Sierra Sacramento Valley
MEDICINE
March/April 2007
Sierra Sacramento Valley
Medicine 3
PRESIDENT’S MESSAGE Performance Enhancement Regimen? No Dope.
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Our Region’s Risks
SSVMS Public and Environmental Health Committee
Richard Jones, MD
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Useful Idiots Revisted
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The Perils of Single Payer
Lee T. Snook, Jr., MD
David J. Gibson, MD, and Jennifer S. Gibson
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Queen Victoria
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Electronic Medical Record Systems are a Big Plus
Irma West, MD
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David J. Manske, MD
Land of Enchantment, Land of War
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Thanabstetrics
Ben Brown, MD
John Hendry, MD
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IN MEMORIAM David Krankheit, MD
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Voices of Medicine
Del Meyer, MD
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New Applicants
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Yolo County’s Salud Clinic Celebrates its 35th Year
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Board Briefs
David Katz, MD
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Classified Ads
We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.
SSV Medicine is online at www.ssvms.org/magazine.asp
This watercolor by ophthalmologist Dr. Barbara J. Arnold was painted three years ago in Denver. Her goal was to bring the viewer into the forest, “to create an outdoor experience on paper.”
Volume 58/Number 2
The original is 22 by 30 inches, and like last month’s cover, was painted on 300-pound cold press Arches cotton rag.
5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org
bjarnold@ucdavis.edu
March/April 2007
Official publication of the Sierra Sacramento Valley Medical Society
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Sierra Sacramento Valley
MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2007 Officers & Board of Directors Richard Jones, MD President Margaret Parsons, MD President-Elect Kuldip Sandhu, MD, Immediate Past President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Charles McDonnell, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD 2007 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Barbara Arnold, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Tom Ormiston, MD At-Large Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Margaret Parsons, MD Charles McDonnell, MD Robert Midgley, MD Janet O’Brien, MD Richard Pan, MD Earl Washburn, MD
District 4 Ulrich Hacker, MD District 5 Eduardo Bermudez, MD David Herbert, MD Elisabeth Mathew, MD Stephen Melcher, MD District 6 Marcia Gollober, MD Alternate-Delegates District 1 Robert Kahle, MD District 2 Samuel Ciricillo, MD District 3 Ken Ozawa, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Craighton Chin, MD At-Large Alicia Abels, MD Christopher Chong, MD Marcia Gollober, MD Robert Jacoby, MD Anthony Russell, MD Kuldip Sandhu, MD Jeff Suplica, MD
CMA Trustees 11th District Joanne Berkowitz, MD Dean Hadley, MD Solo/Small Group Practice Forum Lee T. Snook, MD Very Large Group Forum Paul R. Phinney, MD Council on Scientific Affairs Allan Siefkin, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor David Gibson, MD, Vice Chair William Peniston, MD Robert LaPerriere, MD Eleanor Rodgerson, MD Gordon Love, MD F. James Rybka, MD John McCarthy, MD Gilbert Wright, MD Del Meyer, MD Lydia Wytrzes, MD George Meyer, MD John Ostrich, MD Medical Students Robin Telerant
Tasha Marenbach
Managing Editor Webmaster Graphic Design
Ted Fourkas Melissa Darling Kelly Davis
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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2006 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.
Sierra Sacramento Valley Medicine
President’s Message
Performance Enhancement Regimen? No Dope. By Richard Jones, MD “Why am I so tired?” I often think after arriving home from my office. Who hasn’t experienced that exhaustion after a full day of surgery, clinic or rounds at the hospital? Why should a day of being a physician be harder than running a marathon or doing a 100-mile bike ride? Moving about your office seeing patients, rounding or operating isn’t that physically demanding, is it? How many muscle groups are at work writing, walking, reading, typing, listening, talking, fretting, transcribing and thinking? I don’t recall my heart rate ever getting above 100 bpm in my surgical cases except for brief flutters during particularly tricky cases. I don’t seem to be panting or have sweat cascading down my neck in clinic discussing eye pathology with a patient. In the office, I am not tachypneic, or tachycardic; the only thing tacky is my chipped, chart-strewn desk. While I am certainly no Olympian, I have had my share of taxing athletic endeavors. I have bicycled as an amateur along some of the famous mountainous stages of the Tour de France twice, wobbled up five passes and 16,000 feet in the infamous California Death ride, and endured many a 100-mile bike century. In Iowa, I spent a week perspiring and riding through surprisingly hilly countryside where 100 degree heat conspired with 100 percent humidity. Since evaporation seemed impossible, I thought riding faster would blow the sweat off and undoubtedly my intellect has suffered since. Many doctors have far more exotic, demanding, risky and physiologically challenging pursuits, so I am certainly unexceptional and my physical accomplishments pale in comparison to theirs. The point is, many of us are no couch potatoes.
So why do we feel so fatigued after a day of work? What can we do about it? Well, it seems logical that if the practice of medicine is like any other endeavor, training, proper equipment, and motivation might be optimized to enhance the VO2 max to get one physically and mentally through the day with energy to spare. I don’t know much about kinesiology, physiology or psychology anymore, but I do know a cataract when I see one, and also know something about the training and tactics bike racers use to improve their performance. Let’s see how professional cyclists’ fortitude is derived and maybe I can emulate it without involving EPO, anabolic steroids or suspicious urine tests.
Is it Training? Could training be the difference? A bike racer, particularly a pro, has undergone years of preparation and qualifying. Virtually all successful champions in the Tour de France are seasoned throughout their young adulthood before reaching the top pro circuit at age 30. Sound familiar? We as physicians have spent the better part of our youth studying to enter a top university, and then tempering our mental muscles even harder to escalate to medical school. After that, we enter our residency and internship like the apprenticeship of the younger professional bike racers. The job of these younger bike racers — or “domestiques” — is to support the leader of the team by fetching water bottles, getting food and doing the hard work of chasing down a breakaway so the leader of the team has
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it easier. That appears similar to internship and residency. We fetch the labs, do the grunt work on rounds and instead of being called domestiques, we are called junior house staff, all to support the attending. Instead of long hours in the bike saddle, we spend long days in the ER, wards or operating rooms and chug black coffee like the bike racers quaff their Gatorade. Like the junior bike racers we pay our dues and move into the big leagues by entering medical practice after years of grueling internship, residency and fellowship. We have been steeled by the crucible of training — and proven we have what it takes to take on the race of medicine. So if our training is similar in concept to the professional biker, why do we sometimes feel so exhausted after a day of work? Could it be our equipment? The bike racer has a 3-pound carbon fiber bike with 14 speeds, yet I have a phone system with 15 lines and a cell phone weighing 3 ounces. Besides, I usually drive to work and my white coat, tie and Docker pants are far more comfortable than the lycra–clad, sweat-wicking tights worn by a racer (although my wife might say that the odor of each is indistinguishable at the end of a day). The bike racer has his tools and supporting ”domestiques,” and I have mine. But he uses his equipment to ride on average 50 miles a day, while that may just be the number of patients I see.
Organized medicine is like the peloton, blunting the winds of medical liability, easing the drag of reimbursement inequity, and buffering us from the gusts of
Energy Management?
legislation that hamper our goals of proper patient care.
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The professional bike racer’s stamina involves training and proper equipment akin to the skills and support that we physicians also share. So could the difference be in energy management? Why do 100 riders breeze down a road at 35 miles an hour with only inches between one another when they know touching their wheels together will cause a catastrophic and painful collision? Drafting in pace lines, groups or, in bike–speak, a “peloton” is all about energy management. Riding with the help of fellow cyclists will reduce the amount of effort by 30 to 40 percent by simple aerodynamics. All in the peloton are supposed to contrib-
Sierra Sacramento Valley Medicine
ute to the effort since the groups’ pull helps every individual rider. Those riding in the back of the slipstream draft without sharing the labor are seen as ”leeches” and face ostracism; they are remembered when they might need the help of the group. Not. Our medical practices are helped by a similar phenomenon. Organized medicine is like the peloton, blunting the winds of medical liability, easing the drag of reimbursement inequity, and buffering us from the gusts of legislation that hamper our goals of proper patient care. The exception is that those doctors who don’t participate in organized medicine, unlike racers in the peloton, are not ostracized or banished. The slackers get a free ride from the efforts of those doctors who do participate. On two occasions, I rode my bike in the Tour de France, pedaling along the same roads a few hours before the real bike racers swoosh through the streets or clamber up the mountain passes. One year was in the Alps and the other the Pyrenees. I was sufficiently trained and equipped, and followed the proper biking etiquette by participating in the fast pace lines that preceded the long, arduous, and mercilessly hot ascent into the mountains. Those were the years when a heat wave flambéed France and thousands of elderly perished in their solitary unairconditioned apartments; at times, I was certain my name would be part of the grim census. Thus, it should have been a physical and mental ordeal — certainly much harder than a day in the office. Why wasn’t it?
The Fervent Fans Along the route of the Tour de France are thousands of fervent fans from all points of the globe, making it the longest continuous tailgate party in the world. Many arrive days in advance and line the roads for miles, a hodgepodge of encampments trailers, sleeping bags and beer kegs. Flags of all the nations fly, but fists don’t. When the real bike racers approach, the tranquil community erupts with excitement; the fans hoot, scream, honk, spray water, wave their nations’ flags and show appreciation for the
racers as they chug and strain to the summits of the Alpine and Pyrenean passes. When I came gasping up the mountain, I expected little attention, perhaps even derision. To my astonishment I got a similar reception, including doubling my French vocabulary by hearing “allez” so many times. Perhaps the fans were getting warmed up for the real racers to follow or, more likely, they felt sympathy for the visage of a thin, pale, sweating and wheezing ophthalmologist grinding up the grades. What should have been grueling was blissful; what should have been painful was pleasurable and what could have been a sacrifice was really an honor. I had fans! And now it dawns upon me, perhaps belatedly due to my hyperthermic brain damage, that the difference between pain, fatigue and joy and energy was a function of learning to recognize that praise and cheer are out there and, like endorphins, are powerful assuagers of fatigue and stimulants to the soul.
Yes, our medical practices can be challenging, but we are up to it; we have been properly prepared by years of training like the racers. We have the equipment of modern medicine to rival the space age composite equipment of bike racers, and we have the organized medicine “peloton” assisting our advances. But to provide the crucial energy to combat our exhaustion and ennui, we must open our emotional receptors to the daily thanks that we normally shrug off, accept the cheers, cookies, joy and pathos generated by our care of our patients. The bike racers may have their cheering fans, but we have ours, too! They are the grateful patients we help heal and care for and whose appreciation and respect we must accept as a powerful antidote to fatigue. It is a powerful performance-enhancing substance we should add to our daily regimen. And it doesn’t show up on urine tests! rajones@sbcglobal.net
We all have our champions. Thank you for being ours. Bobby is a two-time organ transplant recipient.
