San Francisco Medical Society Blog

Qing Dong, MD: SFMS April 2013 Member of the Month

Wed, 08 May 2013 11:34:00 GMT

Qing Dong, MD, PhD is a board certified pediatrician who specializes in general pediatrics and endocrinology. She established Sound Pediatrics in 2010 after spending more than 20 years on medical research and clinical practice dedicating to provide comprehensive pediatric care.

Dr. Dong received her medical degree from Tongji Medical University in Wuhan China, and completed a general pediatric residency at Riley Hospital for Children in Indianapolis as well as a clinical fellowship in pediatric endocrinology at UCSF.

A physician scientist at heart, Dr. Dong has published many papers in the field of cancer research, endocrine, and metabolism. Her current research focuses on calcium homeostasis, as she has discovered several novel mutations in the calcium-sensing receptors.

To view Dr. Dong's practice information, please click here.

I am a SFMS member because SFMS is a professional home that unites physicians from all specialties and health care sectors, and provides a venue for independent physicians in private practice like me to stay connected with my colleagues. I joined SFMS at the advice of my practice consultant who teaches practice management for private physicians.

I think the most helpful SFMS member resource is the practice promotion assistance I received through the online Physician Finder tool and the SFMS patient referral hotline.

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

I think patients need doctors, not robots. The transformation of health care from volume-based system to a value-based system—with the goal of improving efficiency, access and outcomes while reducing costs—will enable physicians to focus on patient care.

I love practicing Pediatrics because I am able to follow a child from birth to adulthood. Every time I see a newborn, I still feel the excitement of the first time parent. Being able to follow the growth and development of my patients from baby years to adulthood is probably my greatest joy. Also, over time I really feel like I become part of the patient’s extended family. This often gives my well-child-care visits a sense of catching up on life, just like we do with relatives and friends who live many miles away. Since I opened my own private practice, my extended families have been growing exponentially.

What is your favorite restaurant in San Francisco?

This is a tough one. There are too many good ones out there that cater all tastes and budgets. I used to follow Michael Bauer’s top 100 guide when I first moved to the city. Now, I prefer to explore different parts of the city to find small eatery from different regions of the world. I still enjoy reading Michael Bauer’s long and elaborated articles about his restaurant adventures. I always wonder how he makes a living on that.

If I wasn't a physician, I would like to be a stand-up comedian. I memorized every 单口相声 (an equivalent of monologue) available in China when I was a child. When I first came to America, I learned English partly by watching Johnny Carson. I hardly missed his shows. I am always amazed by the creativity and the ability of making people laugh. Life is over when you lose the ability to laugh.

Medical Philanthropy in San Francisco – Zero Prostate Cancer Run

Tue, 09 Apr 2013 14:52:43 GMT

By David Kornguth, MD

As a physician at Golden Gate Urology (GGU), I see the human toll of prostate cancer on a daily basis. All of us at GGU seek to help patients and their families stay healthy. This is the reason why my colleagues and I decided to sponsor an event benefitting men and their families who face prostate cancer and draw awareness to prostate cancer prevention and screening.

The ZERO Prostate Cancer Run is the first Bay Area prostate cancer run. It’s part of the ZERO Prostate Cancer Challenge, that brings together athletes, physicians, cancer survivors, and those who care about them to help fund research to end prostate cancer and to provide free testing and education.

The June 15^thevent includes fun and interactive activities to educate and raise awareness of the disease. In addition to the 5K run/walk, we are organizing a shorter walk that allows patients to learn about prostate cancer in a healthy environment.

At GGU, our vision is to lead the transformation of health care in the bay area by partnering with patients, doctors and researchers in providing better urologic care and enhanced patient education as we strengthen our community outreach to create a lasting positive impact in our field. We want men to know the truth about prostate cancer treatment so their lives are healthier and enjoyable. For those with prostate cancer, we want to cure them.

Prostate cancer is the most common cancer found in men with over 200,000 men diagnosed each year. Fortunately, most men are diagnosed with early stage prostate cancer and can be cured. A simple blood test called a PSA can help find even early prostate cancers. PSA tests save lives, yet many men do not get screened. If more men learn about modern treatment techniques and the truth about prostate cancer, fewer men will die or develop disability because of advanced prostate cancer.

The goal of the ZERO Prostate Cancer Run is to promote prostate cancer education and prevention. I hope you will consider joining GGU and fellow colleagues in this event.

Click here for event details.

All Golden Gate Urology physicians based in San Francisco are members of the San Francisco Medical Society. To find a SFMS member physician by location, specialty, type of insurance accepted, and more, please use the SFMS Physician Finder, a free service provided by the SFMS.

Health Policy Report: Medical Policy-Making 2012

Mon, 08 Apr 2013 15:32:41 GMT

The 2012 SFMS delegation to the California Medical Association’s (CMA) annual House of Delegates meeting took a wide range of proposed resolutions for consideration by the statewide gathering. Each resolution, some with modification, moved important health care issues forward in the areas of health care delivery, health care mandates, and pharmaceutical industry issues, including medication disposal and insurance coverage.

Our roster of policy proposals this year, with outcomes, included:

Tracking Prescriptions to Curtail Medication Abuse (Rokeach, Loring, Turner): CMA supports the development of a fully functional, Web-based prescription drug monitoring program (PDMP), whether it be an improved CURES (Controlled Substances Review and Evaluation System) program or a new one that should be fully funded, including through a fee-per-prescription paid by manufacturers and suppliers of drugs monitored.

Reducing Overutilization: Physician Leadership (Denys, Fung, Eng): CMA supports physician-led, evidence-based efforts to improve appropriate use of medical services and will educate physicians, hospitals, health care leaders, and patients about the need for physician-led, evidence-based efforts to improve appropriate use of medical services. This resolution originally referred to the “Choosing Wisely” effort that will be the topic of the January/February 2013 edition of San Francisco Medicine.

