BILL ANALYSIS Ó ----------------------------------------------------------------------- |Hearing Date:June 23, 2014 |Bill No:AB | | |2214 | ----------------------------------------------------------------------- SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT Senator Ted W. Lieu, Chair Bill No: AB 2214Author:Fox As Amended:April 21, 2014Fiscal: Yes SUBJECT: Emergency room physicians and surgeons: continuing medical education: geriatric care. SUMMARY: Enacts the Dolores H. Fox Act to require the Medical Board of California to consider including a course in geriatric care for emergency room physicians and surgeons as part of its continuing education requirements. Existing law: 1)Licenses and regulates physicians and surgeons under the Medical Practice Act by the Medical Board of California (MBC) within the Department of Consumer Affairs (DCA). (Business and Professions Code (BPC) § 2000 et seq.) 2)Requires MBC to adopt and administer standards for the continuing education of licensees, and requires each licensee to demonstrate satisfaction of the requirements at regular intervals. (BPC § 2190) 3)Requires all general internists and family physicians, who have a patient population of which over 25% are 65 years of age or older, to complete at least 20% of all mandatory continuing education hours in a course in the field of geriatric medicine or the care of older patients. (BPC § 2190.3) 4)Requires all physicians and surgeons to complete a mandatory continuing education course in the subjects of pain management and the treatment of terminally ill and dying patients, as specified. AB 2214 Page 2 (BPC § 2190.5) 5)Requires MBC to consider including a course in the following subjects when determining its continuing education requirements: (BPC § 2191) a) Human sexuality and nutrition; b) Child abuse detection and treatment; c) Acupuncture; d) Nutrition; e) Elder abuse detection and treatment; f) Early detection and treatment of substance abusing pregnant women; g) Special care needs of drug addicted infants; h) How to routinely screen for signs exhibited by abused women; i) Special care needs of individuals and their families facing end-of-life issues; and j) Pain management. This bill: Enacts the Dolores H. Fox Act to require the Medical Board of California (MBC) to consider including a course in geriatric care for emergency room physicians and surgeons as part of its continuing education requirements. FISCAL EFFECT: This measure has been keyed "fiscal" by Legislative Counsel. The May 14, 2014 Assembly Committee on Appropriations analysis cites minor and absorbable costs to MBC (Contingent Fund of the MBC). COMMENTS: 1.Purpose. This bill is sponsored by the Author in order to require the Medical Board of California, in determining continuing education AB 2214 Page 3 requirements, to consider including a course in geriatric care for emergency room physicians and surgeons. According to the Author, "California faces a critical shortage of physicians with geriatric care expertise. For many elderly, the emergency room is where the first signs of major health complications are revealed, but often they are not recognized or properly diagnosed. Elderly patients do not exhibit the same signs or symptoms of illnesses as younger patients, often times causing the elderly patients being misdiagnosed." The Author believes that the lack of specific training in geriatric care hinders emergency room physicians in their ability to provide the best care to senior patients. The Author argues that current continuing education training requirements for emergency room physicians are insufficient to meet the needs of the elderly, and states that this bill is necessary to ensure that emergency room doctors have the knowledge and skills required to competently treat elderly patients. 2.Background. A March 13, 2014 New York Times article titled "Emergency Rooms Are No Place for the Elderly" states: "The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms." The article further indicates that over the last five decades quality emergency care has become synonymous with speed. Survival rates for patients suffering stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. However, when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued with chronic diseases like diabetes, high blood pressure and heart disease, and take numerous prescription drugs which interact in complex and often times dangerous ways. The elderly are also more likely to suffer dementia and cognitive disorders that make answering even the simplest questions difficult. The Times further notes that in recent years a growing number of physicians and health facilities have begun to focus on the needs of the growing elderly population as it interacts with the emergency room. A number of changes have been suggested, including routine screening for dementia and cognitive impairments, the use of AB 2214 Page 4 non-slip flooring to decrease the risk of falls and training staff to be more effectively tuned to the needs and circumstances of the elderly. The Times writes that in recent years, "?about 50 medical centers have incorporated such changes in their emergency rooms, a notable improvement from a decade ago when none existed." 