There are those who have given blood. There are those who have gratefully received blood. Then there are the medical professionals who have cared for Yes, you do save lives. www.bloodsource.org
|
not-for-profit since 1948
every man, woman and child who needed blood this year. Thank you for being our life saving champion.
March/April 2007
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The Perils of Single Payer A number of physicians now think single-payer is the answer to health care financing. Be very, very careful what you wish for.
By David J. Gibson, MD, and Jennifer S. Gibson See the online edition of this article for 11 accompanying graphs. David Gibson is a member of the SSVMS Editorial Committee and a senior partner and chief medical officer at Illumination Medical, Inc., a health care consulting and medical management company. Jennifer Gibson is an economist specializing in evolving health care markets as well as a futures commodity trader specializing in oil and gas. In an article published online with the previous issue, we gave a broad overview of the reform efforts being tested in the health care market. This article explores the implications for the health care system if the single payer system is enacted in California. Since the Nixon Administration in the mid 1970s, physicians have been unhappy with managed care. They have chafed at restraints imposed by utilization review and third party quantization of quality and outcomes. Few physicians have not expressed the hope that managed care would simply disappear. Well, we are about to get our wish. Employers are relentlessly retreating from the uncontrollable cost of defined benefit coverage for health care. Those still committed to providing health care benefits are considering defined contribution plans, similar to 401K packages, in their retirement benefit. These defined contribution health plans have high deductibles and co-payment designs. That means significant increases in noncollectable payments as patients face unexpected health care service costs. Today, employers see a misallocation of
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resources that bears little relationship with favorable outcomes under the current system.1 Medicare data demonstrate marked variations by region in the use of hospital resources and ambulatory diagnostic testing for the care of chronically ill elderly patients. Studies demonstrate that lower utilization of acute care hospitals and less frequent physician visits actually lead to better results for patients.2 In a recent poll,3 an overwhelming 80 percent of respondents were dissatisfied with the amount the nation spends on health care, estimated to be $2.2 trillion, or $7,129 a person for those less than age 65, this year. The average yearly cost of the most common type of insurance plan for families offered by employers hit $11,765 last year, with the average employee paying $3,226 of that total. Average premiums have risen 87 percent since 2000, while workers’ earnings have risen 20 percent. The American public is literally being priced out of the health care market.
Single Payer (Universal) Coverage In the abstract, it is not difficult to make a case for converting our health care financing to a single payer system similar to Canada’s. America spends more than twice as much per person on health care as do other industrialized countries. We are also the only such country not providing universal health insurance coverage. From a return on investment point of view, despite the disproportionate spending, America’s rate of infant mortality ranks highest among 10 Organization for Economic Co-operation and Development (OCED) industrialized nations. Our cancer mortality rate ranks fourth behind
Japan, Sweden and Australia. We rank seventh in cardiovascular mortality. Without reform, health care spending in the United States will double over the next 10 years to more than $4 trillion, or one in five dollars of gross domestic product, in 2015. Serious efforts to reform health care have occurred so far in a vacuum. The assumption is that we can move from the current employerbased financing system to an alternative without inconveniencing the public and requiring all of us to re-think the type of health care services that we deem to be acceptable. Despite increasing dissatisfaction with the current system, the public is deeply ambivalent about alternatives. When polled4 about their preference to convert to a universal/single payer system, 56 percent responded affirmatively. However, support for changes to the system dropped to about one-third or less when respondents were asked if they would support universal coverage if it included restrictions on the doctors or treatments they could have, or if it cost them more than they are now paying in taxes or premiums.5 The ambivalence is well grounded. Countries with single payer systems routinely rely on supply constraints to control health care spending, including limiting the number of hospital beds, controlling the spread of medical technology, and restricting the number of physicians while controlling their incomes. What happens if California adopts a single payer system similar to Canada’s? Sen. Sheila Kuehl’s Health Insurance Reliability Act (SB 840), which was vetoed last year, is an example. We have had almost 50 years of experience to project how a similar system would affect our delivery system here in California.
Hospitals Hospitals are not the cost fulcrum on which the Canadian system is leveraged. In Canada, hospitals are paid through annual, global budgets negotiated with the provincial and territorial ministries of health, or with a regional health authority or board. In short, they do not compete.
Since publicly funded health care began in Canada, health care services and the way they are delivered have changed from a reliance on hospitals and doctors. They have shifted to alternative care in clinics, primary health care centers, community health centers and home care treatment using medical equipment and drugs, and public health interventions. This dramatically differs from America’s hospital-centric and high tech diagnostic and treatment system design. While the number of hospital beds per capita in the U.S. was in the bottom quartile of OECD countries in 2002, the average U.S. expenditure per hospital day was $1,850 in 1999, three times the OECD median.6,7 OECD data show that U.S. hospital services are more expensive, staffing costs are significantly higher, patients are treated more intensively, and hospitals are less efficient. Hospital admissions per capita were lower in Canada than in the United States in 2000. In addition, Canada’s health system delivers far fewer highly sophisticated procedures than does the U.S. system. For example, the U.S. system has four times as many coronary angioplasties per capita and about twice the number of kidney dialyses.
Hospitals are not the cost fulcrum on which the Canadian system is leveraged.
Cost per hospital bed day Japan Czech Rep. Korea Norway Switzerland Finland Germany Netherlands Luxenbourg Australia France Italy Canada Denmark USA
$90 $101 $115 $151 $206 $213 $229 $256 $261 $274 $288 $364 $539 $826 $1,204 Source: OECD data; 2000; 1997 bed day cost values
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Physician8
Diagnostic Technology Availability
Physicians’ incomes are much higher in the United States than they are in other OECD countries. This disparity, when translated throughout the entire health care industry labor cost structure, is the primary cost driver for the U.S. system. America’s disproportionate labor cost is the prime factor in the discrepancy in total system cost with other OCED countries.9 In 1996, the most recent year for which data are available for multiple countries, the average U.S. physician income was $199,000. The comparable OECD median physician income was $70,324. The ratio of the average income of U.S. physicians to average employee compensation for the United States as a whole was about 5.5. Germany’s was the next highest, at only 3.4; Canada, 3.2; Australia, 2.2; Switzerland, 2.1; France, 1.9; Sweden, 1.5; and the United Kingdom, 1.4. In Canada, physicians in general practice total 76 percent of physicians in practice today. Conversely, only one third of the active physicians in the United States are in general practice, general internists, or general pediatricians.10 This disparity in physician training is getting worse, with a growing concentration of specialists and a declining percentage of primary care physicians entering practice in the U.S.
The availability of diagnostic technology is significantly less in every country with a single payer system. For example, the US has 3.3 times the number of CAT scanners that are available in Canada. The availability of MRIs is 9.4 times greater. This disparity of imaging technology availability will be exacerbated into the future should the current financing system remain in the United States.
Ratio of average physician income to the average employee compensation 5.5 The median U.S. physician income was $199,000 compared with OECD median physician income of $70,324.
3.4
3.2 2.2
1.9 1.4
US
Germany
Canada
Australia
France
Source: 2000 OECD Health Data
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United Kingdom
Conclusion No reasonable person should conclude that reforming the financing system for health care in California would not have a profound effect on the delivery system itself. Single payer systems in Canada and other OECD countries differ substantively from America’s delivery system. American hospitals now charge three times the rate per bed day compared with the median in OECD countries. Physician incomes are 50 percent to 75 percent lower in OCED countries than in America. The ratio of generalists to specialists will rapidly trend to parity or beyond should single payer come to California. Access to high-tech diagnostic technology will be significantly reduced and plans for growth in the development of this technology will be scrapped. It should be noted that the less aggressive reform measures installed in Hawaii have also significantly changed the health care system in that state. The supply of hospital beds has been reduced from the current national average of 4.2 acute care hospital beds per 1,000 population to 2.1. Likewise, the access to hightech diagnostic modalities has been significantly reduced. Hawaii has one MRI scanner per 1 million people, while the U.S. average is one per 100,000. Even Canada has one per 400,000. Massachusetts has now initiated a system quite similar to the Hawaiian model. It will be informative to watch the effect this move will have upon the nationally recognized medical system and world-renowned teaching institutions within that state. The difference between single payer systems and America’s current system will require aggres-
sive restructuring here in California. Medical education will be completely revamped and reoriented to training generalists. Hospitals will need to re-draft their business models. In an environment that devalues inpatient services, and in which pricing is dictated by the payer, there will be no advantage to developing large regional oligopolies like Sutter or Catholic Healthcare West. There will be no incentive for hospitals to subsidize medical groups like the Sutter Medical Group or the U.C. Davis Medical Group. In fact, the entire multi-specialty group practice business model, which now depends upon revenue from in-house lab and diagnostic scanners, will no longer compute under single payer. Resources will be redirected into community based low-tech public health and preventative care facilities and services. The annual “juice bill” session of the Legislature dealing with scope of practice will end. Single payer will dictate broadened capabilities for health care para-professionals. Pharmaceutical manufacturers will have to adjust to a single purchaser that will dictate product pricing. That payer will favor generics and multi-source discounted products. Equipment manufacturers will likely abandon the market for the near future. All of the third-party utilization management, quality assurance and outcomes scoring we have resisted in the current system will be retained and enhanced in single payer. No one should naively assume that business in health care will go on as before. This reforming of the financing system will produce disruptive and dislocating changes. Is this what we have been wishing for during the past 30-years?
5 Politicians have a track record of promising entitlements but not raising the taxes to pay or them. As Fritz Mondale and Phil Angelides demonstrated, you do not get elected if you forthrightly state that you are going to increase taxes to pay for services. 6 As a partial explanation for this high cost, the highly fragmented and complex U.S. payment system requires more administrative personnel in hospitals than needed in countries with simpler payment systems. 7 The United States also exceeded the OECD median in nurse staffing level in acute care hospitals. In 2002, there were 1.4 nurses per U.S. hospital bed, compared with the OECD median of 1.0 nurse per bed. 8 “The Supply of Physician Services in OECD Countries”; www. oecd.org/dataoecd/27/22/35987490.pdf 9 “Health Spending in the United States and the Rest of the Industrialized World” (Health Affairs, July/August 2005), Gerald F. Anderson, Peter S. Hussey, Bianca K. Frogner, and Hugh R. Waters of the Bloomberg School of Public Health at Johns Hopkins University. 10 “Managing Primary Care in the United States and in the United Kingdom,” Kevin Grumbach, and John Fry; NEJM; Volume 328:940-945; April 1, 1993; Number 13.