"Pay for Delay" Practices on Generic Medications (Susens): CMA will ask AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” illegal in the United States. As noted in a recent NEJM piece, that might already be the case!

Increasing Utilization of POLST Orders (Newman, Schickedanz, Lopato): CMA encourages physicians to become educated about all aspects of the POLST form and to integrate discussions about, and use, POLST in all appropriate instances where medical services are provided to patients at the end of life. Surprisingly to many, this was perhaps the most hotly debated resolution of the year, as our original allowed for nurse practitioners to fill out POLST forms for physician confirmation, as is done in some other states.

Medical Mandates for Insurance Coverage and Medi-Cal (Chan): CMA supports the principle that mandated coverage for private insurers should also apply to publicly financed entities, when appropriate; and will advocate that the state legislature must budget for the increased cost to Medi-Cal and enrollees of the California Health Benefit Exchange when passing mandated coverage.

Promoting Quality and Transparency in Graduate Medical Education (Schickedanz): CMA supports efforts to urgently address the anticipated imbalance between the number of medical school graduates and available residency training positions; and greater transparency at all levels in the calculation, distribution, and tracking of graduate medical education (GME) funding; and will petition the Centers for Medicare and Medicaid Services to address perceived disparities in the distribution of GME funding.

Cell Phone Use in Cars (Udovic-Constant, Fouras): CMA will support public education efforts regarding the dangers of distracted driving, particularly activities that take drivers’ eyes off the road, and will ask the AMA to do likewise. Our original was more forceful, asking for more severe penalties and even bans.

There was much more, with something of interest to every specialty, practice setting, and personality.

Click here to view the full list of the new policies adopted at the 2012 CMA House of Delegates.

Interested in submitting a resolution or suggesting a resolution idea for 2013 HOD? Please contact SFMS at membership@sfms.org.

John Fullerton, MD: SFMS March 2013 Member of the Month

Wed, 03 Apr 2013 11:26:36 GMT

John Fullerton, MD, MRO, CMD, CFP, FACP, AGSF, FAAHPM is primary care physician and clinician educator for more than 26 years. He is board certified in Internal Medicine, Geriatrics, Addiction Medicine, Hospice & Palliative Medicine, with added certificates in Long-Term Care, Hospice Medical Directorships and Home Care.

Dr. Fullerton received his medical degree from the University of Miami, and completed his Internal Medicine residency training at CPMC (formerly known as Pacific Presbyterian Hospital). As one of the earliest hospitalists (hospital-based physician) on the Garden Sullivan Campus of CPMC in 1989, Dr. Fullerton became a leading expert in areas of HIV/AIDS, palliative care (including End-Stage AIDS), geriatric medicine, and addiction medicine.

Dr. Fullerton is the Co-Founder and Chief Medical Officer for Hampton Health, LTD., which specializes in ambulatory and urgent care, including a focus on the transitions of care between acute, rehabilitative & hospital-based SNF, nursing home, secured Dementia Units, Assisted and Independent Living Facility care, Home Care, and Hospice & Palliative Care. In addition, Dr. Fullerton serves as the Director of Geriatric and Palliative Education and Key Faculty for training of the Internal Medicine Residency Program at Dignity Health/St. Mary’s Medical Center. He also participates as clinical faculty of UCSF, Stanford, USC, and Yale University Medical School(s) in their respective Department(s) of Medicine and serves as voluntary clinical faculty for medical students and medical residents at the San Francisco Free Clinic.

To view Dr. Fullerton’s practice information, please click here.

I am a SFMS member because I have always taken great pride in being involved in the local medical community, having trained and practiced general internal medicine in SF. I still consider it a privilege to maintain an office in the “heart of SF”, remain active clinical faculty at UCSF and Dignity/St. Mary’s Medical Center, and to be a proud member of the SFMS 23 years after serving as Chief Resident at CPMC.

I think the most helpful SFMS member resource is the social and professional networking function that membership brings along with the excitement that comes upon receiving a new Directory from the SFMS, containing the listings with all of my esteemed colleagues.

What is the most important thing you learned in medical school or residency?

To seek out and serve clinically all who require our assistance and a duty to clinically instruct the next generation of primary care providers, including a focus for decades on the urban, under-served in SF in areas such as geriatrics, HIV/AIDS, addiction medicine, palliative medicine, those with disabilities, and those who have no insurance. This path has lead me to the most rewarding parts of my career, including training in medicine (and chief residency) at CPMC, early hospital-based work & training in SF at Garden Sullivan Hospital, long-term clinical instruction as teaching attending for surrounding training programs at the San Francisco Free Clinic, and Director of Geriatrics at Dignity/St. Mary’s Medical Center (Key Clinical Faculty to train Internal Medicine Housestaff at their Sister Mary Phillippa Healthcare Center [SMPHC]).

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

Now that primary care providers will occupy a central position in Obama Care as the ranks of the uninsured get covered and more lives therefore go “at risk” in ‘Round Two of Managed Care’, it is incumbent upon the primary care doctors to come together through groups like the SFMS and the CMA to position themselves as the comprehensive providers of professionally compassionate and ethical care within medical home delivery models, along the spectrum of a truly seamless vertically integrated continuum of care-starting at the acute care hospital and hopefully ending at home. This will require creativity regarding the “transitional models of care”, the coordination and cooperation of sub-disciplines, our growing and vital relationship with technology and social media, and how we flexibly handle our inter-relationships with non-physician providers, advanced practice nurses and PAs, practice-based nurses and case managers as key elements in our own inter-disciplinary team (IDT) approach to the spectrum of general internal medicine/primary care within our own and within our aggregated practices. In the end, there will be a necessary “reorientation” of the primary care providers along with their sub-specialty referral networks toward more preventive medicine, more cognitive medicine, more holistic (patient-centered) medicine, more co-sharing of “risk”, and less invasive, procedure-based approaches-particularly during the last 1-2 years of life.

