinically based approach to this complex issue, distilling knowledge from existing, longer documents. Covered topics include:

Screening questions
Diagnosis
Intervention options
How to document medical records
Reporting protocol

The original guide has been widely distributed and well received by clinicians citywide and beyond, and it was cited in the Journal of the American Medical Association as one of the best such resources. This new version has been updated with current contact information and new information.

Click here to see the SFMS Domestic Violence Guidelines.

San Francisco POLST Coalition Update: Mainstreaming Palliative and End of Life Care

Wed, 24 Oct 2012 15:28:41 GMT

By Jeffrey Newman, MD, MPH, and Steve Heilig, MPH

“When it came time for my family to discuss end-of-life care issues for my father, the POLST framework was invaluable. It greatly facilitated early and useful dialogue and allowed us to come to a very comfortable consensus despite a longstanding history of disagreement over his earlier long-term care issues.” —Keith Loring, MD, FACEP, emergency physician and SFMS board member

There is an ever-increasing focus on health care provided toward of the end of life, for multiple reasons. For one thing, there is growing awareness that end-of-life care has often fallen short of what is desirable and possible, and thus the growth of palliative care, new models of long-term care, and so on. A generation of baby boomers is bringing their high expectations for self-determination into their later years. New policies will force attention to cost issues as reimbursement becomes more tied to quality and use standards.

The modern medical ethics movement can be seen at least in part as a “patient empowerment” trend, and one way this has been codified into practice is through the use of various advance directives used to document patient preferences for care. The documents have been available for decades, but still only a minority of patients completes them. And it must be admitted that more forms are not a panacea—but they can help immensely when patients might no longer be able to tell clinicians what they desire.

The SFMS and some key partners have been working with grants from the Metta Fund and the California HealthCare Foundation to support a number of activities increasing conversations among patients with advanced illness, their physicians, and other health care professionals. Advanced directives and POLST documents are more widely used in nursing homes, hospitals, and ambulatory care. Again, however, most patients in the “last chapter” (operationally defined as life expectancy of less than a year) still do not take advantage of these opportunities. A recent survey of EOL attitudes and practices among California adults reveals that while 82 percent believe that it is important to have wishes in writing, only 23 percent have done this; 47 percent would like to have “the conversation” with their physician (61 percent of those over 65); and 70 percent would like to die at home, but this occurred in only 32 percent of deaths in 2009.¹

Another recent study of POLST implementation among nursing homes in California indicates that POLST use has become common, especially in areas served by a POLST Coalition, as in San Francisco. We and other Coalitions have assessed the POLST process in nursing homes and offered suggestions for quality improvement.²

Steven Pantilat, MD, a leading figure in palliative medicine at UCSF, has offered the following practical suggestions to increase availability and access to palliative care: Establish organized programs at all hospitals, open access to hospice without giving up advanced illness management, expand the supply of physician and nurse specialists, educate all clinicians in basic palliative care, and educate the public through a marketing campaign.³ Widespread programs to reduce hospital readmissions should also focus on advanced illness and EOL issues that underlie many of these cases. The San Francisco Department of Aging and Adult Services (DAAS) has been awarded a Medicare Community-Based Care Transitions Program (CCTP) contract to provide services through a hospital-to-home transitional care model focused on lowering hospital readmissions. This collaborative model includes DAAS, nine additional community-based organizations, and eight hospitals in San Francisco County. Services include coaching, care coordination, and a support services package of meals, homecare, and transportation. We are exploring opportunities to incorporate assessment of needs for palliative and EOL services and referral.

Among the many ways San Francisco physicians can support this and other hospital readmission efforts is to provide early follow-up appointments for patients after hospitalization—and, when appropriate, initiate referrals to palliative care, advanced illness management, and hospice. And whenever appropriate, consider using a POLST form with your patients—for the third time in this journal, the actual form is included here for your convenience. Your patients, their families, and some of your colleagues will be grateful.

For more information, see POLST California's website. For a copy of the POLST form, click here.

Dr. Jeff Newman is director of the Sutter Health Institute for Research and Education, adjunct professor at UCSF, and a former SFMS board member. Steve Heilig is on the staff of the San Francisco Medical Society and is coeditor of the Cambridge Quarterly of Healthcare Ethics.

References

1. Lake Research Partners and the Coalition for Compassionate Care of California. Final Chapter: Californians’ Attitudes and Experiences with Death and Dying. http://www.chcf.org/publications/2012/02/final-chapter-death-dying#ixzz28ve6oIpt.

2. Wenger NS, Citgo J, OMalley K. Implementation of physician orders for life-sustaining treatment in nursing homes in California. J Gen Intern Med. August 2012. http://link.springer.com/article/10.1007%2Fs11606-012-2178-2.

3. Pantilat SZ. When it’s the right care, more is better. Arch Intern Med. 2012; 172(15):1172-3.

Postscript

At last month’s annual CMA meeting, the following new statewide policy was adopted:

INCREASING UTILIZATION OF POLST ORDERS

Authors: Jeffrey Newman, MD; Leslie Lopato MD, Adam Schickedanz, MD

That to increase and improve use of Physicians Orders for Life- Sustaining Treatment (POLST), CMA encourage physicians to become educated about all aspects of the POLST form and to integrate discussions about, and utilize, POLST in all appropriate instances where medical services are provided to patients at the end-of-life.

Bad Bugs, From Farm to Us: Curtailing Antibiotic Overuse in Agriculture

Tue, 04 Sep 2012 09:57:09 GMT

By Steve Heilig, MPH; Philip R. Lee, MD; and Lester Breslow, MD

Editor’s Note: With ever-increasing microbial resistance to our ever-challenged arsenal of antibiotics, clearly we need to do everything possible to stay ahead in the Darwinian race between bacterial pathogens and humanity. One intervention, increasingly indicated by research and supported by many reputable health organizations, is to decrease the massive prophylactic and growth-promoting use of antibiotics in the production of food, primarily meat.

Ten years ago, the SFMS brought policy to the CMA and then to the AMA urging more careful and curtailed use of antibiotics in food production. We also hosted a daylong invitational conference on this topic, cochaired by two living legends of public health, Phil Lee, MD (a longtime SFMS member, UCSF chancellor emeritus, Stanford medical professor, and former United States Assistant Secretary of Health), and Lester Breslow, MD (dean emeritus of the UCLA School of Public Health, former California state health director, and past-president of the American Public Health Association), along with then-SFMS President George Susens, MD. This meeting resulted in a new network of advocates working to preserve antibiotics, as well as an editorial in the Western Journal of Medicine (then edited by SFMS member Linda Clever, MD). This piece, reprinted below, has become one of the most-cited articles on this topic, no doubt due to the stature of Lee and Breslow. Breslow died in April of this year at age 97, prompting extensive tributes, from the New York Times to many professional forums. Breslow said he saw himself as “a political activist for disadvantaged people”—which, with respect to microbes, could include anybody. This reprint is offered as one more thanks—and, sadly, it remains all too relevant.

Click here for the list of references used in this article.

Antibiotics are arguably the single most important and widely used medical intervention of our era.