Medical education will be completely revamped and reoriented to training generalists.
DJGibson@winfirst.com 1 Dartmouth Atlas of Health Care 2006; at www.dartmouthatlas. org/atlases/2006_Chroni_Care_Atlas.pdf 2 Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School. 3 USA TODAY, ABC News and the Kaiser Family Foundation; September ‘06 4 USA TODAY, ABC News and the Kaiser Family Foundation; September ‘06
– by Will Nakashima, MD
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Electronic Medical Record Systems are a Big Plus By David J. Manske, MD I read with interest Dr. Eduardo Bermudez’s essay in the January/February 2007 issue of Sierra Sacramento Valley Medicine. I find myself drawn to make some comments on my own experiences and observations with the EMR. Over the last 18 months the advent of our comprehensive EMR has been an interesting adventure into the 21st century, an adventure that seems to have challenged us all and made us take a hard look at how we relate and adapt to a changing world. It seems to me this experience has distinguished our medical group into two groups of people who deal with change in dramatically different ways. Perhaps this speaks to something deeper in the human psyche. I am an orthopaedic surgeon and have practiced at the Kaiser-Permanente South Sacramento Medical Center for nearly 21 years. As a consequence of my tenure, I have a very busy surgical and busier office practice, with many returning customers and many new patients every week. Patients come to see me from a variety of Kaiser facilities scattered around the Sacramento Valley, as well as from the Bay area. In the 20th century these people often came unaccompanied by any charts or X-rays, these records remaining at their home facility altogether or arriving the day after the consultation. X-rays needed to be repeated at the expense of more radiation exposure for the patient and higher health care costs. Prior procedures or work-up had to be surmised, guessed at or repeated, with the same problems of patient inconvenience and expense.
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Now I have complete access to the entire patient chart from South Sacramento and indeed the entire Sacramento Valley service area. As more facilities come online these records will be available from any of our Northern California facilities. This can only dramatically improve our service to our patients, improving their satisfaction and reducing the costs of providing their care. And I am less stressed and far happier! My typical office workflow has become much more efficient and I have found the computer to be a minimal hindrance to my patient-provider interaction. In fact, I think that the patients’ experience has been dramatically improved by the presence of the computer. I have situated my exam rooms so that eye contact is not lost, I do my post-visit charting in my office after each visit, and I am able to quickly pull up patient lab results and X-rays, for my review and the patient’s edification, with no more inefficient thumbing through a paper chart or digging through a bulky X-ray jacket. My patients are usually very impressed! Our Secure Messaging feature allows me to communicate with my patients in a very timely fashion, much preferred to the old-fashioned phone call method, when we often might play “phone tag” for days. I can personally answer their questions in as much or as little detail as needed, for review at their convenience. Many of my patients are delighted to have this service offered and I encourage all to sign up for this access. Postop phone visits are easily made and just as easily documented, again to the mutual satisfaction of patient and provider. The EMR helps me manage my hospital patients in a much more timely and efficient
manner as well. Upon completion of rounds I can finish my documentation on the spot, at one of many available terminals or, if late for the OR, I can finish this in the operating room as my next patient goes off to sleep. This is very nice. I have designed many of my own “order sets” and this has made the process of writing orders much faster for me. My time stress has gone down many-fold. No longer do I have to squint to decipher hand-written consultation notes when medical consultation is needed. Illegibility has become an anachronism! Our system makes it very difficult to make medication errors. All of these changes help me and tremendously benefit my patients. As I am writing this, I have gotten a call from the nurse caring for one of my hip replacement patients. I find it necessary to give her an order. In the 20th century, I would likely have given a verbal order and then had to hunt down the paper chart later, to sign that order within the regulatory 48 hours. But now I have just opened the patient’s hospital chart, in my office, entered the order, and electronically signed it, with just a few mouse clicks. The patient gets good care, all of the regulatory bases are covered and I am back to my computer to continue this essay! When on-call from home, I can review X-rays taken in the ED, schedule surgery for a patient with a hip fracture and have the whole “ball rolling” before I even head out for the hospital. If necessary, I can check on my patient’s progress from the same home computer. (And while speaking of home access, I find that this is very helpful when on call but try to minimize my use of the computer otherwise, for the benefit of my time with my family. I have become so efficient that I very rarely have homework, realizing that some things can wait until the next day.) Now, I don’t mean to imply that all is perfect. There are glitches, as with any computer application. There are the occasional down times and the system still needs some tweaking to improve user friendliness — but all of these problems are being addressed by lots of very smart people and I look forward to continued improvement in the
product. I can handle the little problems, realize that they are temporary and move on. This has not been the case for some of my colleagues. As the system has rolled out, there have been those among us who have struggled, a struggle of their own making I fear. Not unlike Eeyore, the downcast donkey in the Pooh stories, there are some who, from the very beginning, have intoned, “We’re not going to make it, it’s not going to work,” and these poor unfortunates have indeed had a tough time of it. Every little issue becomes a mountain, convincing them again that the system is doomed to failure, a selffulfilling prophesy. Change in any shape seems to cause them great consternation. As an example, one of our surgeons stormed into the office of our OR assistant manager, red in the face that the cautery machines had been changed. “I can’t handle change!” he snarled. She calmly reminded him that he’d been married three times, that he could indeed handle change! Mouth open, he retreated, perhaps to re-evaluate his change management style. I am a firm believer that we create our own reality. Call it karma or the “glass is always half full,” but I have tried to approach the EMR as a new adventure, one destined to make things better for all of us. And I have struggled very little. The system is the same for all of us, we have all had the same problems, but I have a different way of approaching change that seems to work well for me. I can come to work with a smile on my face and really mean it! The 21st century has not brought us flying cars (at least not yet!) but the EMR will be seen to be a great stride forward for health care, I am convinced. I am very proud to belong to an organization that has made this such a priority, and I’d like to personally thank all of those hard working people for bringing this system to us and for their ongoing efforts to make it always better. I have and will continue to benefit from the EMR, but more importantly, this is even more the case for my patients!
No longer do I have to squint to decipher hand-written consultation notes when medical consultation is needed. Illegibility has become an anachronism!
David.Manske@kp.org
March/April 2007
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Thanabstetrics By John Hendry, MD So live, that when thy summons comes to join The innumerable caravan, which moves To that mysterious realm, where each shall take His chamber in the silent halls of death, Thou go not like a quarry-slave at night, Scourged to his dungeon, but, sustained and soothed By an unfaltering trust, approach thy grave Like one that wraps the drapery of his couch About him, and lies down to pleasant dreams — from Thanatopsis, by William Cullen Bryant, 1815 The day before Thanksgiving, I went to the funeral of a young man who had been killed a few days before when a van pulled out in front of his motorcycle in the town of Auburn. He was 25 years of age. His mother, Mary, my patient, is devastated. She keeps asking, “Why?” — sobbing repeatedly, “I just want my boy back!” The service took place in a beautiful cemetery in Newcastle in the foothills of the Sierra Nevada. The late afternoon sun was streaming through the clouds, radiating off the trees in their colorful autumn foliage. Just up the slope from the gravesite was the older part of the cemetery, with stone monuments under the pine trees dating back to the 1870s. A long freight train higher up on the hill rumbled by in the distance, its melancholy whistle signaling the start of its transcontinental journey. Each in turn, the people who had known him well spoke about their memories. He was a wonderful young man, quite talented mechanically, and an artist as well. He was named “Donnie.” I had been the first to see him when he was born. With his mother, I had seen him in
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ultrasound pictures even before he was born. On his birthdays and many times at Christmas over the last quarter century, Mary would send me pictures of him as he was growing up. There would be no picture this Christmas.
H
e loved his mom very much, as she did him. For the first years of his life, it was just the two of them together. And he had taken good care of her, even when he was a child. He was the most important thing in her life. He had invited me to his first birthday party, though I suppose he had help from his mom in writing the invitation. And now he was gone. She had lost him, and very nearly had lost as well the will to go on without him. Mary is a religious person, and that is a great comfort for her now. She feels she will see Donnie again soon. She believes in God, but doesn’t understand why she has to suffer this loss, why her boy never had a chance to lead a full life, why his wife and little daughter no longer have a husband and father. When the coffin was lowered into the ground, she could barely preserve her dignity, because she didn’t want to let go, because she wanted to be lowered with it into the grave, and she had to be gently pulled away, the last goodbye of a mother to her son. After the service I held her in my arms for a few minutes. I was too sad to say very much, but I told her that all these people gathered here cared very much about her, knew how difficult it would be for her to go on, and were there to give her support to face the challenge of a life seemingly diminished by the loss of the son that she had loved so very deeply, the son who had died before she would, and, by our mortal perspective, before his time. After the gravesite ceremony, most of the
people went to the reception at the historic Portuguese Hall in Newcastle. Most of those who had arrived by motorcycle to the cemetery didn’t stay for the reception. They roared off eastward into the mountains wearing their “leathers” with the logo and letters of “The Messengers of God.” Perhaps they had a gathering somewhere else to attend to mark the passage of one of their brothers. White doves were released from the gravesite, about 10 of them. At first they flew just above the cemetery grounds, first in one direction and then suddenly like an echelon of jets in close maneuvers reversing their direction, each time the sun reflecting brilliantly off their wings. Gradually they began to distance themselves from the cemetery, heading higher and to the east in their aerobatic zigzag flight.
Ii
had no place that I wanted to go, so I wandered through the rest of the cemetery, looking at 140 years of headstones. The older stones told me that the people below had been natives of “Cornwall” or “Surrey” or “Dublin” or “Leicester.” Those of slightly more recent vintage were natives of “Lisbon,” “New York,” “Pennsylvania.” But those of less than a century, and indicating no other place of origin, by default let me know that they were from where they were now...from here, from nowhere, from everywhere. Some of the most recent stones had room on the inscription face to add another name, a companion. Others, more explicit and somewhat more complete, had one name with dates of “born” and “died” but the other name with only as yet a date of “born.” Curiously, though perhaps understandably, none of the stones had only a single name with just a date of “born,” and a hyphen awaiting some still future date of “died.” And where was my stone? Was it lying deep and still not quarried in Penryn only a few miles away, within Griffith’s granite wall, supplier of granite stone for a century and a half to former citizens from San Francisco to Reno? I am very thankful for the opportunity and privilege that I have been granted in my career
as an obstetrician, extending now more than 30 years, to have been able to help to bring forth more than 5,000 new lives into the world. But how much it saddens me that any of those lives should be buried at an age less than mine, though nowhere is it written, neither in scripture nor in stone, “Thou shalt outlive thy mother’s obstetrician.” Life goes on, for Mary, for me, for you, and for all the others at that autumnal ceremony. We all have so much more to do, in my case many more new babies to deliver — and so little time left in which to accomplish all those worldly, though not mundane, life interactions represented solely by the hyphen yet to be carved between the dates of “born” and “died” on the stone that waits for each of us in Griffith’s Quarry.