I love practicing Internal Medicine because the breadth of practice of General Internal Medicine also promotes life-long learning and trans-generational care, including in additional growing areas such as palliative care, geriatrics, addiction medicine, home care, and long-term care medical directorships. The ability afforded by practicing General Internal Medicine enables me to focus on the “baby boomers” in a city like SF and to help them with their preventive care and chronic diseases (if needed) while assisting their aging families through the stages of life and their corresponding levels of care, including assisting with their end-of-life care (when needed).

What is your favorite restaurant in San Francisco?

Spruce (in Laurel Village) and Caffe Macaroni (in North Beach).

If I wasn't a physician, I would like to be a constitutional lawyer or a professor or a philosophical fiction author.

One Physician’s Story on Medical Volunteerism

Thu, 28 Mar 2013 16:49:28 GMT

By Howard B. Kleckner, MD, Medical Director, thesecondopinion

I first started volunteering in medicine while I was on summer vacation from high school. My mother, faced with the possible of a teenage son hanging around the house for the summer, found a summer job for me volunteering at a local hospital. Following that, my career was set.

Fast forward 50 years and I, like many other physicians in their 60s, was facing retirement. For most of us, practicing medicine had been a way of life. Few of us had developed other interests and hobbies. Medicine both consumed and fulfilled us and despite all the hassles it remains the most rewarding of all careers. So much of our identity had been connected with our profession and we were now facing giving it up.

I felt 35 years practicing Oncology had given me knowledge and skills which I could continue to share in some way. It was the only thing I knew how to do well. Fortunately my retirement plan provided me with sufficient financial security that I and my family would not have to worry. I knew I would miss the collegial interaction, the intellectual stimulation, and the powerful relationships one develops with patients and their families. At the beginning of training medicine is all about obtaining knowledge, as we practice we discover it is all about people and relationships. I knew I would miss these. I began to ask and look around for things I could do which would utilize my skills and experience.

I remembered having sent cancer patients who could not afford a second opinion or sought an independent eye from outside of our health plan network to thesecondopinion in San Francisco. I inquired and was invited to attend a session and then asked to join as a volunteer medical oncologist.

Thesecondopinion is a 501©3 nonprofit which provides free second opinions to people with cancer in the State of California regardless of income. It has been existence over 30 years in different forms. More than 60 volunteer physician cancer specialists meet 3 times a month and reviews 3 cases each on the Tumor Panel. All medical records, imaging studies, and pathology slides are obtained and reviewed by panelists in advance of the meeting. On the day of the Tumor Panel, the 4 or 5 physicians consisting of a medical oncologist, radiation oncologist, radiologist, pathologist and surgical specialist discuss the cases over lunch at our offices at 1200 Gough in San Francisco. The patients and their families are then invited in one by one to spend 30 to 40 minutes with the Panel asking questions about the diagnosis, treatment, or prognosis. It takes the form of a Tumor Board, but the questions are patient and not doctor driven. The session is recorded on CD and given to the patient and a letter is sent summarizing our discussion to the attending physicians somewhat like a formal consultation. Patients and families are incredibly grateful and leave with more comfort and clarity about their disease.

Two years ago I was asked to become Medical Director, a job with more responsibility but still part time and providing me with sufficient time and flexibility to pursue other interests. I still have time for my grandchildren, community engagements, reading, and trips. As thesecondopinion is a nonprofit, I am also engaged with fundraising but it is a joy to tell our story to foundations and donors. The community has been extremely generous and supportive. I feel I can give back now using my years of experience in a different role and continue to make a difference in people’s lives.

Click here for more information about physician volunteer opportunities at thesecondopinion.

Click here to view more physician stories about medical volunteerism in the March 2013 issue of San Francisco Medicine.

Thesecondopinion is a 501©3 nonprofit organization which provides second opinions for California cancer patients about diagnosis and treatment at no cost. The organization have been in existence for over 30 years and are located at Geary Boulevard and Gough Street in San Francisco. Click here for more information or view a short CBS5 video clip about the organization.

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.

Photos from the 145th SFMS Annual Dinner

Thu, 21 Feb 2013 15:25:14 GMT

More than 160 physicians, physicians-in-training, and supporters/partners of the SFMS celebrated 145 years of physician advocacy and camaraderie with the SFMS at our Annual Dinner.

Event highlights include the installation of Shannon Udovic-Constant, MD, a pediatrician at Kaiser Permanente San Francisco, as the 2013 SFMS President and the featured presentation from Catherine R. Lucey, MD, Professor of Medicine and Vice Dean for Education at the UCSF School of Medicine, on the Choosing Wisely Campaign.

SFMS would like to thank our members, sponsors, and special guests Senator Mark Leno, Assemblymember Phil Ting, Supervisor David Chiu, Supervisor Eric Mar, CMA President Paul Phinney, and Dr. Catherine Lucey for their support of this event and the medical society.

Click here to view more photos from the Annual Dinner.

Technology and Health Care

Mon, 11 Feb 2013 11:25:59 GMT

By Toni Brayer, MD

One of my tennis friends asked me about new innovative smart phone technology and why it hasn't been embraced in health care. She had just watched a video about Dr. Eric Topol, Chief Academic Officer at Scripps Health in San Diego, and his demonstrations of how a smart phone could monitor blood sugar, take EKGs and cardiac ultrasounds, and really deliver health care to the patient at home.

My friend's question, "If this technology is here, why isn't it being used?"

According to Dr. Topol, new apps for the smart phones could eliminate 80% of echocardiograms that are done in facilities at costs between $300 and $1500 each. Having patients come into the office when they experience symptoms or for diabetics to get their blood sugar regulated could be eliminated. New technology could be data driven and personalized and save millions of wasted dollars in health care. So why is medicine so far behind the innovation curve?