Almost every medical specialty uses antibiotic therapy at some point. These drugs have prevented incalculable suffering and death and are perhaps still the closest medications we have to a “magic bullet.”

Of course, bad bugs can bite back, and bacterial adaptation and resistance were reported soon after antibiotics were first used. The struggle to stay one step ahead of pathogens has been widely described and debated. Correcting the overuse of antibiotics in human medicine has gradually become a priority, with slow but heartening progress being gained in this Darwinian race. Still, the rise of multidrug resistance and the ready transfer of resistant traits among pathogens require heightened action if we are to prevent increasing outbreaks of infections that become more difficult, or even impossible, to treat.

One essential course of action is to minimize any and all causes and reservoirs of antibiotic resistance. Besides medical use in humans, there is the troubling issue of use in agriculture, specifically in livestock production. Antibiotics have long been routinely used not only for the treatment of infections but also as a means of getting animals to market faster by growth promotion. Controversies about these practices have resulted in numerous reports, dating back decades, urging more caution or outright bans on the practice. The World Health Organization and other leading medical and public health bodies have advised that animals not be dosed with antibiotics used in humans—to little avail here in the United States to date, even though our own Food and Drug Administration took this position as far back as 1972.¹

Still, many longtime observers of the issue were surprised—or even shocked—to learn the true extent of antibiotic use on farms; estimates are that upward of 70 percent of all antibiotics manufactured are used in agricultural settings.² Although the exact percentages are uncertain, agricultural antibiotic use is apparently more substantial than previously thought. And the type of use is worrisome because it involves continual, subtherapeutic doses that would seem to provide ideal environments for the selection of resistant pathogens.

The introduction of new molecular epidemiologic tools has heightened the worry because these tools have been used to show that resistant bacteria originating on farms are finding their way into humans.^3-10 The extent of this epidemiologic “spillover” to date is uncertain—assertions of the extent of bacterial resistance arising from farms vary widely—and this needs to be a higher research priority. But there is no question that the phenomenon does exist.

Recognizing this risk, the American Medical Association’s House of Delegates adopted a policy that “nontherapeutic use of antimicrobials in animals that are also used in humans should be terminated or phased out based on scientifically sound risk assessments.”¹¹ Reaction from the pharmaceutical industry, in the guise of a trade association of manufacturers of animal drugs, was swift. The Animal Health Institute erroneously claimed “The assertion that there is increasing evidence that resistance developed in animals is spreading to humans is not true,” and it went on to oppose any further restriction on agricultural use.¹²

As a case study of such profit-motivated opposition, Bayer Corporation vigorously contested the FDA’s proposal to withdraw a widely used class of antimicrobial, fluoroquinolones, from agricultural use. These medications are used to combat some of the same bacterial pathogens that are treated with the same drugs in human medicine. Hence, there is a high risk of resistant strains finding their way from animals to humans.¹³ Abbot Laboratories, the other major manufacturer of fluoroquinolones, showed admirable scientific judgment and corporate responsibility in agreeing to the FDA’s request. Unfortunately, judging from the Animal Health Institute’s response to the AMA, we fear the drug industry’s reactions may more closely mirror Bayer’s shortsighted approach. But notably, even some forward-thinking agricultural leaders are now questioning the wisdom of such stonewalling.¹⁴

Admittedly, we tend to give more credibility to those who do not have any financial interest in the status quo. Leading experts unequivocally state that our current practices of feeding antibiotics to animals go against “a strong scientific consensus that it is a bad idea” and that the long stalemate on this issue constitutes a “struggle between strong science and bad politics.”¹⁵ The intentional obfuscation of the issue by those with profit in mind is an uncomfortable reminder of the long and ongoing battle to regulate the tobacco industry, with similar dismaying exercises in political and public relations lobbying and even scandal.¹⁶ As with tobacco control, science and health concerns should take precedence over profit in regulating the overuse of antibiotics in the production of meat and other agricultural products.

Antibiotics do have a place on farms, but the benefits of their use can likely be preserved while minimizing harm. We need to learn more about the extent of risk, but the delay tactic of allowing current practices to continue while “more research” is conducted is unacceptable. Enough is already known to justify a more cautious, preventive approach.¹⁷ Other nations are ahead of the United States in this regard and have banned routine agricultural use, with demonstrable benefit in reduced bacterial resistance.¹⁸

We call on the FDA or legislators to, in the coming year, ban the nontherapeutic agricultural use of antibiotics. This ban should be lifted only if it is scientifically proved, in unbiased studies, that this use does not contribute to bacterial resistance in humans. Producers of agricultural antibiotics should be required to submit data on the specific antibiotics used, in sufficient detail to track usage and resistance trends. Finally, individual and business consumers of meat should begin to demand that the meat they purchase be grown without the routine use of antibiotics.

The need to preserve the efficacy and supply of our antibiotic tools becomes even more crucial. It is time for our government to act in the public interest on this important issue.

Click here for information on the growing campaign surrounding this issue, including the AMA-endorsed Preservation of Antibiotics for Medical Treatment Act (PAMTA, H.R. 965/S. 1211).

For a recent update on how Denmark is leading on this issue, see Pig out: If farmers do not rein in the use of antibiotics for livestock, people will be severely affected. Nature 486, 440. 28 June 2012.

Originally published: West J Med. 2002 January; 176(1):9–11.

References

1. World Health Organization. WHO acts to safeguard vital treatments for the future. WHO/39 September 11, 2001. www.who.int/inf-pr-2001/en/pr2001-39.html.
2. Mellon M, Fondriest S, Union of Concerned Scientists. Hogging it: Estimates of animal abuse in livestock. UCS Nucleus. 2001; 23:1-3.
3. Witte W. Medical consequences of antibiotic use in agriculture. Science. 1998; 279:996-997.
4. Ferber D. Superbugs on the hoof? Science. 2000; 288:792-794.
5. Alliance for the Prudent Use of Antibiotics, Tufts University. Annotated Ecology References. www.healthsci.tufts.edu/apua/Ecology/EcoFaq.html.
6. van den Bogaard AE, London N, Driessen C, Stobberingh EE. Antibiotic resistance of faecal Escherichia coli in poultry, poultry farmers and poultry slaughterers. J Antimicrob Chemother. 2001; 47:763-771.
7. Van Looveren M, Daube G, De Zutter L et al. Antimicrobial susceptibilities of Campylobacter strains isolated from food animals in Belgium. J Antimicrob Chemother. 2001; 48:235-240.
8. White DG, Zhao S, Sudler R et al. The isolation of antibiotic-resistant salmonella from retail ground meats. N Engl J Med. 2001; 345:1147-1154.
9. McDonald LC, Rossiter S, Mackinson C et al. Quinupristin-dalfopristin-resistant Enterococcus faecium on chicken and in human stool specimens. N Engl J Med. 2001; 345:1155-1160.
10. Sorensen TL, Blom M, Monnet DL, Frimodt-Moller N, Poulsen RL, Espersen F. Transient intestinal carriage after ingestion of antibiotic-resistant Enterococcus faecium from chicken and pork. N Engl J Med. 2001; 345:1161-1166.
11. American Medical Association. Antimicrobial Use and Resistance. House of Delegates resolution 508 (A-01), June 2001. www.keepantibioticsworking.com/library/uploadedfiles/American_Medical_Association_Resolution_508_-_.htm.
12. Animal Health Institute. Statement on AMA Resolution on Animal Antibiotics. June 20, 2001.http://www.ahi.org/News Room/Press Release/2001/June/ama.htm.
13. Olsen SJ, DeBess EE, McGivern TE et al. A nosocomial outbreak of fluoroquinolone-resistant salmonella infection. N Engl J Med. 2001; 344:1572-1579.
14. Richardson L. Animal agriculture's BSOD. California Farmer. 2001; 284:6.
15. Falkow S, Kennedy D. Antibiotics, animals, and people—again! Science. 2001; 291:397.
16. Marshall E. Scientists quit antibiotics panel at CAST. Science. 1979; 203:732-733.
17. Kriebel D, Tickner J. Reenergizing public health through precaution. Am J Public Health. 2001; 91:1351-1355.
18. Aarestrup FM, Seyfarth AM, Emborg HD, Pedersen K, Hendriksen RS, Bager F. Effect of abolishment of the use of antimicrobial agents for growth promotion on occurrence of antimicrobial resistance in fecal enterococci from food animals in Denmark. Antimicrob Agents Chemother. 2001; 45:2054-2059.