3.Geriatric Care. Geriatric medicine is medical specialty that addresses the complex needs of older patients and emphasizes maintaining functional independence even in the presence of chronic disease. Geriatric medicine requires an interdisciplinary approach between physicians, nurses, social workers, occupational therapists and family members in order to provide comprehensive care for these patients with multiple needs. Geriatric medicine is its own specialty. After an internal medicine or family practice residency, physicians can complete a one or two-year fellowship training in the medical, social and psychological issues that concern older adults to become certified in geriatric medicine. This specialty is increasing in importance as the population ages and that aging population lives longer. People over the age of 85 are the fastest growing segment of the population, and it is no longer a rarity for people to live to be one hundred. Geriatricians are primary care physicians who specialize in care for people 65 and older and can also serve as consultants to other physicians and to hospital programs that work with the elderly. Geriatricians are typically board certified in Internal Medicine and have additional training in areas pertaining to elder care. They address issues such as memory loss, arthritis, osteoporosis, mobility and Alzheimer's disease. The Rand Corporation states that there is a shortage of geriatricians in the United States, with fewer than four certified geriatricians in the United States per 10,000 individuals 75 years of age or older. Less than 1% of graduates from United States medical schools choose geriatric medicine as a career. With diminishing access to specialized care for older patients, an inevitable consequence will be more older patients will seek treatment in the emergency room. These facts underscore the need for this bill. 4.Continuing Education Requirements. The MBC requires all physicians to complete at least 50 hours of approved continuing education for AB 2214 Page 5 each two-year period immediately preceding the expiration date of the license. The MBC approves continuing education providers and establishes criteria for acceptable courses. The MBC requires all physicians to complete a mandatory continuing education course in the subjects of pain management and the treatment of terminally ill and dying patients. It also requires all general internists and family physicians who have a patient population of which over 25% are 65 years of age or older, to complete at least 20% of all mandatory continuing education hours in a course in the field of geriatric medicine or the care of older patients. The law further establishes a list of subjects that the MBC considers when establishing continuing education requirements for physicians and surgeons. This bill would require the MBC to add geriatric care for emergency room physicians to that consideration list, but does not mandate that the actual courses be required. 5.Related Legislation. AB 2198 (Levine) of 2014 requires a psychologist, marriage and family therapist, educational psychologist, professional clinical counselor and clinical social worker, who began graduate study on or after January 1, 2016, to complete a minimum of 15 hours of coursework on suicide prevention, before being issued a license. Further requires, commencing January 1, 2016, a person licensed in these professions who began graduate study prior to January 1, 2016, to take a six-hour continuing education course on suicide prevention in order to renew a license. ( Status : This measure is also scheduled to be heard in this Committee on June 23, 2014.) AB 1820 (Wright, Chapter 440, Statutes of 2000) requires coursework and training in geriatrics for general internists and family physicians. AB 253 (Eng, Chapter 678, Statutes of 2007), sponsored by the MBC, drastically changed the MBC's structure and membership. Previously, MBC was made up of two Divisions, the Division of Licensing and the Division of Medical Quality. The Division of Licensing handled all policy decisions related to the MBC's licensing functions. The Division of Medical Quality dealt with all enforcement policy decisions. For the most part, each Division operated independently from the other Division. The MBC realized that this was not the best arrangement in order to meet its mission of consumer AB 2214 Page 6 protection. AB 253 restructured the MBC to eliminate the two divisions, resulting in a single, unified MBC. The bill also reduced the membership from 21 Members, to 15 Members. 6.Arguments in Support. The California Commission on Aging (CCoA) argues that, "California faces a critical shortage of medical professionals with geriatric care expertise. For many elderly, the emergency room is where the first signs of major health complications are revealed, but often they are not recognized or properly diagnosed. By recommending that geriatric care training be made available in continuing education coursework, AB 2214 could provide emergency room professionals access to important information on the complex health issues that elders face." California Long-Term Care Ombudsman Association (CLTCOA) states: "Frequently, the lack of specific training in geriatric care hinders emergency room physicians in their ability to provide the best quality care for their senior patients. The current continuing education training requirements for emergency room physicians are insufficient to meet the needs of seniors, particularly those seniors who live in long-term care facilities. AB 2214 is an appropriate solution to this problem." 7.Suggested Conforming Amendments. This bill amends Section 2191 of the Business and Professions Code which refers to the "Division of Licensing" and "division" rather than to the "board." AB 253 (Eng, Chapter 678, Statutes of 2007) restructured the MBC to eliminate the Division of Licensing and the Division of Medical Quality, resulting in a single, unified MBC. Staff recommends conforming amendments to update this code section to appropriately refer to the "board." SUPPORT AND OPPOSITION: Support: California Commission on Aging California Long-Term Care Ombudsman Association Opposition: None received as of June 18, 2014 AB 2214 Page 7 Consultant:G. V. Ayers