The answer: No-one pays for it.

Why aren't all physicians using email to communicate with patients and save them an office visit? The politically correct answer is "remote medicine is not as good as seeing the patient in person and making sure the diagnosis is correct". The real answer is: No-one pays for it.

United States health care has complicated payment systems for work done. The payor for health care services is either Medicare/Medicaid (CMS) or hundreds of different (for-profit) insurance companies. CMS sets the payment rules that everyone follows. Medicare and all insurers will only pay for face to face visits. Reimbursement is for doing more and the more you do the more you get.

The doctor that tries to save a patient time and travel by covering a number of problems in one office visit will not be rewarded and, in fact, will be reimbursed less. If you do a skin biopsy on the same day you do a visit for arthritis flare, CMS and insurance companies will not pay for both things. Do them on separate face to face visit days and... voila!... a better reimbursement for your time and skill.

Email, remote monitoring, remote echocardiograms, discussing tests via a smart phone are freebies. No patient visit means no reimbursement. The cost of putting in high technology is borne by the physician too.

Most physicians and hospitals and surgery centers and labs and pharmacies are happy with this status quo. There is great fear of change and so we continue to spend more on health care than any nation in the world. We do wasteful mass screenings and 1/3 of all prescriptions are a waste. People who need care are not getting it and others are getting too much that they don't need.

ObamaCare is trying to make some gradual changes by supporting pilot programs to change the way healthcare is delivered. But it is slow going and innovative answers are out there. If we could just figure out how to pay for services, while using new cost-saving technology we would all be following Dr. Topol's future dream.

Originally published in EverythingHealth, February 10, 2013.

Toni Brayer, MD is an internist and Chief Medical Officer for Sutter Health West Bay Region. A SFMS member since 1987, Dr. Brayer has served as President, CMA delegate, Editor of San Francisco Medicine, and on numerous committees over the years. She is a Fellow of the American College of Physicians and an Assistant Clinical Professor at UCSF. Dr. Brayer blogs at EverythingHealth.net.

Top Ten Dr. Visit Reasons

Fri, 25 Jan 2013 14:13:19 GMT

By Toni Brayer, MD

Medical training programs should take notice of a new study that was published in Mayo Clinic Proceedings. It listed the top ten reasons why people see a doctor. Keep in mind these were people who lived in Rochester and Olmsted County, Minnesota, but I suspect the conditions are not too different across the United States. As I review the main reasons patients visit me, it seems like they got the list right. Here are the conditions that bring people to visit the doctor:

Skin disorders
Osteoarthritis and joint pain
Back problems
Cholesterol problems
Upper respiratory conditions (not including asthma)
Anxiety, depression and bipolar disorder
Chronic neurologic problems
High blood pressure
Headaches and migraines
Diabetes

They found that most of these chronic, non-acute problems were not age or gender related. Half of the study population had a skin disorder like acne, cysts or dermatitis. Among children and teens the main problems were skin, joint problems and upper respiratory conditions. Patients over 65 showed up with high blood pressure, cholesterol problems and ...again skin disorders.

All of these problems should be handled in a primary care office. With the shortage of primary care doctors, however, we can expect health care expenditures to continue rising if these common problems are taken to specialists. In my community it is difficult to find dermatologists who will see "skin disorders" and most do not accept any insurance. They are happy to deal with cosmetic dermatology and biopsies but not routine dermatologic conditions.

Most orthopedic specialists are not interested in dealing with osteoarthritis, back pain or joint problems that do not require surgery or arthroscopy.

With less than 2% of medical students expressing an interest in primary care medicine it will be interesting to see where the bulk of patients will be getting their care in the future.

Source: EverythingHealth, January 23, 2013.

Toni Brayer, MD is a SFMS member and a past president. She currently serves on the San Francisco Medicine Editorial Board, and is the Vice President and Chief Medical Officer for Sutter Health West Bay Region.

Stephanie Oltmann, MD: SFMS January 2013 Member of the Month

Wed, 09 Jan 2013 15:08:31 GMT

Stephanie Oltmann, MD is a board-certified family physician with the Dignity Health Medical Group – Saint Francis/St. Mary’s.

A native of Germany, Dr. Oltmann spent an intern year in Neurology, worked as a house officer in Australia and the U.K. specializing in urgent care and emergency medicine, and completed her residency in Family Medicine in Long Island, NY, where she also served as chief resident. Her special clinical interests include neurology, chronic disease management, preventive care and travel medicine. To view Dr. Oltmann’s practice information, please click here.

I am a SFMS member because I believe the SFMS is one of the best ways that we, as physicians, can stay informed and engaged with each other and active as a community resource on issues of health, wellness and better living.

Which SFMS member resource is most helpful to you?

The most helpful resource in the medical society is the membership. Whether it is learning from other members about how to meet the professional and personal challenges that physicians often face, or hearing from others about career directions that I never thought possible, I get more out of being a physician by being part of the organized physician community.

My greatest achievement outside of practicing medicine was helping a young person, who delayed becoming a physician in order to work and support his family, return to school and successfully apply to and graduate from medical school. After years of hard work, presenting him with his own doctoral hood was more satisfying than the day I was presented with my own.

What is the most important thing you learned in medical school or residency?

I was once advised that, in order to achieve personal balance, I should always pursue my life, outside of medicine, with the same intensity that I’ve pursued my medical career. Since finishing residency, I’ve gone back to school to study art and foreign language, ran for public office, maintained pre-med school friendships and started new ones with people who know me from the local community or the interest group, not the clinic. This has helped me avoid professional burn out and make medicine that fun thing I do, when I’m not working hard at enjoying the rest of my life.