Why the FDA Said No to a Ban of Bisphenol-A in Food Packaging

Wed, 13 Jun 2012 16:56:42 GMT

By Peter Curran, MD, President's Column originally printed in June 2012 issue of San Francisco Medicine

The Food and Drug Administration (FDA) came out last month with a thumb-down on a ban of the chemical bisphenol-A (BPA) in food packaging, which came as a surprise to environmental groups such as the National Resources Defense Council (NRDC). Sarah Janssen, senior scientist at the NRDC, says, “The agency (FDA) has failed to protect our health and safety...” Other advocates went further, saying that the FDA is no longer meeting its obligation to protect the public health. Even the Obama administration was pulled into the debate; disappointed activists claiming that a perceived national climate of overregulation by government resulted in apparent apathy by the White House to side against industry in an election year. Why is BPA apparently being relegated to the trash heap of possible-but-not-scientifically-proven environmental toxins, along the lines of cell phones and microwaves?

This is no thinly studied chemical. In fact, the government has spent an estimated $30 million studying BPA, first approving its use in the epoxy liners of plastic bottles and soup cans as a “food additive” in the 1960s. Lately BPA has been labeled an endocrine disrupter with serious potential harmful health effects, including cancer, heart disease, and infertility, particularly in children and the developing fetus. An estimated 90 percent of humans are thought to have trace amounts of BPA in their bodies, most likely from leaching of the chemical from food containers. Governor Jerry Brown signed into law the Toxin-Free Infants and Toddlers ACT last year, banning the use of BPA in baby products starting in 2013. Companies have already responded by creating BPA-free products; it has become fashionable to advertise BPA-free alternatives. Campbell’s company has decided to phase out BPA from its soup cans, following the lead of similar corporations.

What happened with the latest negative ruling for the ban of BPA by the FDA? In 2008, the agency released a draft ruling that BPA is safe in food contact materials. Later in that same year, a subcommittee of the FDA reexamined the ruling after new information surfaced. An interim update was issued in 2010. The chemical industry argued that the potential exposure levels from BPA products are minimal and that the chemical is quickly eliminated from the human body and that, moreover, the food-safety benefits of epoxy liners greatly outweigh any risk from BPA. Meanwhile, in 2008 the NRDC submitted a citizen petition requesting that the Commissioner of the FDA prohibit the use of BPA in human food packaging and revoke all regulations permitting the use of any food additive that may result in BPA becoming a component of food. At one point, the chairman of the FDA committee studying BPA was accused of accepting a $5 million unreported research grant from a lobbyist in the chemical industry. Following a court order, the FDA was compelled to make a final ruling by the end of March 2012. The FDA met the deadline by one day and basically remained unpersuaded by the NRDC’s recommendations, and, probably less reported, its tactics. The FDA said after its ruling that there was not compelling scientific evidence to justify new restrictions. More research and monitoring will continue on one of the most studied chemicals of all time. Another report from the FDA on BPA is expected later this year.

Was the FDA’s decision on BPA a failure to ensure the public health, or simply a failure of the NRDC to succeed in the art of negotiation? Dr. Janssen claims, "The FDA is out of step with scientific and medical research. This illustrates the need for a major overhaul of how the government protects us against dangerous chemicals." Meanwhile, from the FDA camp, spokesman Douglas Karas emphasized in a statement that the agency's decision is not a "final safety determination on BPA” but rather a "decision on the NRDC petition." When two sides feel strongly about an issue, there is a need for consensus. If there is fundamental disagreement with an opponent’s position, it is time for compromise. That was the real failure on BPA.

Considering BPA: State of the Art or Willful Ignorance?

Wed, 13 Jun 2012 13:17:40 GMT

By William H. Goodson III, MD, and Shanaz H. Dairkee, PhD

“The Food and Drug Administration said Friday that it lacks scientific information to ban the chemical bisphenol A from food containers.” —Wall Street Journal, March 31, 2012

“ ...FDA supports reasonable steps to reduce exposure of infants to BPA in the food supply… FDA will support changes in food can linings and manufacturing to replace BPA to minimize BPA levels….” —U.S. Food and Drug Administration website, March 30, 2012.

While it is technically correct that the FDA did not ban bisphenol A (BPA), the Wall Street Journal misled readers when it ignored the clear FDA statements that we need to reduce BPA exposure of our most vulnerable citizens. This is a prototype example of the spin-versus-spin arguments that characterize most of the environmental chemical debate. These arguments are not about truth. They are about control of public perception. It is time for willful efforts to skip the spin, outline the challenges, and answer the questions that affect the safety of our children and grandchildren.

The BPA debate centers around three types of data:

BPA promotes breast cancer in animals. Animals exposed to BPA, either in utero or through nursing from dams fed BPA, develop breast epithelial abnormalities and are more susceptible to breast cancer induction by the carcinogen dimethylbenzanthracene (DMBA). Like natural estrogen, BPA stimulates growth of human breast cancer cells transplanted into mice. This is not unexpected, because BPA has been known since the 1930s to act as an estrogen. Note: The concern is not that BPA by itself causes cancer but rather that, through excessive estrogenic stimulation, it promotes cancer. The debate centers on the relation of animal doses to human exposure.
In cell culture studies, BPA causes nonmalignant human breast epithelial cells (obtained by fine needle aspiration from women volunteers) to grow faster and evade apoptosis (programmed cell death), a necessary step for radiation and drugs to kill tumor cells. These changes are referred to as hallmarks of cancer because they are prerequisites for cancer to occur. BPA by itself is sufficient to induce these abnormalities. It is especially relevant that they occur in nonmalignant cells, because these are the target cells that must undergo the required changes for breast cancer to occur. These changes occur in concentrations that are found in fetuses, mothers, and mother’s milk.
Although most of us ingest BPA daily, it is metabolized quickly. Recent studies have shown that BPA in canned soups and similar products causes a spike in serum BPA, followed by a rapid fall back to preingestion levels. Some critics conclude from this that BPA cannot be around long enough to cause harm.