…how much it saddens me that any of those lives should be buried at an age less than mine…
DrJohnHendry@aol.com
NEEDED: Docents and Volunteers for the SSVMS Museum of Medical History The Museum has been open five years and is becoming more popular for school tours, especially since Kaiser Permanente generously provided a grant to subsidize the cost of bus transportation for Sacramento City Unified Schools. Docents are needed to help with these tours. Additionally, other volunteers are needed to assist with research, historical book organization, writing and many other tasks. Be a part of both helping to preserve our 150 years of medical heritage and educating our community about it. Contact Dr. Bob LaPerriere, curator, at (916) 481-4525 or drbob@winfirst.com.
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Voices of Medicine A new tack on Medicare payment, electronic prescribing errors, a dim view of transparency.
By Del Meyer, MD
Medicare’s New Direction Stephen Kamelgarn, MD, discusses “Medicare Pay for Performance” in the January issue of The Bulletin of the Humboldt-Del Norte County Medical Society “Medicare, the 800 lb. gorilla, is about to strike out in new directions. As recently reported in the New York Times, the 109th Congress, in a last minute flurry of legislation, approved a change in Medicare reimbursement, that not only will not cut physicians’ reimbursements 5.3% as originally intended, but will actually increase their pay by 1.5% — if they provide quality care as defined by the government. “Physicians will qualify for the 1.5% increase if they report data on the quality of care: for example, how often they use a particular drug after a heart attack, or control blood pressure in patients with diabetes. On the surface this is a good idea. “We’ve been talking about employing evidence-based guidelines for medical practice for years, and in those areas where there have been a lot of studies (blood pressure and diabetes, for instance) it is easy to draw up guidelines that all practitioners should follow to practice good medicine. And it is true, that in many areas of medical practice, there is a consensus of what the proper practice is. “However, most of what we do is not backed up by a hundred double blind studies that unequivocally point us in the right direction. And since there is so much controversy in how we deal with a variety of conditions, who’ll be the arbiters of what good medical practice is — a government bureaucrat that wouldn’t know a CT
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from a 4-legged cat?; a committee? How will the data be collected and assessed — a series of electronic check boxes where the questions are so poorly worded that they’re impossible to figure out? Do the physicians have to hit a benchmark of 100% for all of their patients with the particular condition to qualify for the extra money? How much extra time and effort, i.e., money will the individual physician have to spend in order to obtain his or her ’bonus?’”… The entire article appears at www.humboldt1. com/~medsoc/images/bulletins/JANUARY%202007 %20BULLETIN_for%20web.pdf
A Different Kind of Error Emily Dalton, MD, discusses “Electronic Prescribing: A Help or a Hindrance?” in the December 2006 issue of The Bulletin of the Humboldt-Del Norte County Medical Society. “The CMA Alert’s top story from 8/17/06, reported that the Institute of Medicine urged all prescriptions be written electronically by 2010. I agree, but I don’t think the reduction in errors will be as dramatic as they hope. They cited facts: such as medication errors are among the most common medical errors; that they harm 1.5 million people, and cost more than $3.5 billion annually. They stated that the problem is so serious that the average hospital patient is subject to one medication error per day. Causes for these errors included unexpected drug interactions, confusion over similarly named drugs, bad handwriting, drugs given to the wrong patient, and patients not understanding how to take the medication. Electronic records may help with some of these — such as handwriting, but not with others, such as patient comprehension or drugs dispensed to the wrong person…
“I decided to try electronic prescribing. By and large it has been fun and effective when it works (which it does most of the time) and patients like it. The set-up I use involves a small device called a pocket computer. You can use other devices like advanced cell phones, Treos, Blackberries or personal digital assistants, but I chose a pocket computer because it has the most memory and processing capability… “I have yet to be convinced that electronic prescribing will result in error reduction. I still get calls about mistakes from the pharmacists, but they are mistakes of a different nature. They are never due to poor handwriting, but at times my unsteady hand has selected the wrong name from my patient list and I’ve accidentally sent over the right prescription but for the wrong patient. (The laxative prescription error was probably the most embarrassing such incident). Pharmacists have called to ask if I really meant to prescribe a gallon of Dimetapp, or if I really meant the dosing to be every hour instead of every day. These are not mistakes one would ever make on a traditional written prescription, but are very easy to do when you are pointing and selecting from various options listed in close proximity on a computer menu on a very small screen…” The complete article can be found at www. humboldt1.com/~medsoc/images/bulletins/DECEM BER%202006%20BULLETIN_for%20web.pdf
Transparency in Medicine Moris Senegor, MD, editor of the San Joaquin Journal of the San Joaquin County Medical Society, wrote in the Winter 2006 issue on “Whether You Like It or Not...transparency is here!” “In the last decade hospitals have developed elaborate Quality Departments, measuring various parameters of their care both locally, and against national databases. The trend first hit the field of cardiac surgery, which lends itself easily to objective, mathematical analysis of outcomes such as mortality, complications, hours spent in ICU, numerous physiological parameters and more. The Society of Thoracic Surgeons (STS), created a national database reflecting averages, against which any hospital could measure their
results. It has functioned well and allowed for adjustments in perceived weak areas, as well as cross-communication between different hospitals. For instance an obscure hospital in Pennsylvania has outshined its brethren in rapid extubation after open-heart surgery, and found itself transformed into a mecca for those interested in improving their early extubation statistics. Our Stockton St. Joseph’s Hospital sent a high level delegation of surgeons, anesthesiologists and nursing staff to Lankenau Hospital in Wynnewood, PA for a fact finding visit, and has since made efforts to adopt their practices… “Why such an intense effort for one detail of a multitude in services offered? Because CMS, the government branch overseeing Medicare and other health policy has issued an edict that this be done. Soon they plan to change the way they pay hospitals by rewarding the top 20% in such statistics with higher reimbursement. With a multimillion dollar per year carrot dangling in front of their faces, hospitals are enthusiastically creating the infrastructure to make Herculean efforts in improving care for the parameters dictated. “What does this all mean to us, and where is it headed? “To begin with, it is obvious that the parameters currently measured are not comprehensive in covering all areas of care provided by full service hospitals. Therefore those that do well in pneumonia, cardiac services, and diabetes will be identified as “the best,” and rewarded; never mind that their record in obstetrics, neurosurgery, or orthopedics might be dismal. The government promises to correct this defect in due course by measuring a more comprehensive set of parameters… “Another burgeoning problem that this new high stakes game ushers in, is the issue of honesty in reporting. The gargantuan financial incentives will induce some to lie and fudge their numbers…” The complete article can be found at www. sjcms.org/magazine/Winter%20Quarter,%202006. pdf
I still get calls about mistakes from the pharmacists, but they are mistakes of a different nature.
DelMeyer@HealthCareCom.net
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Yolo County’s Salud Clinic Celebrates its 35th Year By David Katz, MD, Medical Director, CommuniCare Health Centers Salud Clinic, the West Sacramento branch of Communicare Health Centers, celebrated its 35th anniversary on Nov. 24, 2006. Approximately 100 individuals attended, including West Sacramento and Yolo County representatives, state legislators and officers of the Medical Society. It was a festive event hosted by Communicare’s Executive Director, Robin Affrime. After a moving presentation by founder Dr. John Loofbourow describing Salud’s humble beginnings, numerous local elected officials took great pride in presenting plaques and declarations that will adorn the clinic’s new walls. The clinic is now located in the Yolo County Offices on Triangle Court; a $2 million dollar building campaign is under way to add nearly 10,000 square feet of new office space to serve the health care needs of the indigent. Please take time to read the following account of this remarkable clinic! — Christian Serdahl, MD
The Beginning Grass roots planning to establish Salud Clinic in East Yolo County began in 1970, through the efforts of John Siden, Paul Gutierrez, Jess Perez and Dr. John Loofbourow along with the thousands of East Yolo County residents who petitioned for its creation. In community meetings at Broderick Christian Center throughout the following year, the concept of founding a primary health care facility located in and serving the needs of the underserved East Yolo County communities was nurtured and grew.1
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Salud Clinic was needed, in the words of Dr. Loofbourow, because “illegal and substandard housing areas persisted with a high incidence of tuberculin reactors, drug users, alcoholics, and chronically ill adults; water was less than optimal. Care for local county indigents was available only in Woodland, and public transportation was scarce and expensive.”2 The Salud East Yolo Medical Facility Board of Directors was established later in 1970 as a volunteer organization to oversee the construction of the Salud East Yolo Medical Facility (to be known as Salud Clinic) to serve the underserved East Yolo County communities. Funding for construction came from a multitude of small donations by members of the community and through the fundraising effort of the Salud Foundation. Dr. Loofbourow recalls that the Foundation was created to foster “user owned independent health facilities which operated in partnership with practicing physicians.”2 Dr. Loofbourow purchased “an old ramshackle building at 530 C Street in Broderick”2 to house the clinic. After renovation by many community and student volunteers, Salud Clinic opened on May 21, 1971, complete with laboratory and X-ray facilities. Pediatric, adult primary care and family planning services were provided. A school-based dental disease prevention program was also provided. As word of Salud Clinic services spread, more residents sought care, and by 1973 the staff was serving 50 patients a day. Salud Clinic introduced the innovation of trained community health workers to Yolo County. They were drawn from the community
and culture group to be served, had children of their own, and showed a willingness to pursue educational opportunities. Funded by the American Cancer Society, a one-year training program was established using Salud facility for training and clinical opportunities. The program enrolled 12 students, and the clinic hired 10 of them half time. Dr. Loofbourow stated at the time, “The role of community health workers in communication with patients, health education and disease prevention is central to the development of a successful community clinic.”1 American Public Health Association stated that community health workers perform outreach services, patient tracking, home visiting, and are viewed as “an integral component of the health department’s personal health care program..”2
Becoming a Yolo County Health Department Clinic From 1971 through 1973, Salud Clinic was mainly financed by donations, but, according to Dr. Loofbourow, it was chronically short of operating funds. “By early 1973 the Clinic was in financial jeopardy…. An ad hoc county committee was appointed to consider options regarding the future of the clinic. A Federal Revenue Sharing grant for $200,000 was obtained with the provision that it be also approved by the Yolo County Board of Supervisors. Dr. Otis Cobb, the county health officer, urged that combining the medical functions of Salud with the preventive focus of the health department would result in a strong, integrated program.”2 Ultimately, the clinic was placed under the management of the Yolo County Health Department. Later, the clinic moved into East Yolo County Health Department facilities down the street. As part of the County Health Department, Salud continued to provide primary care, prenatal, and dental services under the guidance of Dr. Otis Cobb and Dr. Bob Bates, for more than two decades. The Board of Directors of Salud Clinic became the Salud Advisory Board. In 1994, with the closing of Yolo General Hospital and the formation of the Yolo Health Alliance, Salud Clinic became a community
clinic once again, joining CommuniCare Health Centers. In 1995, Salud moved to its current location in the Yolo County offices on Triangle Court, at 500 B Jefferson Boulevard in West Sacramento. The clinic provided 22,000 patient visits in 2005 for primary health care, dental care, and perinatal services, and continues to expand to meet the health care needs of a growing community.