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

Moving this country from a “health cost system” to a “health care system” will either be the biggest challenge to us, or the biggest opportunity for us. It will be difficult, but we must decide if health care in this country is going to be an economic privilege or a human right and how best to make the path we choose a viable and sustainable reality for everyone.

I love practicing Family Medicine because I love that my clinics are in the neighborhoods and communities where I live and am also active in. Most of my patients come from the local area around the clinics, so I get to know them and their families, not just as patients, but as neighbors, too. It’s like being a small town doctor…in a big city!

What is your favorite restaurant in San Francisco?

I admit, on special occasions, I treat myself to a Bacon Double Del Cheese Burger at the Del Taco fast food restaurant on Market Street. I think it’s the special sauce that makes it taste so good!

If I wasn't a physician, I would likely ended up a comic book or animation artist. It’s the other thing I’m good at.

Justin Morgan, MD: SFMS December 2012 Member of the Month

Tue, 04 Dec 2012 12:37:07 GMT

Justin Morgan, MD is a family physician with the San Francisco Department of Public Health’s outpatient clinics.

Dr. Morgan is a resident of the Fillmore neighborhood, President of San Francisco’s African American Medical Association, a clinical instructor at UCSF and UC Davis, a member of the African American Democratic club. He is a community activist with over 10 years of experience providing primary care for low income families as well as working in the community on issues of health advocacy and youth mentorship. To view Dr. Morgan’s practice information, please click here.

Which SFMS member resource is most helpful to you?

What is the most important thing you learned in medical school or residency?

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

What is your favorite restaurant in San Francisco?

I admit, on special occasions, I treat myself to a Bacon Double Del Cheese Burger at the Del Taco fast food restaurant on Market Street. I think it’s the special sauce that makes it taste so good!

If I wasn't a physician, I would likely ended up a comic book or animation artist. It’s the other thing I’m good at.

Obamacare—Past, Present, and Future, Part 4

Wed, 28 Nov 2012 14:47:43 GMT

By Andy Calman, MD, PhD

Note: This article was originally published in the October 2012 issue of San Francisco Medicine. Due to members' request for more information on health care reform and its impact on medicine, SFMS is publishing a four-part series in the SFMS blog section. Click here to read Part 3 of this 4-part series on Obamacare and its impact on U.S. physicians and patients.

How Is Obamacare Paid for?

The main new source of revenue for Obamacare has nothing to do with Medicare. Beginning next year, there is a new 3.8% tax on “unearned” income, such as capital gains, dividends, and interest income, for those with total incomes over $200,000 per year ($250,000 for couples). This is coupled with a 0.9% increase in the Medicare tax on earned income over $200,000/$250,000. These new taxes on upper-income taxpayers, though receiving little ink or airtime, are among the most important reasons why Obamacare has been targeted for repeal.

Other, smaller sources of revenue are a 40% excise tax on so-called “Cadillac” health plans (those having premiums over $27,500 per family); taxes on the pharmaceutical, insurance, indoor tanning, and medical device industries; and limitations on cafeteria-plan and health expense deductions.

Over the next ten years, Obamacare (including its associated taxes) is estimated by the Congressional Budget Office to result in net savings to the federal government of $109 billion. However, this does not include the cost of SGR repeal, the “crowd-out” phenomenon, employment migration due to the elimination of “job-lock,” increases in medical inflation, and other factors that are inherently difficult to predict and are outside the scope of this article.

Impact on Physician Practices

Most physicians will be impacted by Obamacare, regardless of their specialty and mode of practice. Combined with the subsidies for EHR in the HITECH Act, Obamacare will drive medicine toward more data-driven, technology-intensive, outcomes-oriented reporting in order to be eligible for contracting and payment. This has already begun in the Medicare system with PQRI and PQRS initiatives and is spreading to the private insurance sector. Additionally, the ACO initiative will likely accelerate the trend toward practice integration and buyouts by larger entities.

In fifteen months, approximately 30 million Americans will begin to enroll in Medicaid and subsidized private health insurance plans. Access problems, especially for Medicaid enrollees, are inevitable. Mandated managed care plans for Medicare-Medicaid dual-eligibles may accentuate this problem. Access problems may drive state legislation toward increased scope of practice for limited license practitioners in order to meet the increased need.

It should not escape physicians’ notice that “bending the cost curve” is aimed squarely at our profession. In addition to finding new ways to limit physician compensation, Medicare and private insurers will look to physicians to limit their use of costly diagnostics, pharmaceuticals, and procedures and to justify everything we do with outcomes reporting.

On the other hand, the health exchanges and subsidies will, for the first time, allow many working-class and middle-class families the opportunity to have real health insurance. We may be shocked in the next few years at the backlog of previously untreated patients who are now crowding our waiting rooms, and we may be gratified at our increased ability to provide the care that these members of our community need.

The challenges posed to our profession by Obamacare are real. We will need to become more efficient in the face of increased electronic documentation requirements and declining or stable reimbursements. However, physicians are resourceful and energetic people. Just as we have met the challenges of incorporating new knowledge and techniques and found ways to make the difficult transition from paper charts to computers, we will find ways to handle the transitions of the next few years as well. Regardless of legislative and electoral outcomes, the nation and our patients need our services, and the huge, dysfunctional, but ultimately homeostatic health care economy will find ways to adjust. Obamacare as enacted in 2010 is not the final word on the subject. By staying informed and uniting as a profession to advocate for fair, responsible solutions, we can help shape a positive outcome.

Dr. Andrew Calman practices ophthalmology at CPMC-St. Luke’s and teaches at CPMC and UCSF. He is past president of the California Academy of Eye Physicians and Surgeons, chair of the SFMS’s Political Action Committee, and served for many years on California’s Medicare Carrier Advisory Committee as well as the National Health Policy Committee of the American Academy of Ophthalmology.

Happy Thanksgiving - Thank You to All SFMS Members!