The real situation, however, is more complicated.

First, clearance may not be functionally permanent. Most clearance is by conjugation to glucuronate, a frequent mechanism to clear hormones, chemicals, and drugs from the blood. However, the enzyme glucuronidase can deconjugate BPA from glucuronate, and significant levels of glucuronidase are present in many tissues. In the case of the breast, biologically active glucuronidase is present in mother’s milk and, for example, contributes to neonatal jaundice by deconjugating the baby’s bilirubin in the gut. It is difficult to expect that the BPA known to be in human breast milk would not be activated the same way.

Second, it is argued that BPA rises and falls too quickly to cause harm, but this ignores what reproductive endocrinologists have known for years. Reproduction responds to spikes in hormone levels as much or more as to constantly elevated hormone levels. It may be that spikes, such as from a preadolescent eating BPA-rich food, would pose a greater risk.

These studies do not imply that BPA by itself causes breast cancer, but rather the estrogenic activity of BPA causes changes that promote breast cancer. The cancer-promoting properties of estrogens are the reason millions of women discontinued menopausal hormone replacement therapy after the Women’s Health Initiative showed that combination estrogen plus progestin therapy increased breast cancer. Unfortunately, women living in the United States cannot decide to discontinue their exposure to BPA. BPA is present in food packaging, house dust, cash register receipts, etc., such that 95 percent of Americans and 90 percent of Canadians test positive for BPA in their urine.

Thirty years ago, Lippman and Bolan recognized the importance of cell culture “ . . . in the analysis of estrogen action in nonmalignant tissue . . . ” In our work with nonmalignant cells, we have identified six different major cell features that are altered by BPA in ways that promote hallmark, cancer-like behavior in previously benign cells. The irony in this battle of spin is that if we had a drug that turned off cancer cells in culture as much as BPA turns them on, if we had data showing a clear mechanism of action like we have for BPA, and if we had as much supportive animal exposure data as already exists for BPA, the hypothetical drug would be expeditiously lined up for clinical trials.

It is time for responsible parents and grandparents to demand an end to the battle of spin. Calm minds must sort through the facts objectively and design and perform the studies needed to resolve pertinent questions.

William H. Goodson III, MD, is a breast cancer specialist, senior clinical research scientist at CPMC Research Institute, and former a SFMS president. Shanaz H. Dairkee, PhD, is senior scientist, CPMC Research Institute.

References

Carwile JL, Ye X, Xiaoliu Z, Calafat AM, Michels KB. Canned soup consumption and urinary bisphenol A: A randomized crossover trial. JAMA. 2011; 306(20):2218-2220.
Dairkee SH, Seok J, Champion S, Sayeed A, Mindrinos M, Xiao W, Davis RW, Goodson WH. Bisphenol A induces a profile of tumor aggressiveness in high-risk cells from breast cancer patients. Cancer Res. 2008; 68(7):2076-80.
Goodson WH III, Luciani MG, Sayeed SA, Jaffee IM, Moore DH II, Dairkee SH. Activation of the mTOR pathway by low levels of xenoestrogens in breast epithelial cells from high-risk women. Carcinogenesis. 2011; 32(11):1724-33.
Teeguarden JG, Calafat AM, Ye X, Doerge DR, Churchwell MI, Gunawan R, Graham MK. Twenty-four hour human urine and serum profiles of bisphenol a during high-dietary exposure. Toxicol Sci. 2011; 123(1):48-57.

Environmental Chemicals: Large Effects from Low Doses

Mon, 11 Jun 2012 15:09:35 GMT

By Laura N. Vandenberg, PhD; R. Thomas Zoeller, PhD; J.P. Myers, PhD

Virtually all safety standards for chemical exposures are determined through a process that assumes that high-dose testing will reveal relevant risks because “the dose makes the poison.” For many well-studied contaminants this is a reasonable assumption, but for compounds that behave like hormones, it is demonstrably false. The public health implications of this conclusion are enormous, because it means that many—likely dozens, plausibly hundreds, possibly thousands—of today’s chemical safety standards are too weak by orders of magnitude.

The basis for this conclusion derives from endocrinology. In endocrinology, it is well established that the impacts of hormones (such as estrogen) at high doses can differ from those in the "physiological range" of normal circulating levels of hormones in serum; it is at these concentrations that hormones interact with their receptors to cause physiological and developmental changes by altering gene expression. Indeed, hormones at abnormally high doses are often overtly toxic, through mechanisms that have nothing to do with receptor action.

As research has expanded into the effects of endocrine-disrupting chemicals (EDCs), it has been shown that they follow the same rules that hormones follow. Unfortunately, this runs counter to the core assumption that forms the basis for all toxicological testing done to establish regulatory standards: High-dose testing will be informative about low-dose impacts.

The EPA defines an EDC as “an exogenous agent that interferes with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body that are responsible for the maintenance of homeostasis, reproduction, development, and/or behavior.” Although Rachel Carson examined the effects of many environmental chemicals on health and reproduction in her landmark book Silent Spring, work on EDCs really took shape in 1991, when a group of scientists met at the Wingspread Conference Center in Racine, Wisconsin, to discuss research on the effects of environmental chemicals on sexual development. The Wingspread attendees produced a consensus statement stating, “We are certain of the following: A large number of man-made chemicals that have been released into the environment, as well as a few natural ones, have the potential to disrupt the endocrine system of animals, including humans.”

EDCs are now understood to be any chemicals that interact with the endocrine system, including chemicals that act as agonists and antagonists of hormone receptors, including estrogen, androgen, thyroid, glucocorticoid, retinoid, and others. To determine the mode of action of these chemicals, both in vivo (animal) and in vitro (cell culture) assays have been developed. While most chemicals on the market today have never been tested for safety, much less for endocrine disruption, these assays could be used to test new chemicals for hormonal activity prior to their entry into the environment through the food supply, packaging materials, or as waste; they are also widely used to test for their hormonal activity many chemicals that are already in use. Chemicals with a wide range of uses, including detergents, plastics, cosmetics, pesticides, pharmaceuticals, and flame retardants, among others, have been shown to have endocrine-disruptor activities.

In 2002, the National Toxicology Program (NTP) examined evidence for what has been termed “the low-dose hypothesis,” i.e., the theory that EDCs could have actions at low doses. What is meant by “low doses”? Typically, these are doses in the range of what humans experience in their everyday lives—residues on food, in the air, in dust, and in drinking water. Low doses are often within the range that traditional toxicological testing has determined to be “safe.”

The question is whether EDCs are safe at the doses the typical person experiences. To determine what doses are safe, regulatory toxicology usually starts by administering large doses of a chemical to animals, identifying the highest dose at which no effect is found, and then extrapolating downward to calculate a safe dose. Those “safe” doses are rarely tested. Yet EDCs, like hormones, defy the toxicological dogma: Low doses can have effects that are not expected from high-dose exposures. In fact, these effects can be observed at doses orders of magnitude beneath the highest dose that produces no effect using traditional approaches. The mechanisms by which chemicals cause high-dose effects usually are completely unrelated to mechanisms that EDCs employ at low doses, and the effects of high and low doses can be on completely different endpoints.