Memories of Salud Clinic Memories of the first Salud Clinic in Broderick include those of Dr. Loofbourow, who remembers feeding lunches to all the early volunteer workers at the clinic, using food donated by local groceries and restaurants. Two current CommuniCare staff, Nidia Ochoa, PA-C, and Mariana McCamy, FNP, worked at Salud when it was part of the Yolo County Health Department. They recall Salud staff regularly lunching at Sal’s Mexican Restaurant, which is still a West Sacramento fixture on Sacramento Avenue. Former Yolo County Health Officer Dr. Robert Bates recalls Dr. Cobb’s vision of creating collaboration between the primary care, mental health, and public health services by housing them together in the remodeled high school facility. Dr. Karen Tait worked at Salud Clinic from 1987–1992 and recalls resuscitating a heroin overdose patient who was brought in from a pickup truck by his friends. On November 14, 2006, the Yolo County Board of Supervisors celebrated the rich history and many contributions of Salud Clinic, its staff, and its many supporters over 35 years in a Proclamation marking the 35th Anniversary of Salud Clinic. The Supervisors saluted the Salud Clinic staff and supporters whose “passion and dedication to a healthy future for West Sacramento and the surrounding community has improved the lives of all who live here.”3
The clinic provided 22,000 patient visits in 2005 for primary health care, dental care, and perinatal services, and continues to expand to meet the health care needs of a growing community.
davidk@communicarehc.org 1 Interview with John Loofbourow, MD May 5, 2005 2 “Local Health Department Case Studies” American Public Health Association, Miller, C. 1981, pp. 480-496 3 Minutes of the Yolo County Board of Supervisors meeting, November 14, 2006
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A Head’s Up On Our Region’s Risks By the SSVMS Public and Environmental Health Committee
Unwelcome risks exist no matter where you live. This region is no exception.
“Rare Diseases Are Rare, Except… Among Those Who Have Them.” This quote is an old saw from our medical school training. The trick is to be aware of the peculiar risks your patients face which may make them more likely to have a “rare disease.” We think most often of occupational risks in this category. However, the simple act of living in the Sacramento region places us all in a peculiar risk category for some unusual diseases and conditions. This list is a “heads up” of what those risks are, what we can do about them individually and collectively (public policy) and what diseases they may bring into our offices. Unwelcome risks exist no matter where you live. This region is no exception. We do have wonderful reasons to live here, without the risks some suffer in other places. We do not have hurricanes, hot and humid summers, exploding volcanoes, malaria epidemics and so on. But we do have earthquakes, mud slides, avalanches… The following risk categories are all of a similar magnitude. That is, they all have a relatively low incidence (frequency of new cases) or prevalence (number of cases present in a community). Importantly, we are able to do something about each of them to reduce our individual and collective risks.
Asbestos Asbestos is a rock-fiber once used commercially for insulation and other purposes. Workers who inhale high volumes of highly concentrated asbestos fibers suffer various lung diseases, including a rare form of cancer (mesothelioma). Naturally occurring asbestos (NOA) occurs in
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some rock formations in our region. We are at risk from inhaling dust that contains asbestos fibers. The highest risk is in dusty, dry times of the year. Individual: Avoid producing dust and avoid entering dusty situations. Community: Identify NOA areas and places where moved dirt may contain asbestos fibers (roads, playing fields, parks, construction areas); enforce dust mitigation controls; reduce dust risks on frequently used NOA containing dirt surfaces. References: www.atsdr.cdc.gov/toxprofiles/tp61.html www.atsdr.cdc.gov/asbestos/index.html
Asthma Asthma is a spasm of the air tubes in your lungs. We currently suffer a nationwide epidemic of asthma for unknown reasons. Our region has the peculiar problem of high air pollution (including ozone and wood smoke) which regularly occurs in the summer months. Ozone can precipitate asthma attacks. Individual: Watch weather reports for “Spare the Air” days and stay indoors during period of peak ozone levels. Community: Our ozone drifts in from the populated areas to the east. Less air pollution is the solution to this problem.
Cancer Cancer is the second leading cause of death. This region has two peculiar risks for cancer —radon gas and naturally occurring asbestos. See each individual entry. Individual: Tobacco causes one third and bad nutrition causes another third of cancer
cases. You can reduce two-thirds of your cancer risk by avoiding tobacco and eating a low-fat, high-fiber diet. Community: “Secondhand smoke” from smokers also causes cancer. All California public places are now smoke free by law (work sites, restaurants, etc.) and your home should have rules for smokers as well. Foods are labeled for nutritional value; you can protect yourself and your family with a high-fiber, low-fat diet.
Hantavirus Hantavirus is a severe respiratory disease spread by breathing in small particles of mouse excrement that are stirred into the air. It occurs most frequently among persons who live or work in rural areas. Individual: Avoid disturbing areas of mouse contamination in enclosed, poorly ventilated structures. Remove incentives for rodents such as uncovered garbage and food. Community: Protect family from exposure by trapping rodents in buildings and blocking all areas of ingress for rodents from the outside. References: http://www.cdc.gov/ncidod/diseases/hanta/hps/ index.htm http://www.cdc.gov (search for the word “Hanta”)
Lyme Disease Lyme disease is an infection acquired from the bite of a western black-legged tick. The ticks may crawl onto you when you are outdoors and in contact with brush or logs. Lyme disease is a problem when the western black-legged tick is most abundant, in the fall (October–December) and spring (March–June). Individual: Stay on trails and avoid contact with brush and logs; wear long sleeved shirts and long pants Apply a pesticide to clothing (e.g., DEET). After outdoor activities in tick habitat, examine your entire body for tiny ticks and remove them using tweezers and pulling the tick straight out. Community: Keep trails free of overhanging brush; warn hunters and other outdoor people of the risk.
References: http://www.dhs.ca.gov/ps/dcdc/disb/pdf/Lyme% 20Disease%20Brochure%20June%202005.pdf http://www.dhs.ca.gov (search for the word “Lyme”)
Ozone Ozone is a peculiar form of oxygen produced as an air pollutant from sunlight’s interaction with chemicals. In high concentrations it can react with lungs to precipitate asthma attacks and worsen other lung diseases. This is a seasonal problem highest in the late summer and early fall. Individual: Watch weather reports specific to air pollution. Stay indoors as much as possible during “Spare The Air” days. Community: Less air pollution is the solution to this problem. References: www.lunguse.org (search for “Ozone”) www.arb.ca.gov/aqmis2/ytd_ozone.php www.arb.ca.gov/airways/ccaqs.htm
Plague Plague is an infection acquired from the bite of an infected flea from a wild rodent. Fleas can jump a long distance — sometimes up to 3 feet. Some areas sustain a constant low-level of plague where transmission risk may increase when large numbers of rodents die. Individual: Do not feed rodents (including chipmunks) or handle rodent carcasses. Stay away from rodent burrow holes. A fever with a painful swelling under your arm or in your groin is a possible sign of plague. Wear long sleeve shirts and long pants and use topical pesticides on hikes and outdoor work. Keep cats indoors and away from wild rodents, as they can not only get plague themselves but transmit the disease to humans. Community: Post areas where the problem is active. Close parks and other public areas with rodent and small mammal die offs. This tends to be a problem in late summer and early fall. References: www.cdc.gov/ncidod/dvbid/plague/index.htm
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Radon Radon is a naturally occurring colorless, tasteless, and odorless gas that comes from the decay of uranium found in nearly all soils. It is especially a problem from granite rock. Long-term exposure to elevated levels of radon increases the risk of lung cancer. Individual: Testing is the only way to know if you and your family are at risk from radon. There are simple ways to fix a problem if needed. Free test kits are available from the California Department of Health Services, see the website below for details. Community: Identify geographic areas of risk and publish methods and vendors who can responsibly test and mitigate the facilities, if necessary. References: http://www.dhs.ca.gov/radon/default.htm
Vehicle Accidents Both road travel and off-road recreation can be risky in mountainous areas. We have many injuries each year involving motorists, bicyclists, motorcyclists, and off-roaders. This is a yearround situation. Individual: Be cautious in severe weather, obey driving laws, avoid alcohol use, drive defensively. Consistent use of bike and motorcycle helmets — off road or on — helps prevent serious head injuries.
Community: Enforce highway and liquor laws; inform citizens of risks, responsibilities, and need for us all to engage a community standard of safety.
West Nile Virus (WNV) WNV is an infection acquired from the bite of an infected mosquito. These mosquitoes preferentially bite at dawn and dusk. This problem is only recently arrived in this area; it is seasonal with highest risk in late summer and early fall. Individual: When outdoors, particularly at dawn and dusk, wear long sleeves and long pants, and apply mosquito repellant containing DEET. Make sure doors and windows have tightfitting screens and repair or replace screens with tears or holes. Eliminate standing or stagnant water on your property. Community: Alert public when infected mosquitoes are present, eliminate standing water breeding sites, control larval mosquitoes where possible, spray for adult mosquitoes only when the threat is large. References: http://westnile.ca.gov
Wild Fires “Natural” and man made fires sweep across our area periodically. These occur most frequently in late summer and fall. Individual: Be careful with all fires (especially cigarettes & matches), flee at the first smell of smoke in a rural area in the fire season. Community: Support fire safety programs, remove trees and brush from around your home or business, build with fire safety in mind.
Wood Smoke Controlled home heating with wood produces visible particulate air pollution (smoke) which can precipitate asthma attacks and exacerbate lung diseases. Individual: Avoid wood smoke in your residence.. Community: Consider limitations on wood stove use during weather conditions which are unfavorable. dlyman@dhs.ca.gov 20
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Useful Idiots Revisted “Peer review” in chronic pain cases is neither “peer” nor “review.”