Wed, 21 Nov 2012 12:14:01 GMT

Obamacare—Past, Present, and Future, Part 2

Tue, 20 Nov 2012 11:36:18 GMT

By Andy Calman, MD, PhD

Note: This article was originally published in the October 2012 issue of San Francisco Medicine. Due to members' request for more information on health care reform and its impact on medicine, SFMS will be publishing a four-part series in the SFMS blog section. Click here to read Part 1 of this 4-part series on Obamacare and its impact on U.S. physicians and patients.

Medicaid Expansion and Private Insurance Subsidies

The heart of the Obamacare program—and its most costly provision—is an expansion of access to affordable health insurance. This expansion relies on two prongs: a massive expansion of Medicaid for low-income individuals and families, coupled with income-based subsidies for the middle class to purchase private insurance.

Under Obamacare, in 2014 Medicaid eligibility will be expanded to cover all individuals and families up to 133% of FPL, including adults without dependent children. Federal funds are provided to the states to cover this expansion. However, several states (not including California) have opted out of this Medicaid expansion, fearing long-term runaway costs. Chief Justice Roberts’s decision provided that such states cannot be excessively penalized from opting out. Although they will forfeit the new federal funds for Medicaid expansion, they will not lose their existing Medicaid matching funds.

Federal funds are also provided to bring Medicaid physician reimbursement levels up to 80% of Medicare allowable. However, these funds will only apply to primary care providers, and only for 2016 and 2017. How these millions of new Medicaid patients will find access to care—including specialty care—is a huge open question, especially in the large states like California that reimburse less than the cost of providing care.

For working-class and middle-class families earning between 133% and 400% of FPL, Obamacare provides sliding-scale subsidies, in the form of a refundable tax credit, to purchase private insurance policies through the state exchanges. For example, a family of four at 150% of FPL earning $34,575 would pay no more than $115 per month (4 percent of income) for a Silver plan and would receive additional subsidies to reduce out-of-pocket expenses.

These provisions will not completely eliminate barriers to care. However, the nonpartisan Congressional Budget Office estimates that under Obamacare, the number of uninsured Americans will be reduced to 20 million people in 2016, a 60% reduction. The majority of the uninsured after 2015 will consist of young, healthy adults and low-income individuals in states that have declined to expand Medicaid. Additionally, undocumented immigrants will not be covered under Obamacare.

Substantial reductions in uncompensated emergency room and hospital care under EMTALA can be expected, as the vast majority of Americans will be insured. As a corollary, Federal DSH (Disproportionate Share Hospital) subsidies will be substantially reduced.

Employer Subsidies and Penalties

For 2014 and 2015, the subsidies for small employers (fewer than twenty-five employees, with average employee salaries under $50,000) will increase to a maximum of 50% of employee premiums. These subsidies phase out with increased numbers of employees and increased average salaries. For example, a small doctor’s office with four employees and an average employee salary of $40,000 would receive a tax credit of 20% of employee premiums. However, large employers (fifty or more employees) would be required to provide coverage for their employees or pay a $2,000 per-employee penalty.

After 2014

Beginning in 2015, Medicare physician payment rates will be modified to reflect quality of care, not just volume. The extent to which “quality” will be based on outcomes, use of EHR, low use, patient satisfaction, checking off boxes as in PQRS, or some combination of these, is unclear. This is an area where organized medicine will play a crucial role in advocating for payment methodologies that reflect common sense and real quality (rather than meaningless busywork), rewarding neither overuse nor underuse, and maintaining fairness to physicians.

Beginning in 2017, states can apply to HHS for State Innovation Waivers to provide alternative, state-based health delivery models, as long as coverage and affordability are not inferior to Obamacare. Vermont has already announced its intention to pursue a waiver for a state-based single-payer system. Legislation has been introduced to allow waivers to be issued as early as 2014. States operating under waivers would be exempt from the individual mandate and employer penalties and would receive federal funding equivalent to Obamacare.

In 2018, all existing insurance plans must provide preventive care without co-pays or deductibles. In 2020, the Medicare doughnut hole is entirely phased out.

2012 SFMS Election Results

Tue, 20 Nov 2012 10:45:27 GMT

Thank you all SFMS members who have participated in this year's SFMS election. We are proud to announce the SFMS leadership for 2013.

2013 Officers (one-year term):

President - Shannon Udovic-Constant, MD (2012 President-Elect automatically succeed to the office of President)

Immediate Past President - Peter J. Curran, MD (2012 President automatically succeed to the office of Immediate Past President)

President-Elect - Lawrence Cheung, MD

Secretary - Man-Kit Leung, MD

Treasurer - Roger S. Eng, MD

Editor - Gordon L. Fung, MD

Board of Directors (seven elected for three-year term, 2013-2015):

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 W. Woo, MD

Nominations Committee (four elected for two-year term, 2013-2014):

Izumi N. Cabrera, MD

Justin V. Morgan, MD

Calvin S. So, MD

Yanling Xu, MD

SFMS Delegation to CMA House of Delegates (Two-year term, 2013-2014):

Delegates

Elizabeth A. Andrews, MD

Lawrence Cheung, MD (serves automatically as President-Elect)

Gordon L. Fung, MD

Adam Schickedanz, MD

Andrea M. Wagner, MD

Alternates

Peter J. Curran, MD

Mihal L. Emberton, MD

Steven H. Fugaro, MD

Robert J. Margolin, MD

H. Hugh Vincent, MD

Solo/Small Group Practice Forum Delegate (two-year term, 2013-2014): Eric Tabas, MD

CMA Trustee (three-year term, Oct. 2012–Oct. 2015): Shannon Udovic-Constant, MD

Obamacare—Past, Present, and Future, Part 1

Mon, 19 Nov 2012 16:34:20 GMT

By Andy Calman, MD, PhD

Note: This article was originally published in the October 2012 issue of San Francisco Medicine. Due to members' request for more information on health care reform and its impact on medicine, SFMS will be publishing a four-part series in the SFMS blog section.