In our review of the EDC literature, we found hundreds of examples of these types of responses, termed nonmonotonic responses, in cultured cells, animals, and even human populations. Many of these chemicals have effects at low doses, providing strong evidence that calculated “safe” doses of these chemicals are not, in fact, safe.

Are these chemicals adversely affecting human health? Many of the earliest epidemiology studies examining the effects of EDCs studied occupationally or accidentally exposed individuals, i.e., people who were exposed to relatively high doses, either acutely or over longer periods of time. Now a large number of epidemiology studies have focused on environmentally exposed individuals, i.e., people who are exposed to EDCs from everyday life. These studies show that many of the effects observed in cultured cells and controlled animal experiments accurately predict what epidemiologists are observing in human populations: Associations between human exposures and disease endpoints consistent with the “low-dose hypothesis.”

So where do we go from here? As scientists, these findings suggest for us that EDCs, as a chemical class, act very similarly to the hormones they mimic or block: They act at low doses, with effects that are more pronounced when exposures occur during critical periods of development. Just as hormones have nonmonotonic relationships between dose and effect, nonmonotonic effects of EDCs are expected. This means that high-dose testing is insufficient to establish the safety of low doses.

In our review, we propose some changes to the way risk assessors determine safety of EDCs:

“Safe” doses of chemicals, and chemicals in the range of human exposures, should be tested;

Regulators should assume that EDCs produce nonmonotonic dose responses;

More sensitive endpoints should be included in chemical testing.

What can the average person, or patient, do to reduce EDC exposures? This is, of course, an important issue for health care practitioners and others invested in improving public health. Several studies suggest that making small lifestyle changes can have dramatic effects on exposure levels. Patients should be encouraged to make lifestyle choices that reduce known EDC exposures. However, the lessons learned from the published literature seem to be clear: Even low doses, including reduced exposures from changes in consumer behavior, cannot be considered safe. Thus, widespread changes to chemical safety regulations are likely to have the widest effects on human health.

We encourage physicians, nurses, public health administrators, and others working in the medical field to read our recent review and to get involved with the many scientific societies that support new approaches to chemical regulation that better reflect current scientific understanding than do standard toxicological procedures. Your expertise provides an important voice to help the risk assessment community develop new approaches to chemical risk assessment, especially as it pertains to EDCs. Hormones are important signaling molecules that dictate the health of individuals throughout the life course, and therefore the effects of EDCs simply cannot be ignored.

Laura N. Vandenberg, PhD, is with the Center for Regenerative and Developmental Biology and Department of Biology at Tufts University. R. Thomas Zoeller, PhD, is with the Department of Biology at the University of Massachusetts in Amherst. J.P. Myers, PhD, works for Environmental Health Sciences in Charlottesville, Virginia.

References

Vandenberg LN, Colborn T, Hayes TB, Heindel JJ, Jacobs DR, Lee D-H, Shioda T, Soto AM, Vom Saal FS, Welshons WV, et al. (2012). Hormones and endocrine disrupting chemicals: Low dose effects and non-monotonic dose responses. 2012. Endocrine Reviews. Online 2012 Mar 14.
Kavlock RJ, Daston GP, DeRosa C, Fenner-Crisp P, Gray LE, Kaattari S, Lucier G, Luster M, Mac MJ, Maczka C, et al. Research needs for the risk assessment of health and environmental effects of endocrine disruptors: A report of the U.S. EPA-sponsored workshop. 1996. Environ Health Perspect. 104;715-740.
Carson R. Silent Spring: 25th Anniversary Edition. 1987. New York: Houghton Mifflin Co.
Wingspread Consensus Statement. In Chemically Induced Alterations in Sexual and Functional Development: The Human/Wildlife Connection. T. Colborn and C. Clement, eds. 1992. Princeton: Princeton Scientific Publishing, pp. 1-8.
Melnick R, Lucier G, Wolfe M, Hall R, Stancel G, Prins G, Gallo M, Reuhl K, Ho SM, Brown T, et al. Summary of the National Toxicology Program's report of the endocrine disruptors low-dose peer review. Environ Health Perspect. 2002. 110;427-431.
Rudel RA, Gray JM, Engel CL, Rawsthorne TW, Dodson RE, Ackerman JM, Rizzo J, Nudelman JL, Brody JG. Food packaging and bisphenol A and bis(2-ethylhexyl) phthalate exposure: Findings from a dietary intervention. Environ Health Perspect. 2011. 119;914-920.
Hunt PA. Assessing chemical risk: Societies offer expertise. Science. 2011. 331;1136.

Reducing Cancer Risks: Dr. Margaret Kripke on the Environment and Cancer

Fri, 08 Jun 2012 11:53:49 GMT

Margaret Kripke, PhD is professor of immunology and Vivian Smith Chair Emerita at the University of Texas MD Anderson Cancer Center, one of the world’s leading cancer research and treatment institutions. Dr. Kripke was also one of two panelists, along with Dr. LaSalle Leffall of Howard University College of Medicine, who served on the President’s Cancer Panel, which in 2010 produced the report "Reducing Environmental Cancer Risks: What We Can Do Now." The report sparked unprecedented attention, as well as some controversy. Her remarks below come from an interview done for the Collaborative on Health and the Environment.

The President’s Cancer Panel consists of three people who are appointed by the United States President to survey the landscape in cancer research and treatment, and to try to point out what gaps there are and what could be done to accelerate the agenda of reducing cancer. I was appointed in 2003 by George W. Bush, and I served on the panel until 2011. I was nominated to serve in the role of basic scientist; typically the panel has a cancer advocate, a scientist, and a clinician.

We focus on a different topic every year, do an extensive review of the science, and conduct hearings around the country. This topic was extremely controversial. Part of the reason is that environmental carcinogenesis is a topic where there’s a lot of uncertainty. So you have to consider what is going to be the public message and what conclusions could we draw when there are so many things where there’s just not enough information.

The second issue was that this is a very emotional issue for a lot of people, who are concerned about why they got cancer and are convinced that their cancer was caused by something in the environment. I was concerned that we would be diverted from an objective analysis to an emotional issue.

The third issue was that there is a stated figure about how many cancers are caused by environmental agents, and that figure is 6 percent. And it wasn’t clear to me that the President’s Cancer Panel should be focusing on an issue that only affected perhaps 6 percent of cancers. So I was not wildly enthusiastic about this as a topic at the outset.

But one of the reasons I agreed that we should do this is that 6 percent is still 20,000 deaths per year—40,000 people with cancer and 20,000 deaths per year. Those people deserve a voice. A second argument is that this is a subject of huge public interest at the moment. And the third argument is that cancer research has not focused on this area. I’ve been a cancer researcher for my entire career. I go to all the cancer meetings, and hardly ever do you hear anything about environmental carcinogenesis. It’s just not part of the mainstream of cancer research.