By Lee T. Snook, Jr., MD Recently you were enlightened by one of our legal colleagues who had the courage to call a spade a spade. He outlined the complicity of physicians acting in their capacity of contracted or employed emissaries of the insurance industry, in this case workers’ compensation, to perform “peer review” (see “Useful Idiots,” SSV Medicine, June/July 2006). The purpose of this review is to further the report. I must inform you, my colleagues, that this sham called peer review is neither “peer” nor “review.” I have many examples and will share some with you. First on the subject of “peer.” I am a board certified anesthesiologist, internist and pain medicine specialist who also is credentialed in addiction medicine. My “peers” have been orthopedic physicians, chiropractors, neurologists, anesthesiologists, internists, family physicians, and others. Most of the time they are from out of state. Their practice experience has very little to do with mine. They can hardly be considered “peers.” I have to explain to them the most simple of pain management principles. They have very little idea what the special needs of my patients are. It is also abundantly obvious that they don’t care, either.
Routine Denial of Care They are conflicted. Every peer review interview that I am subject to results in denial of care or some bait and switch tactic. At first I took the high ground and gave them credit for meaning well and trying to control costs. However, since mid-2005 things have deteriorated at an alarming rate. These doctors are part of an organized review machine and are paid to review. It should be no
surprise that for the most part the reviews end in denial of requested care. The standard reason for denial is that the recommended treatment is not supported by ACOEM Guidelines. The American College of Occupational and Environmental Medicine, with CMA support, became presumptively correct by legislative mandate as part of the Governor’s comprehensive Workers’ Comp reform. I sat on the CMA’s Workers’ Compensation TAC and in good faith supported my colleagues with assurances that the reform was necessary and that other guidelines would be incorporated as part of the “reform.” This, of course, never happened. Other guidelines were considered too permissive. This translates into “too costly.” And we all want to control costs, don’t we?
Current Guidelines The current ACOEM guidelines are based on the second edition textbook published by the Occupational Medicine Physicians. Somehow, this book, some 500 pages in length, has become the Bible, Torah, and Quran of medicine. It is really a boy scout’s guide to medicine. Although it has a nice introduction to work-related injuries, it is wholly insufficient and lacking when it comes to pain, my area of expertise. Because it is the controlling authority, it has been misused as a utilization review tool. I can assure you that my practice, for the most part, is not supported by the book and, therefore, it can be argued, is illegitimate. Hundreds of patients have failed traditional medical approaches and have benefited from the care I have given them. Remember that by the time
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The motive here is cost control. After all, we can’t do all things for all patients, I hear.
they get to me, they are in chronic pain. If I can reduce their pain by 50 percent, then I am successful. Obviously, the ACOEM — which preaches not medications but “functional restoration” and a return to work — cannot possibly apply to my patient population. My patients have chronic disease and will not get much better at all. So? You say, too bad for them. Show them the door, and let them learn to live with their pain without medical care. I will tell you that when your turn comes up for pain management, you suddenly lose your hostility and abhorrence for pain relieving therapies, including opiate medications. That brings me to the board-certified pain specialists in California who deny the care I have recommended. If they in fact do practice pain medicine in a practice similar to mine, then they should know better. Shame on them. There is a special ring in Dante’s Inferno for them. Their “peer review” will be forthcoming from someone more powerful than I and my suffering patients. They cite “evidenced-based medicine.” They know that there is very little in print, and certainly
Wilke Fleury ad p/u Jan/Feb 07
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very little indeed that supports what they do for a living. You see, clinical experience and clinical judgment is now old hat. In today’s modern medical lexicon, there is only RCT, randomized controlled trials, as legitimate evidence. The ACOEM guys are pushing to have only RCTs as the basis for determining medical care. Please. I challenge all of you, every one of you out there, to show me the RCT evidence, high quality, that supports all of what you do in your practice. Honestly. Don’t tell me that the motive here is really “GOOD MEDICINE.” The motive here is cost control. After all, we can’t do all things for all patients, I hear. There is much more to discuss, which I will be glad to share on subsequent correspondence. But for now, I want everyone to know that I went to doctor school to practice medicine. If you want to practice cost control, go to business school and run a medical peer review group, or an insurance plan. I understand there is good money there. lsnook@pain-mpmc.com
Queen Victoria She pioneered the use of chloroform, and carried the hemophilia gene.
By Irma West, MD Victoria was the only legitimate child of the Duke of Kent, one of the sons of George III, the “mad” king who reigned during the American Revolution. George IV succeeded his father in 1820. His only child, Princess Charlotte, should have been the next queen but died after 50 hours of hard labor giving birth to a dead son. Losing two heirs to the British throne was too much for the attending physician, Dr. Richard Croft, who put a bullet through his head. King William IV, who had no heirs, succeeded his brother, George IV. The Duke of Kent was next in line but had no heirs. He dismissed his French mistress of 27 years and married a young royal German widow, Victoire of Sax Coberg, who gave birth to Victoria in 1819. When Victoria was an infant, her father developed a persistent cold and fever. His medical treatment included the application of leeches and removing a gallon of blood. He did not survive. Victoria lived in seclusion in Kensington Palace where her mother rarely left her. Their beds were side by side. Security was tight for good reason. Intrigue and financial shenanigans were rampant among some of the royals who would have preferred Victoria out of the way. Victoria and her mother were estranged from King William’s court. Her mother’s wealthy brother, King Leopold of Belgium, was not only a kindly father figure for Victoria, but also provided financial support. Victoria did not know until she was well into her teens that she was heir to the throne. Her tutors felt she should find out by reading history. When she became Queen at 18, the first thing she did was move her bed out of her mother’s bedroom, and provide an apartment for her mother in a distant part of the palace; thereafter,
she had nothing to do with her mother. When Queen Victoria was 20, she proposed to Albert, the second son of her mother’s brother, the Duke of Sax Coberg. (Protocol required she do the proposing.) He was one of several prospective husbands pushed in her direction by the European and English royals. Albert was the first choice of King Leopold who was delighted when they fell in love. Queen Victoria was almost 5 feet tall. Albert, also 20, was a well-built, handsome and 5 feet 7. His education was superior to hers, particularly in the arts and science. He was well liked and a wise and effective consort. Queen Victoria became a conscientious and hard working queen, at the same time producing five princesses and four princes. At the birth of her youngest son, Leopold, she became the first in Britain to use chloroform during delivery and was pleased with the result. For recommending it, she ran afoul of the Church of England which decreed women must suffer pain during delivery. The Queen ordered the Church to reinterpret the Bible and it complied. Dr. John Snow, Britain’s first anesthesiologist, administered the anesthetic — the same Dr. Snow who had the handle on the Broad Street pump removed to halt London’s severe cholera epidemic of 1854. Prince Leopold was the only prince to inherit hemophilia. Some critics wrongfully blamed the chloroform. Queen Victoria was a carrier as were two daughters, one of whom passed hemophilia to her grandson, heir to the throne of Russia; he and his family were murdered during the Russian Revolution.
March/April 2007 23
By most accounts Queen Victoria was a poor and at times cruel mother. She had no experience with children and was uncomfortable with them. She set up overly restrictive regimens and berated Prince Leopold for deformities caused by hemophilia. When Albert died, possibly of typhoid fever, at 42, Queen Victoria sank into a deep depression, wearing mourning clothes for the rest of her life. When she emerged from her sadness, she erected statues and buildings named after him. One is the Royal Albert Hall in London. Medical advice encouraged Queen Victoria to resume horseback riding. A trusted kiltwearing servant, John Brown, was summoned from Balmoral Castle in Scotland. He brought Victoria’s horse, Flora, and took charge of her riding program. He had been credited with saving her life twice, once when her carriage overturned. He soon became her constant companion, bodyguard and general assistant, generating no end of gossip. After rarely leaving her side for more than a day in 18 years, he died
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of erysipelas in 1883. During the rest of her reign, Queen Victoria’s popularity increased and she was given credit for the remarkable progress of Great Britain during her 64 years on the throne. On January 17, 1901 Queen Victoria suffered a stroke, lapsed into a coma and died 5 days later. She designated items to be buried with her. They included an alabaster cast of Albert’s hand and a picture of John Brown with a lock of his hair. Her oldest son subsequently went through the palace destroying statues of John Brown. imariewest@aol.com References: Erickson, C. Her Little Majesty: The life of Queen Victoria. Simon and Schuster, N.Y. 1997 Marshall, D. The Life and Times of Queen Victoria. Praeger Publishers, N.Y. 1974 Potts, D.M., Potts, W.T.W. Queen Victoria’s Gene. Sutton Publishing 1995 Stachey, L. The Illustrated Queen Victoria. Weidenfield and Nicolson, N.Y. 1988 Thompson, D. Queen Victoria: The Woman. Pantheon Books, N.Y. 1990 Weintraub, S. Victoria: An Intimate Biography. E.P. Dutton, N.Y.
Land of Enchantment, Land of War By Ben Brown, MD Reprinted from Sonoma Medicine magazine. Dr. Brown, a family physician, is medical director of the Southwest Community Health Center in Santa Rosa and founder of the Burmese Refugee Care Project/Planet Care. Burma, land of enchantment, the rice bowl of Asia, covered with the footsteps of the Buddha, filled with exotic animals and with terrain rich with geographic and cultural diversity. I walk through the Burmese jungle on my way to a hill-tribe village, across beautiful hills with birds that seem to have streamers coming off their tails. The people have silver spools in their ears and wear exotic handwoven colorful dresses. I am not here as a tourist; I am quite far from the areas the Burmese authorities allow tourists to see. I am here for another reason, to help establish even a small thread of a health care system in this beautiful yet war-torn area. As I look through the beauty, I notice that the hills are patterned with bomb trenches, like the veins on the back of a swarthy hand. I am dangerously close to the war, so close I can hear the gunfire. When a plane flies over, it is time to run for one of those trenches. This area is the proverbial front line in a civil war that has ravaged Burma for more than four decades. Why has this country been so ravaged? Formerly British ruled, Burma had a brief stint of independence after World War II. A chain of killings led to an unstable situation and what in 1963 looked like a small world event. The headline “Burma has bloodless coup and closes its doors to foreigners” has turned into the next killing fields. Two decades of relatively
quiet extermination and two decades of more open extermination have left more than 10% of Burma’s 45 million people either internally displaced, on the run, displaced into neighboring countries, under house arrest, or dead. The current government, which changed its name from SLORC (State Law and Order Restoration Council) to SPDC (State Peace and Development Council), rules by totalitarian dictatorship. They have occasional well-publicized events to appease the international press. They held an election in the late 1980s, and then put the victor (Aung San Suu Kyi, winner of the Nobel Peace Prize) and her party under house arrest. They changed the name of the country from Burma to Myanmar.