Obamacare/PPACA—Beyond the Politics

Few people think it’s perfect, or anywhere near perfect. Many Americans believe Obamacare went too far. Others wish it had gone farther and had offered Medicare for all. But love it or hate it, the Patient Protection and Affordable Care Act of 2010—now referred to by both parties as Obamacare—is no longer a bill. It’s the law, and it's already being implemented. It’s time to get past the politics and familiarize ourselves with the many changes that have already taken place, the flood of newly insured patients arriving in little more than a year, and the long-term changes that will alter—for better or worse—nearly every aspect of how we practice our profession. Only a handful of Capitol Hill staffers and CMS bureaucrats know everything packed into the 907 pages of the PPACA, and the thousands of pages of its enabling regulations. But because every doctor needs to be aware of the key provisions, it is worthwhile to review a succinct implementation timeline.

What Has Already Changed

A number of the provisions of Obamacare have already taken effect.

Small businesses employing fewer than twenty-five employees—whose average wages are less than $50,000 per year—can currently receive subsidies of up to 35% for insuring their employees during tax years 2010 through 2013. The Medicare doughnut hole has been reduced by 50% and will be eliminated in 2020, with phased-in discounts for drugs in the doughnut hole. Insurers can no longer discriminate against children with preexisting conditions.
For adults with preexisting conditions, temporary high-risk pools (Pre-Existing Condition Insurance Plans, www.pcip.gov) have been created to bridge the gap until the state insurance exchanges begin enrollment in 2014. These plans are priced at the same community rates as those for healthy patients, with a maximum annual out-of-pocket of $5,950 and guaranteed issue—an excellent value for cancer patients and others who cannot otherwise obtain insurance.
There is a ban on lifetime coverage caps, and on rescission of coverage for Americans who get sick. All new individual plans must offer preventive care including mammograms and colonoscopies, as well as contraception (with exemptions for certain religious organizations), with no co-pays or deductibles.
Young adults can now stay on their parents’ policies until age 26, even if they reside elsewhere. States who provide Medicaid up to 133% of FPL (federal poverty level) receive federal matching funds. And last month, thousands of astonished Americans received rebate checks from their health insurance companies due to a provision requiring that 80% of premium revenue (85% for large groups) be spent on actual health care.

2014: Individual Mandate, Medicaid Expansion, and Health Insurance Exchanges

Although many of the provisions implemented so far are popular, some of the provisions that will transform health care beginning in 2014—just over a year away—are more controversial. Americans who are not already covered by public or private health insurance will be required to purchase an individual plan or pay a penalty. CBO estimates that about 1.2% of the population will pay the penalty in 2016.

The penalty—1% of income, rising to 2.5% in 2016, with a minimum of $695 per year for individuals and $2,095 for families—is rather small compared to the cost of health insurance, and many Americans will elect to pay the penalty/tax instead of purchasing expensive coverage. Persons with religious exemptions, such as Christian Scientists, are exempt from the penalty. Additionally, there is an exemption if the least expensive available plan exceeds 8% of family income. These people, as well as individuals under 30, will have the option to purchase cheaper “catastrophic” high-deductible plans instead.

Beginning in 2014, the ban on discrimination against people with preexisting conditions will apply to adults as well as children. Annual spending caps will be banned. Consumers and small businesses will be able to shop for plans in “health insurance exchanges” set up by each state, comparing the cost and features of standardized Bronze, Silver, Gold, and Platinum benefits packages. These benefits packages must provide specified “minimum essential benefits” and will be actuarially standardized so that, for example, a Bronze Plan would cover 60% and a Platinum Plan 90% of services for an average population, with the remainder paid by co-payments and deductibles. However, the annual out-of-pocket maximum would be capped at $5,950 per individual ($11,900 per family) for individual plans and at $2,000 ($4,000 per family) for small group plans.

Policies offered by the exchanges must offer “guaranteed issue” and “community rating,” where premiums are adjusted only by geographic region, age, and tobacco use, without regard to gender or preexisting conditions.

Some states have declined to set up their own exchanges. The department of HHS is empowered to set up exchanges for these states, but funding for these federal exchanges is uncertain and depends on the will of the next Congress.

St. Mary’s Medical Center Received Top Recognition for Patient Safety

Fri, 16 Nov 2012 12:37:30 GMT

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

SMMC and its physicians are long-time supporter of the San Francisco Medical Society, making patient safety a top priority 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.

Launched in 2010, Patient Safety First is a groundbreaking three-year, $6 million collaboration designed to improve quality of care, reduce health care costs and ultimately save lives by improving patient safety and perinatal care in California. The program is funded by Anthem Blue Cross, evaluated by the National Health Foundation, and operated by California’s Regional Hospital Associations. A total of 180 hospitals across the state participate in Patient Safety First, representing almost half of all hospitals in California.

A study by the National Health Foundation on the first two years of the program finds more than 973 lives have been saved as a result of reducing sepsis mortality. In addition, an estimated $19 million in costs were avoided as a result of this statewide patient safety initiative, $3.75 million of which was a result of reducing early elective deliveries.

One of the goals of Patient Safety First is to see a 30 percent reduction in sepsis mortality. Sepsis is a potentially deadly medical condition that causes inflammatory responses in the entire body during the presence of an infection. And, because babies delivered prior to 37 weeks of gestation have a higher rate of infant mortality and are more likely to have other medical issues, including lung problems, brain impairments and infections, another goal of Patient Safety First is to see hospitals reduce elective deliveries prior to 39 weeks to 5 percent or less.

In addition to a focus on early elective deliveries and sepsis, Patient Safety First targets other hospital acquired infections, including ventilator associated pneumonia (VAP), central line blood stream infections (CLBSI) and catheter associated urinary tract infections (CAUTI).