I was so naive in terms of my belief that we were being protected from things in our environment. And I was left with a sense that we have very little knowledge about what really is going on in our environment, and we need much more information.

This was an enormously eye-opening experience. I always assumed that if you have something in the workplace that’s regulated, the regulations would be enforced. And this turns out not to be true in all cases. So we have carcinogens in the workplace that are regulated—and the regulations may be very unevenly enforced. I always assumed that if something was a known human carcinogen, that it would be regulated. This is clearly not the case. There are carcinogens in our environment that have been banned in Europe and Canada but still remain unregulated here. Second, I always assumed that before things were put on the market, they would be tested. And that, too, is absolutely not the case. We test very few things for cancer-causing properties. The United States has not regulated much of anything since the 1990s. And the third point is that it’s estimated that there are somewhere around 80,000 man-made chemicals that are currently in our environment, most of which have been put there since the end of World War II. And only around 2 percent or fewer of those have actually been tested for cancer-causing properties. Now, some of them obviously are not candidates for cancer-causing agents, but others are, and we seem to espouse the “reactionary principle,” which is that until something is demonstrated to be harmful, we don’t worry about it; whereas in other places in the world people say, "If we think it’s going to be a problem and there’s uncertainty, we should take a precautionary approach to putting things into the environment."

So our first recommendation is that a precautionary, prevention-oriented approach should replace current reactionary approaches to environmental contaminants in which human harm must be proven before action is taken to reduce or eliminate exposure. It’s the thing that would probably have the most impact on future generations—to quit putting things out there that are untested and then have to bring them back. It was described to us as looking at the end of the pipeline. You have a process—a manufacturing process—that produces a chemical or something that goes into the environment and it comes out of the end of the pipeline and is distributed. To put it back in is very difficult. The remediation of things that are already out in the environment is much more costly than having engineered the process from the beginning to not create toxic by-products and toxic products at the end. In those cases where there is a high potential for risk, we ought to be thinking about that at the beginning, not at the end after it’s already on people’s carpets and on their lawns.

We then included some other recommendations:

We need to determine the full extent of environmental influences on cancer.
The nation needs a comprehensive, cohesive policy regarding environmental contaminants and protection of human health (not just cancer).
Children are at special risk for cancer due to environmental contaminants and should be protected.
Continued epidemiologic and other environmental cancer research is needed.
An environmental health paradigm for long-latency disease is needed.
Existing regulations for environmental contaminants need to be enforced and updated; stronger regulation is needed.
Radiation exposure from medical sources is underappreciated.
Medical professionals need to consider occupational and environmental factors when diagnosing patient illness.
Workers, other populations with known exposures, and the general public require full disclosure of knowledge about environmental cancer risks.
The military needs to aggressively address the toxic environmental exposures it has caused.
Safer alternatives to many currently used chemicals are urgently needed.

One of our major conclusions from the report is that children are certainly at greater risk, and the evidence is accumulating that there is an increase in cancer in children for no apparent explainable reason, and also an increase in the number of birth defects in children. I think that’s an extremely important canary in the mine, if you will.

The gratifying part is that there are so many people who are interested in the report, and that people who are interested in environmental issues have been very supportive. On the other hand, there have been a lot of critics of the report —saying that it focuses specifically on environmental causes of cancer and does not include “lifestyle” factors such as tobacco, nutrition, exercise, and so on. But our report two years previously had been on lifestyle factors and their role in cancer causation. We spent half of the report looking at tobacco and half of the report looking at nutrition and exercise, obesity, and those factors in cancer. And number one, of course, is getting rid of tobacco. So we felt we had looked at that issue fairly comprehensively. And I don’t think that this report detracts from other issues. I think people understand multicausality of diseases, and I don’t think that saying there are things in your environment that might be dangerous keeps people from thinking tobacco is bad for you also.

It’s relatively easy to generate a lot of concern and support for curing cancer. We have talked for decades in this country about the war on cancer, the cure for cancer. That has been the focus, and people are energized around that agenda, as they should be. It’s much more difficult to say, "Let’s look at causation of cancer," because the immediate effects are not apparent. It has to come from the American public. It will only change if there is public pressure to do so, because there are a lot of economic interests in the world that are geared toward not having that happen.

There is a separate section in the report that asks, “What can individuals do to reduce their personal risk of cancer?” Because you can’t put out a report like this and not give people some clues as to what they might do. If you work in an industry with chemicals, wash your clothes and take your shoes off before you come into the house—little practical things that people can do, which I think are very important. I participated in an interview and a questioner said, “I’ve never smoked in my life, I’m extremely healthy, I run marathons, there is no one in my family who has ever had cancer, and I have cancer. What about me?” And so to people who say, “Don’t look at environmental causes of cancer because there are other things that are more important,” I say, "What about these people?" People do need to have their concerns addressed, and I hope the report does that.

Click here for a list of the President’s Cancer Panel reports and downloadable links.

References List from June 2012 San Francisco Medicine

Wed, 23 May 2012 11:47:40 GMT

The June 2012 issue of San Francisco Medicine focuses on human health and the environment. Please click on the individual article links below to view the references for each article.

Considering BPA

William H. Goodson III, MD; and Shanaz H. Dairkee, PhD

Ecological Health

Ted Schettler, MD, MPH

Fukushima’s Lessons

Robert M. Gould, MD

The Diabetes Epidemic

Robert M. Sargis, MD, PhD; Sarah G. Howard, MS; Retha R. Newbold, MS; and Jerrold J. Heindel, PhD

“Red Flags” in the Emergency Department: Pain Treatment vs. the Painful Epidemic of Addiction

Tue, 01 May 2012 10:55:21 GMT

The New York Times today reported on the difficulty of sorting out legitimate pain from drug-seekers in emergency settings. SFMS board member Keith Loring, MD and staffer Steve Heilig wrote about this—with practical tips—in the April issue of San Francisco Medicine.

Every emergency clinician knows them, and most learn to dread them—the patients who might be “drug-seekers” or might be in real physical pain—or might be both. How to screen the addicts from the "legitimate" pain patients?

Faced with these and a multitude of other patients for whom pain is the chief complaint, objectivity and consistency in approach are paramount. A quick set of questions is generally sufficient to devise an appropriate diagnostic and treatment plan that minimizes overprescription of narcotics, adequately treats patients with real pain, and helps identify patients for whom the disease of addiction should be considered and addressed:

Is the pain new or long-standing?
Is the pain associated with an obvious or clinically identifiable physical abnormality or disease process?
Is the pain being treated on an outpatient basis and if so, by whom?
What medications, if any, has the patient used to treat the pain?