These events look to the world like change, but little really changes. Same people, same policies, and — unfortunately for the country’s population — same war. These events look to the world like change, but little really changes. Same people, same policies, and — unfortunately for the country’s population — same war. What kind of war is this? You might call it a political war of dictatorship vs. democracy. You might call it a race war of central Burmans against the ethnic minorities. But most of the experts would say that, at its core, this is a war of greed. A few people in power, in a country rich with resources, have transformed their fertile jungle into one of the poorest countries in the world. March/April 2007 25
So far, Burma has managed to fly under the world’s radar screen. As long as the Burmese continue to sell their natural resources at bargain prices, their fellow countries simply look the other way. I walk into the villages expecting the worst: soldiers with infected wounds, missing limbs, and twisted lives. What I see is disturbingly different. I see forlorn women and children, with malarial fevers, measles, dysentery, and bellies swollen with worms. Many of war’s true victims are not the ones out fighting; they are the accidental ones, accidentally hit or accidentally left. The ones who were just in the way or the ones who were, out of necessity, left behind to fend for themselves in a world of wolves. I have been returning to the Thai-Burma border area for 15 years. I have led many mobile medical trips. I have taught medics and have spent countless hours alongside them as they care for the people. I wish the stories I am about to write were made up, like some Stephen King nightmare, but they are not. These are cases I have witnessed, patients I have doctored, victims I have watched buried.
Many of war’s true victims are not the ones out fighting; they are the accidental ones, accidentally hit or accidentally left. Pregnant woman hit by a mortar. Seven months pregnant, she was fishing from a stream when a bomb fell near her. She woke up in a military hospital days later with an 18-inch scar from her pelvis to her ribs. Her baby was not hit, though the same could not be said for her intestines. Despite a horrific scar and a long recovery, this one has a happy ending. Both the mom and the baby survived. Forced porter raped each night. In the early days of the war, government soldiers would kidnap the men and force them to carry guns and supplies. Now they also kidnap women. One woman escaped to tell us her tale. She was forced to carry 40-pound loads up steep hills barefoot. She was fed only once a day, usually a
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meal of rotten rice. Then she was gang-raped by the soldiers. She is “lucky” … she escaped. Forced to leave her family to work in factories in Thailand, a 15-year-old girl arrives at the clinic infected and septic. She is beautiful, though as she lies in bed shaking with chills and rigors, her beauty is hard to see. I ask the medic if she has malaria. She says, “No, she has a belly problem from an infected illegal abortion. She came here without her parents, and a man offered her a place to stay. He said he would take care of her forever, and then he left. She found out later she was pregnant. A co-worker said there was a woman in the factory who could help her. So she went to the woman and that was that.” Unfortunately, that was not that. The woman forced a small piece of wood through the girl’s cervix and left it in place. Not surprisingly, the wood caused a serious pelvic infection. (More surprisingly, the procedure works most of the time). The girl was too sick. All the medicines and fluids we gave were not enough. She died. Stepped on a land mine. A sweet 9-year-old girl was walking back from her grandmother’s home with flowers in her hair when she stepped on a land mine. She was close to the border and made it to the clinic and then to the hospital. She lost her leg. Pregnant with twins, weighed 98 pounds at term. No money and no food, she came to us in early labor and delivered two babies. The big one weighed two and a half pounds, a bit more than his sister. It is summer and warm; they might survive. If these were stories of the way animals were treated, I would cry thinking about the cruelty. When I think that this has happened to beautiful, simple people, I feel my humanity trampled. Is my role here accidental? I came, I saw, I cared, and I came back to help. I initially went back because I fell in love with the people, then because I knew they needed me, and now because I am their friend. We started a small nonprofit organization, Planet Care (http://planetcare.org), originally the Burmese Refugee Care Project), and we have done some good. In Thailand, just across the Burmese border,
what was once a converted barn is now a medical village with departments for medicine, surgery, reproductive health, child health, lab and blood bank, eye care, prosthetics, malaria and tuberculosis management, and migrant and cross-border outreach. We also train most of the health-care workers along the border. The clinics we built inside Burma were burned down, so we created backpack heath worker teams. They have grown from the initial seven teams to 70 teams. Last year, the clinic treated 49,000 people (99,000 visits and 8,000 admissions), and the backpack teams saw an estimated 150,000 patients. About half were women and children. We fitted prosthetic limbs for 250 people, delivered 1,439 babies (30% to teenaged moms), trained 212 health workers, and provided ongoing training and internships for about 200 more. Although all the patients come to the clinic because of the war, only a handful are direct war
casualties. The clinic serves not only people’s physical health, but also their spirits, by offering a bastion of hope. It is a place where people can grow and learn and serve. What have I learned from my 15 years in Burma? They have taught me how to hold a country and a people in my heart. I feel at times like a witness, at times like a student, at times like a helpless nothing, at times like a hero, and at times like a priest, just praying for a way for this to stop; a way for the bullies on the playground to wake up and see that what we do to another we do to ourselves. When the bullies wake up or get told they can’t keep doing this, I will see myself as a celebrator, and deeply celebrate our victory. Then we can begin our long road of repair. Until that time, I will continue to be a servant and a friend, doing whatever I can to help.
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Donations Wanted for the Medical Student Scholarship Fund The William E. Dochterman Medical Student Scholarship Fund grants scholarships to medical students who have graduated from a high school in El Dorado, Sacramento or Yolo County, and who are enrolled in an accredited American medical school on a full-time basis. Kris Wallach, program manager for the Society’s Community Services, Education and Research Fund, recently contacted a number of scholarship recipients to evaluate the program by their subsequent professional course. The very first scholarship was awarded to Henry Ichiho. He wrote the following note: “I would like to express my deep appreciation for the scholarship — it was quite an honor not to mention how helpful... “I graduated from the University of California-Irvine Medical School, completed an internship and a pediatric residency at Mount Zion Medical Center in San Francisco. I moved to Honolulu, trained as a neonatologist and worked at the Kapiolani Medical Center for Women and Children in Honolulu for a while. Then I attended the University of Hawaii, School of Public Health and received a Master of Public Health degree in maternal and child health, worked for the Hawaii
Department of Health as the Chief of Children with Special Health Care Needs Branch, and then as Chief of the Maternal and Child Health Branch. “In 1986, I went into private consulting and provided medical and health consultation services to public health programs in Hawaii and in the U.S.-related Pacific islands of American Samoa, the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands. “I am currently in the final year of a PhD program in Social Welfare at the University of Hawaii School of Social Work where I am focusing on research methodology and skills. I hope to graduate with a PhD by December 2007. I am also continuing to provide consultation services to health programs here in Hawaii and also in the Pacific Island jurisdictions. “— Henry Ichiho, MD, MPH” Please consider making a tax deductible donation to the William E. Dochterman Medical Student Scholarship Fund. For more information, contact CSERF/Scholarship 5380 Elvas Avenue Sacramento, CA 95819. (916) 452-2671 The Community Service, Education and Research Fund (CSERF) is a 501(c)(3) component of the Sierra Sacramento Valley Medical Society.
March/April 2007 27
(adv’-quik ‘ly) to do with great speed, as in updating your disability income protection limits.
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Not if you’re a SSVMS member! Members may increase their Long Term Disability income protection benefits during a special enrollment period now underway. SSVMS and Hartford Life and Accident Insurance Company know you don’t have a lot of time available for certain things. That’s why they’ve now made it easy for you to update your disability protection . In the two minutes it takes to complete the enrollment form, you can have $1,500 per month added to your long term disability benefits if you are a member under age 50. Members ages 50 – 59 can add $1,000 per month. GUARANTEED ISSUE Members actively practicing full time are eligible to receive these benefits on a guaranteed issue basis, subject to standard pre-existing conditions limitation. There is no long underwriting process to go through. Call Marsh Affinity Group Services for details at 800-842-3761. Or send an e-mail to CMACounty.Insurance@marsh.com. Need higher limits? Call us.