Kaiser Permanente San Francisco Receives National Recognition for Quality and Safety

Thu, 08 Nov 2012 14:07:03 GMT

Kaiser Permanente San Francisco Medical Center has been recognized by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for achieving exemplary outcomes in surgical procedures. It was one of only 28 hospitals in the nation to be lauded for “exemplary outcomes” in inpatient and outpatient surgical procedures.

The ACS NSQIP recognition program commends a select group of hospitals for exhibiting high quality and safety standards in five clinical areas: DVT (deep vein thrombosis, thrombophlebitis and pulmonary embolism); cardiac incidents (cardiac arrest and myocardial infarction); pneumonia; surgical site infections; and urinary tract infections. The 28 hospitals cited attained exemplary results in two or more of the five areas.

“This accolade is well-deserved recognition of the fine work our physicians and staff do every day in delivering the best care for our surgical patients – before, during and after their procedures,” said Robert Mithun, MD, SFMS member and Physician-in-Chief at Kaiser Permanente San Francisco Medical Center. “Our physicians, nurses and staff work together to ensure that our patients receive personalized, coordinated and technologically advanced care—and we are having a positive and often life-changing impact on the health and well-being of our members and the communities we serve.”

ACS NSQIP is the only nationally validated quality improvement program that measures and enhances the care of surgical patients. The goal of ACS NSQIP is to reduce infection or illness related to a surgical procedure and surgical mortality, and to provide a firm foundation for surgeons to apply what is known as the “best scientific evidence” to the practice of surgery. When adverse effects from surgical procedures are reduced or eliminated, a reduction in health care costs follows. ACS NSQIP is a major program of the American College of Surgeons and is currently used in more than 500 hospitals.

Help Shape the Future of SFMS. Cast Your Vote in the 2012 SFMS Election!

Thu, 08 Nov 2012 11:35:16 GMT

Please cast your ballot to elect SFMS officers, board, and delegation members to represent SFMS at CMA if you have not yet done so.

All physicians currently in practice, residents, and UCSF medical students who held current membership with the SFMS are eligible to vote. One ballot per member.

Simply click on the "VOTE" button to access your e-ballot, or go to https://www.surveymonkey.com/s/2012SFMSElection.

The e-ballot should take no longer than 5 minutes to complete. All ballot information will be kept confidential.

Biographical sketches for each of the candidates are published in the October issue of San Francisco Medicine.

All completed ballot must be submitted electronically by 5 PM on November 13, 2012. Any ballot received thereafter is invalid. Election results will be posted on the SFMS blog by November 18, and subsequently published in San Francisco Medicine.

Questions? Please contact SFMS at (415) 561-0850 ext. 200 or email membership@sfms.org.

Sooji Rugh, MD: SFMS November 2012 Member of the Month

Wed, 07 Nov 2012 11:21:28 GMT

Sooji Rugh, MD is a bariatric physician with board certification in Internal Medicine and Obesity Medicine. She is the founder and medical director of Greenlite Medicine, a medically supervised weight loss practice with locations in San Francisco and Silicon Valley.

Dr. Rugh received her undergraduate degree from MIT, medical degree from the University of Pittsburgh, and completed her residency training at Harbor-UCLA. She currently serves on the board for National Association of Women Business Owners-Silicon Valley (NAWBO-SV), and is a founding committee member of the Northern California MIT Life Science Forum, dedicated to the promotion of life sciences and health related endeavors. A SFMS member since 2011, Dr. Rugh also retains membership with the Obesity Society and American Society of Bariatric Physicians. To view Dr. Rugh’s practice information, please click here.

I am a SFMS member because SFMS offers great opportunities for networking with other physicians. As a relative newcomer to San Francisco and as a practitioner in a private practice, not affiliated with a larger organization, I found it to be a challenge to meet fellow physicians. SFMS offers the opportunity to expand my professional network and hopefully develop new friendships.

Which SFMS member resource is most helpful to you?

In addition to the numerous ways to network with other physicians, I see so many resources offered to members such as the ICD-10 training seminar and webinar series. As I attend more meetings, I’ve also become increasingly aware of the passion and commitment that many of the physician leaders in SFMS and CMA have to public policy and health initiatives. It’s great to be part of an organization with a commitment to the local community they serve.

My greatest achievement outside of practicing medicine is my family. I feel lucky to have literally run into my husband, Nick, while training for the D.C. marathon. We have two children, Meena (14) and Tae (11) who are developing into lovely young adults. Although I state they are my greatest achievement, I can’t honestly take the credit. They, however, can certainly take credit for bringing out the best in me and reminding me of my life priorities.

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

As an obesity specialist and internist, I can’t help but focus on the impact of obesity—especially childhood obesity—on the future of health care. It is projected that 50% of our population will be obese by 2030. The associated co-morbidities will create a tremendous burden on the health care system. This undeniable problem may have nudged the FDA to break from its 10-year denial for the NDA (New Drug Approval) of obesity drugs. Medicare too has taken heed and recently adapted coverage for obesity counseling. But similar to other chronic diseases, obesity is rooted in lifestyle habits and we can’t ignore that implication that our lifestyle is killing us. The future of our children depends on it. We, as a community and a society, need to make a concerted effort to value the lifestyle change required for better health.

I love practicing Obesity Medicine because of the ability to make a profound difference in someone’s life. The results that come with weight loss not only help create remarkable physical transformations, but life-altering changes in attitude and confidence.

If I wasn't a physician, I would like to be a movie producer. I love a good story, no matter what the medium. I used to watch tons movies as little girl, and in college I loved learning about movie making and recall how Alfred Hitchcock used ceilings to create the mood of enclosure and entrapment. Recently I took a crash course on videography and video editing at my local community media center. Maybe you can catch my work on YouTube one day.