The answers place patients in one of four categories:

Acute pain associated with an obvious medical or surgical cause. This category of patients is straightforward and the major focus on their pain should be to achieve adequate relief with whatever medication is necessary.
Acute pain with no clear or objectively identifiable physical abnormality or disease process. This category of patients is the most likely to include the drug-seeker or addict who is wise to the system and is even willing to undergo an involved workup in order to obtain opiate pain medication. These patients will go from hospital to hospital in hopes of staying under the radar. A clinician has to be willing to research the patient’s visit history at their own and other emergency departments in order to begin to address the possibility of drug-seeking in the patient. This is also where a program such as CURES in California can be helpful.
Chronic pain that is untreated. This group of patients is easy to identify and very difficult to manage. Chronic pain is complex, often requiring treatment by a specialist. These patients need to establish care with a pain specialist but often will not or cannot. They return to the ED for pain control, get variable treatment each time, and create increasing frustration for everybody. The pattern can be broken, but this requires coordination and agreement among ED staff to ultimately be willing to withhold pain medication. For this to occur, patients need to be informed in writing in their discharge instructions and it must be documented in their ED record that they will no longer be given narcotic medications in the ED without the approval of a primary physician or pain management specialist.
Chronic pain that is being treated. Once identified, these patients should never be given pain medication unless approved by their own physician. Patients with chronic pain who are under treatment by a pain specialist generally contract that they are never to go to the ED for pain treatment. Some still try, in hopes that the ED is too busy to contact their physician. But for the emergency physician, that is always a call worth making.

No matter which category of patient, the disease of addiction can be present. Sensitivity to this possibility is crucial; saying nothing only contributes to a patient’s willingness to remain in denial of their problem.

This is an excerpt from the featured article in the April 2012 issue of San Francisco Medicine on Pain Management. Click here to view the full journal.

Keith Loring, MD, is an emergency physician at St. Mary’s and CPMC Davies hospitals, an SFMS board member, and an active member of the San Francisco Emergency Physicians Association. Steve Heilig is with the SFMS and is a former Robert Wood Johnson drug policy fellow.

Pain and Pain Medication Abuse: Two Epidemics in Tension

Tue, 24 Apr 2012 16:26:27 GMT

By Steve Heilig, SFMS Assistant Executive Director

The New York Times just printed a cover story titled "Tightening the Lid on Pain Prescriptions." The Wall Street Journal printed one on the same topic a week before.

Clearly, we have a serious problem -- two of them, in fact. It's long been demonstrated that pain has been widely under-treated in this country. Efforts to improve that have been underway for some time. But it's also increasingly recognized that unwise use of pain medications is a growing epidemic, with dire results: Fatal, unintentional drug overdoses occur every 19 minutes in this country, and opioid analgesics -- oxycodone, for example -- have been responsible for more of these deaths since 2003 than heroin and cocaine combined. And that's just the tip of the abuse/addiction epidemic. For every such death related to opioid analgesics, 461 people report nonmedical use of these meds, and 35 visit an emergency department. There, doctors learn to dread them -- the patients who might be "drug-seekers," or might be in real physical pain, or might be both.

These are not entirely mutually exclusive diagnoses. Addiction is painful -- it has even been likened to slavery. And many addicts started as honest people in physical pain. Medication diversion and abuse has become a major epidemic. Up to three-quarters of non-medical opioid users report their drugs were prescribed to somebody else -- in other words, they are sharing and selling them.

The April issue of San Francisco Medicine contains authoritative perspectives on some of the issues, including: An overview of the "pain problem", A review of the addiction epidemic and strategies to combat it, A review of the use of cannabinoids for pain, and How yoga can help with pain.

Clearly there is much to be done in terms of addressing both epidemics of under-treated pain and pain medication abuse and addiction. California’s official medical guidelines for managing pain are available online here.

But one important practical tool to help track the prescriptions of pain meds, the Prescription Drug Monitoring Program is going underutilized and unfunded, as noted here.

As noted therein, this "CURES" system allows doctors and pharmacists to "instantly look up the prescription histories of customers and refuse to provide medication to a patient whose drug shopping habits seemed suspicious or out of control. More than 40 states are using similar systems to help curb prescription drug abuse."

The funds needed to upgrade and operate this neglected tracking system would no doubt prevent much higher costs elsewhere. So as is so often the case, the choice is between prevention or playing catch-up, aka, penny-wise or pound-foolish. And unfortunately pinching pennies usually wins out, and then we wonder why the problem is so bad while we try to clean up the consequences. Perhaps California politicians and regulators can see their way to an exception this time, for the benefit of all concerned.

And, I can't help but add, this would seem to be a bigger problem than a few profiteering cannabis clubs, annoying to some politicians as those might be.

Submit Feedback to the Jan/Feb President's Column

Thu, 09 Feb 2012 09:00:05 GMT

If you are interested in this topic or have comments about this op-ed from SFMS President Peter Curran, MD in San Francisco Medicine, please join the online discussion by submitting your comments below. We welcome your feedback!

Not Quite as it Seems

Health insurance premiums for individuals in California increase, while incomes remain flat. Blue Cross Anthem attempts to raise individual premiums by 40 percent in 2011. Seven million Californians are without health insurance. Assembly Bill 52 (authored by Assemblyman Mike Feuer, D-LA) seeks to prohibit health insurance companies from increasing health care premiums without obtaining prior approval from the Department of Managed Health Care or the Department of Insurance.

The CMA would naturally be in favor of this, right? Wrong. AB 52 sailed past the CMA Council on Legislation in March and two CMA Board of Trustee (BOT) meetings, despite an “oppose” position from the CMA.

The CMA position is that any rate regulation is a bad idea, because what insurers lose from premium hikes they will simply make up with lower physician reimbursement. The CMA believes it should instead focus on enforcing rate review and “invest in meaningful ways to bring down health costs.”

A CMA staff member following the bill put it to me this way: “The reality is that insurers are going to get their Wall Street projections.” When I suggested that this oppose position perhaps gives the appearance of the CMA sleeping with unlikely bed fellows (that is, insurance companies), he quickly added that the CMA does not make policy; the House of Delegates (HOD) that meets each year to discuss and vote on numerous resolutions makes the policy. In other words, the physicians make the policy and the CMA functions to enforce that same policy.

A member of the CMA BOT said the same thing: It is understood that the CMA position on AB 52 is based on established CMA policy. In fact, a similar bill authored by former Assemblyman and current Insurance Commissioner Dave Jones was killed last year and did not have the support of the CMA. When I spoke with a representative from Mike Feuer’s office, she said that the CMA has been approached several times in the past on AB 52 and similar bills and has always been against anything related to rate regulation.

If CMA is against AB 52 and rate regulation, then I should be able to find a resolution from the HOD that supports that claim. The CMA lobbyist mentioned a resolution from HOD 2007, so I went to the archives. All I found from 2007 was adopted resolution 206a-07, Health Insurance Companies as Public Utilities, which resolved that the “CMA study and make recommendations regarding the establishment of a regulatory body . . . to regulate health insurance industry financing, compliance with state and federal laws, and the provision of mandatory health care coverage.”

I know from my experience with the CMA HOD that when a resolution is recommended for further study, it usually means there is less than a unanimous consensus of physician opinion at the House. It wasn’t until I spoke with Ruth Haskins, chairperson of the CMA Council on Legislation, that I learned CMA “policy” can be either real policy from the HOD or more like what the CMA has supported in the past. Regarding insurance regulation, Haskins believes there was no guiding CMA policy when it came to AB 52.