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In Memoriam
David Krankheit, MD 1915–1996
By John Ostrich, MD Every couple of years, we here at SSVMS conduct a readership survey to determine what you, our readers, are interested in reading. That’s why we call it a readership survey, and that’s why you are called readers. In any case, we found, somewhat to our surprise, that the most popular articles are obituaries. We therefore will try to run more obituaries, whether any of us die or not. And any similarity to the lives and careers of actual deceased SSVMS members is purely coincidental. This obit was written by Dr. Henry Plantagenet, who was a fairly good (and possibly the only) friend of the deceased. It was found recently in a file labeled “Hold — Not fit for Publication.” As Dave used to say, he was not born on a mountaintop in Tennessee, but not too far away, in Blimpsburg, North Carolina on a cold December morning in 1915. His father was a farrier and his mother helped pay the bills by selling horoscopes to the locals. All five of his siblings died in childhood due to overwhelming hookworm infestations, and at the age of 10 Dave was determined to get the heck out of Blimpsburg and so he joined an itinerant circus disguised as a bearded midget. He made his way to Nashville where, by dint of hard work, he gained entry to Vanderbilt University, and then Vanderbilt Medical School from which he graduated in 21/2 years, some say because he married the Dean’s youngest and least attractive daughter, Tallulah. Soon thereafter, Dave had his surname legally changed to Crockett in order to make it appear that he was related to one of Tennessee’s favorite sons. By the late 1930s, Dr Davy Crockett (that’s what it said on his business card) had the biggest and busiest practice in Nashville. He
wore a coonskin cap whenever he was in public. In 1940, He and Tallulah were divorced, and she moved to California with their son Lester, who was nicknamed “Rocket.” Dave was drafted in 1942 and entered the Army Medical Corps where he managed to procure a R.E.M.F. (e-mail me if you need to know what that stands for) appointment as a medical consultant to SHAEF headquarters in London. he was always proud of his wartime service, most of which was spent lobbying the top brass to stop the loathsome and embarrassing practice of short-arm inspections among the enlisted men. While in London, he wooed and married Lady Elspeth Braxton-Hicks, thrice-divorced heiress to the Sweet- David Krankheit, MD We-Bee chocolate candy fortune. They produced a child, Gwyneth, and returned to Nashville after the war. Elspeth hated Nashville and divorced Dave in 1947 and returned to London with Gwyneth. Dave was despondent after Elspeth left him and he longed to rekindle his relationship with Tallulah who, he discovered, was living in Sacramento. He sold his lucrative practice in Nashville and moved to Sacramento. He had his surname legally re-changed to Krankheit because he knew that no one in California cared about anyone named Davy Crockett. Tallulah spurned him when he finally found her in 1951. She was happily remarried to a mortician and had six more children. Dave decided to stay in Sacramento in any event and soon, with his naturally pleasant personality, medical savvy and boyish good looks, had a successful general practice up and going. March/April 2007 29
Meet the Applicants The following applications have been referred to the Membership Committee for review. Information pertinent to consideration of any applicant for membership should be communicated to the committee. — Charles H. McDonnell, III, MD, Secretary Am. Univ Carribean 2002, 1520 W. Kettleman Ln #B, Lodi 95242 (Office open in Elk Grove - Summer 2007) ARNOLD, Jerry P., Radiology, Baylor College 1972, Marshall Hospital, 1100 Marshall Wy, Placerville 95667 (530) 626-2613 CARPENTER, Charles F., Preventive/Integrative Medicine, Tulane Univ 2000, Sacramento Center for Health & Healing, 2131 Capitol Ave #204, Sacramento 95816 (916) 548-9514 CHIU, Sufen, Child & Adolescent Psychiatry, Univ Maryland 1995, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 703-0265 CHRISTIANSEN, Brett D., Pediatrics, Stritch/Loyola Univ 1995, Marshall Ctr for Primary Care-Pediatrics, 4641-A Missouri Flat Rd, Placerville 95667 (530) 626-1144 D’ADDIO, Karyn, DO, Anesthsiology, Univ Hlth Sciences Col of Osteopathic 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 GRAY, Richard N., Family Medicine, Univ Autonoma de Guadalajara, Mexico 1982, The Doctor’s Center, 4948 San Juan Ave, Fair Oaks 95628 (916) 966-6287
GRIJNSZTEIN, Mark I., Pediatrics/Allergy/ Immunology, Sackler School of Med 1998, Sutter Medical Group, 8170 Laguna Blvd., #200, Elk Grove 95758 (916) 478-6555 HACKERT, John B., Colon & Rectal Surgery, Univ Michigan 1997, 1700 N. State St #18410, Los Angeles 90033 (Office open in Folsom – Summer 2007) KOBES, Rodger D., Psychiatry, Univ Miami 1974, Pfizer, Inc., 1201 K St #1010, Sacramento 95814 (916) 557-1177 LASHER, Todd D., Anesthesiology, Bowman Gray/ Wake Forest Univ 2002, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990 MOIZEAU, Catherine E., General/Family Medicine, St. Louis Univ 2000, Molina Medical Group, 7215 – 55th St, Sacramento 95823 (916) 399-1100 O’FARRELL, Irene S., OB-GYN, Med Col Wisconsin 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 PINGILI, Geetha, Internal/Geriatric Medicine, Stanley Med Col, India 1989, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 8175327
REDDY, Neena M., Radiology, Univ Nevada 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 SCHREIBER, Caroline M., Family Medicine, Univ Michigan 2003, Sutter Medical Group, 1201 Alhambra Blvd., #230, Sacramento 95816 (916) 7397728 SEKERA, Matthew J., Radiology, Univ Illinois 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 SOLIS, Blanca, Family Medicine, UC Davis 1996, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-6670 TUNG, Chiu H., Anesthesiology, Univ of Hong Kong, China 1993, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990 XIONG, Glen L., Internal Medicine/Psychiatry, UC Davis 2001, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 734-1167 ZHENG, Dawei, Family Medicine, Shandong Medical Univ, China 1983, 4635 Freeport Blvd., #D, Sacramento 95822 (916) 457-9879 ZHU, Yanzhi, Internal Medicine, Sun Yat-Sen Univ, China 1986, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 478-5714
David Krankheit continued from page 29 He was the first doctor in California to start a practice exclusively focused on obesity treatment and eventually opened over 30 franchised offices, called “Fat-B-Gone” clinics, up and down the state. Dave married for the third time in 1956, this time to one of his previously obese former patients, Marlene LaGrasse, who turned out to be pretty cute after she shed 80 pounds. But he ran into trouble with the Board of Medical Quality Assurance in 1960 when he was discovered prescribing Dexedrine to the once again pudgy Marlene and most of the members of her bridge club. He had his license suspended and served six months in Leavenworth on federal drug charges. Marlene divorced him while he was in prison, and died a few months later in Pickwickian crisis.
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He did quite well after he got out of prison, having somehow landed a job as a clinical researcher for the giant Swiss pharmaceutical firm Scheiss-Schnitzel-Umlaut. Moving to Switzerland in 1965, he never returned to the USA. I know he died in 1996 because of a call from the coroner in Flugelhorn, Switzerland who told me his body had been discovered in a dumpster behind a fast food joint, and a hand-written note in his pocket identified me as his next of kin. Accompanying this obituary is a police photo of Dave taken in 1975 and published in the local paper after he was arrested following a bar fight in Flugelhorn. The caption reads (translated from the German) “American doctor, Davy Crockett, was arrested last night for hooliganism.”
Board Briefs January 8, 2007 The Board re-elected Dr. Charles McDonnell to a second term as 2007 Secretary and elected Dr. Stephen Melcher 2007 Treasurer. At the request for Dr. Lee Snook, the Board authorized staff to assist in the dissolution of the Sacramento Area Physicians Group. After the expenses of dissolution are paid from the defunct organization’s cash, the balance will go to the Community Service, Education and Research Fund (CSERF), restricted for the William E. Dochterman Medical Student Scholarship Fund. Approved the Membership Report: For Active Membership — Farah Ajmal, MD; Patrick A. Harty, MD; Kelly A. McCue, MD; Haritheertham Nagaraj, MD; Joahnna A. Padilla, MD; Guadalupe Roldan, MD; Kulwinder S. Sehmbey, MD; Matthew B. Zavod, MD For Resident Membership — Samuel V. Bartholomew, MD; Forest H. Mealey, DO For Retired Membership — Robert W. Bonar, MD; John A. Reitman, MD For Resignation — David J. Hak, MD (moved to Colorado); Wendi A. Knapp, MD (transferred to Santa Cruz); Jenny Raphael, MD (moved to Pennsylvania); Benjamin H. VanderZwaag, MD (transferred to Sonoma).
February 12, 2007 The Board: Approved the 2007 SSVMS Work Plan; Approved a request to endorse the Citizens for Flood Safety Campaign by supporting the approval of an increase in property assessments in Sacramento county, and the consolidation of certain flood control districts proposed by the Sacramento Area Flood Control Agency (SAFCA) as part of achieving a 200-year flood protection. Authorized staff to schedule meetings with members of the Sacramento County Board of
Supervisors to establish a dialogue on healthcare issues. Approved the Membership Report: For Active Membership — Smitha G. Agadi, MD; Ketan P. Ajudia, MD; Indro Chakrabarti, MD; Lynn Chien, MD; Thomas J. Curran, MD; Karyn D’Addio, DO; H. Lynn Drummer, DO, Ph.D.; Lewis T. Dudley, MD; Michael P. Giovan, MD; Mark I. Grijnsztein, MD; John B. Hackert, MD; Phuong N. Ho, MD; Saba Hussain, MD; Shannon L. Kathol, MD; Amer H. Khan, MD; Yury Korshkov, MD; Munish Kumar, MD; Todd D. Lasher, MD; Michael H. Luszczak, DO; Michael McCloud, MD; Geetha Pingili, MD; Caroline M. Schreiber, MD; Yelena Y. Sergeyeva, MD; Blanca Solis, MD; Chiu H. Tung, MD; Mark D. Tyburski, MD; Glen L. Xiong, MD; Peter T. J. Yip, MD; Yanzhi Zhu, MD. For Resident Membership — Andrew H. Huang, MD For Reinstatement to Active Membership — Stanley H. Chew, MD; Paul J. Fry, II, MD; Thomas S. Nesbitt, MD; Ivan R. Schwab, MD. For a Change in Membership from Resident to Active — Bonnie B. Quiroz, MD For Resignation — Audrey N. Ewig, MD (Transfer to Solano); Thomas M. Keller, MD (Transfer to Solano); Joseph F. Kranhold, MD (Moved to Arizona); Janak K. Mehtani, MD.
GREAT TRUTHS THAT ADULTS HAVE LEARNED: 3 Raising teenagers is like nailing jelly to a tree. 3 Wrinkles don’t hurt. 3 Families are like fudge...mostly sweet, with a few nuts. 3 Today’s mighty oak is just yesterday’s nut that held its ground. 3 Laughing is good exercise. It’s like jogging on the inside. 3 Middle age is when you choose your cereal for the fiber, not the toy.
March/April 2007
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Conference Room Rentals
Medical Society (916) 452-2671
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MBNA 1-866-438-6262 / Priority Code: MPF2
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Corporate Express /Brandon Kavrell (916) 419-7813 / brandon.kavrell@cexp.com
Practice Management Supplies
Histacount 1-888-987-9338 Member Code:11831 www.histacount.com
Electronic Claims
Infinedi – Electronic Clearinghouse 1-800-688-8087 / www.infinedi.net
Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911
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Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...
Marsh Affinity Group Services 1-800-842-3761 CMACounty.Insurance@marsh.com
HIPAA Compliance Toolkit
PrivaPlan 1-877-218-7707 / www.privaplan.com
Investment Services
Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com
Magazine Subscriptions
Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma
Notary Service/Free to Members
Medical Society (916) 452-2671
Security Prescription Pads
Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php
Professional Publications
UCG Decision Health 1-877-602-3835 / www.decisionhealth.com
Travel Accident Insurance/Free
All Members $100,000 Automatic Policy
Sierra Sacramento Valley Medicine
RAS’ 4th annual spring CME symposium an educational symposium for primar y care providers
Radiological
associates
o f sacRamento
ToPiCs inClude:
satuRday, may 19, 2007 8:00 a.m. t o 1:00 p.m.
n
Peripheral Vascular Disease
n
Pediatric Radiology
n
Imaging Safety
n
Head, Neck & Backpain Work-Up
n
DEXA Scanning & Osteoporosis
2200 HaRvaRd stReet
n
Colon Cancer Screening
sacRamento, ca
Hilton sacRamento
$20 pHysicians
To RegisTeR P lease Call:
(916) 797-6470
an
IMQ/CMA
accredited
aRden West
$10 mid-level pRovideRs
prov ider
Accredited by Accreditation Association for Ambulatory Health Care, Inc.
Radiological Associates of Sacramento Medical Group Inc. is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide Continuing Medical Education for physicians. RAS takes responsibility for the content, quality and scientific integrity of this CME activity. RAS designates this educational activity for a maximum of 5 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.