This is a complicated bill with many ramifications, including not knowing what ultimate effect it would have on patient care or physician well-being. Instead of changing CMA’s position on this bill late in the year (perhaps to a neutral position) and risk losing face with our allies in the legislature, the decision of the BOT in July, with advice from government relations at CMA, was to maintain the oppose position and hope for the opportunity of further study with a two-year bill. This is in fact what happened when the author of the bill decided he lacked the necessary votes in the Senate and determined to try again next year.

When the BOT reconvenes in January 2012 and AB 52 is presented for discussion, the important next step may not be whether the official CMA position remains oppose or becomes neutral, but rather this: Will the CMA support alternative legislation that promotes its own ideals to address the problem of escalating health insurance costs?

If you have thoughts on this topic, please share them below!

Protecting Children: How Far Do We Go?

Mon, 12 Sep 2011 11:54:34 GMT

Hot off the presses! The September 2011 issue of San Francisco Medicine is now available and making its way to mailboxes throughout the San Francisco Bay Area. This issue marks the first installment in a three-part "Medicine for the Phases of Life" series, focusing on pediatric and adolescent medicine. The journal is also available as an eMagazine and can be viewed here. Scroll down to read an introduction about the theme of this month's SFM from SFMS President George Fouras, MD.

Over the years, we as a society have felt that the protection of children from specific items or events is in the best interest of the child. For example, we have legislation that prohibits youth under the age of eighteen from smoking and for youth under the age of twenty-one from drinking alcohol, and minors from having sexual intercourse. In addition, we have, as a society, prohibited advertisements for tobacco products and alcohol over network television. We have done this because we recognized that children are not developmentally ready to deal with such concepts, and to empower parents and caretakers of children to make the decisions they feel are appropriate in the raising of their children. Oddly enough, the depiction of extreme and gratuitous violence, on television and in movies targeted toward the teenage audience, is permitted. Recently, Senator Leland Yee authored legislation designed to protect children from violent video games and to empower families in controlling what media their children are exposed to. As expected, this issue finally reached the U.S. Supreme Court, which, in a seven-to-two decision, struck down this law on free-speech grounds, stating that children have a right to view such media. In a recently published op-ed piece, the gaming industry took this “win” as an affirmation of its position. The piece that was missing is that the basis of the argument was, in my opinion, flawed. These games were compared to Saturday morning cartoons. But the fallacy is that kids do have a capacity to tell fantasy from reality. They know that rabbits cannot speak. But shooting a “hooker” for points is a reflection of life. In another example of irony, the film industry may be compelled to give an R rating to a film that portrays normal, healthy, romantic, and sexual relationships among human beings or portrays violence in a historically accurate manner, yet may give a PG-13 rating to a movie that contains gratuitous violence. Much attention has been raised recently over the nutritional value of foods that are targeted toward children. This has most recently been brought into focus by the First Lady's campaign to raise awareness regarding childhood obesity and the increased incidence of diabetes among children. The medical community has long known of the poor nutritional value of foods targeted toward children, often in the form of high-calorie and high-fat meals with little nutritional value. We have had some wins over the years but are still challenged in trying to change societal norms versus overwhelming corporate influence to maintain the status quo. In the July 25, 2011, issue of American Medical News, the Opinion column noted that the June report of the Institute of Medicine that stated that approximately 10 percent of children from infancy to age two are obese, a figure that rises to 20 percent by age five. Excess weight gained early in life may affect metabolic systems, which may then raise the risk of chronic disease later in life. For another example of corporate influence, we have to look no further than the tobacco industry. After decades of trying to make a difference in how cigarettes and other tobacco products are marketed, and finally winning legislation that can control the tobacco industry, a new development has occurred. The introduction of e-cigarettes, a tobacco-less form of nicotine delivery, is being strongly marketed, especially to children and teenagers, by using fruity flavors and smells that are appealing to younger people and adults alike. E-cigarettes are nothing more than a smokeless nicotine delivery system and have the potential of addicting thousands and millions of people. They completely circumvent all tobacco legislation and present new challenges to efforts to control nicotine addiction. Working with our health department, which recently adopted new policy to bring e-cigs under tobacco regulations, the SFMS will be asking the CMA to look at this on a statewide basis as well. The common thread in all of these examples is that children and teenagers are still growing and developing both mentally and physically. Family members should be the primary people to set rules and boundaries and raise youth to be able to handle more adult choices and situations. Our role as a society is to empower families and to shield them from overwhelming influences that subvert their abilities to raise their children. This is why we must continue to pursue these goals and educate the people who have the political power to help. Click here to view the September 2011 issue of San Francisco Medicine.

SFMS Member Selected for Royer Award

Fri, 15 Jul 2011 12:26:14 GMT

SFMS board member Donald C. Kitt, MD has been named the recipient of the 2010 Dr. J. Elliott Royer Award in Neurology for Community Excellence. The formal ceremony will take place at the Aird Professorship Lecture of the San Francisco Neurological Society in October. The Royer Award honors Bay Area physicians who have made significant contributions to the fields of psychiatry and neurology. Established in 1962 with an endowment from the late Oakland physician J. Elliott Royer, the award is bestowed in psychiatry and neurology in alternate years, naming one academician and one clinician. Please join the SFMS in congratulating Dr. Kitt on receiving this prestigious award.

Health Information Technology Implementation Pearls and Resources

Wed, 19 May 2010 15:16:55 GMT

By Amy Berlin, MD

If you are thinking about adopting an EHR in your practice, there is one thing you cannot do enough of: Plan. Here are some (free) resources to get you started.

The American Academy of Family Physicians Center for HIT (health care information technology) has a host of online tutorials and articles created with the office-based physician in mind. Topics include workflow redesign, EHR vendor selection, and implementation.

Other AAFP articles of interest include: Practicing Without Paper Charts: One Clinic’s Experience Strategies for Better Patient Flow and Cycle Time How to Select an Electronic Health Record System.

The California Health Care Foundation publishes thoughtful articles and reports on a wide variety of health care IT issues and strategies. Highlights are: Electronic Medical Records: A Buyer’s Guide for Small Physician Practices Physician Practices: Are Application Service Providers Right for You?, Clinical Documentation: EHR Deployment Techniques, Open-Source EHR Systems for Ambulatory Care: A Market Assessment.

AMA Practice Management resource center including worksheet 15 questions to ask before signing an EMR or EHR agreement.

Medical Insurance Exchange of California (MIEC)'s publication on important questions to ask EHR vendors

For more on the HITECH Act

Dr. David Blumenthal’s article in the February 4, 2010 edition of the New England Journal of Medicine
The Centers for Medicare and Medicaid Services (CMS) fact sheet on meaningful use
CMS fact sheet on Medicare Incentive Program
CMS fact sheet on Medicaid Incentive Program CMS HITECH FAQs (sign up for updates when answers change)
Office of the National Coordinator for Health Information Technology blog – HealthIT Buzz
CalHIPSO – California’s Regional Extension Center
KLAS publishes independent research on EHR and other HIT vendors. Practicing physicians can obtain selected reports at discounted rates.