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Sierra Sacramento Valley

MEDICINE

January/February 2008


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Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Working Together for Docs, Medicine, and Community

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Annual Meeting

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Voices of Medicine

Margaret E. Parsons, MD

Del Meyer, MD

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Metaphoria

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David F. Dozier Jr., MD

Why Who Wins the 2008 Election Doesn’t Matter

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Homo plastinatus

David J. Gibson, MD, and Jennifer Shaw Gibson

John Ostrich, MD

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On the Shoulders of Giants

Cancers of the Oral Cavity and Pharynx in our Region

Michael J. Fuller

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The First OIG Opinion on Hospital Pay for Call

Monica Brown MPH, PhD; Katrina Bauer, MS, CTR; Vincent Caggiano MD

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IN MEMORIAM Harvey Rose, MD

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Posit on Mandated Medical Translation Services

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Board Briefs

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New Applicants

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Tuberculosis: Its Long History of Affliction

Irma West MD

Wendy R. Keegan, Esq

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The Cupcake Effect

Chia-Chen Lee, FNP

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The Language of Medicine

Nathan Hitzeman, MD

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2008 SSVMS Committees

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An Emergency Room in Buenos Aires

John Loofbourow, MD

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 1982 oil painting, of mule deer in the early morning in Yosemite, is the first in a series of covers by Robert C. Lentzner, MD, a retired specialist in internal medicine and cardiology.

Volume 59/Number 1

“I have always enjoyed painting Yosemite scenes on location with oil, water color, pastels or just sketching in pencil,” said Dr. Lentzner. “As our children grew up, we took yearly vacations in Yosemite. We hiked all the valley and high country trails, some old ones no longer in the guide books.”

5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Official publication of the Sierra Sacramento Valley Medical Society

The original oil painting 15 by 22 inches. Dr. Lentzner can be contacted at P.O. Box 2543, Carmichael, CA 95609-2543.

January/February 2008




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. 2008 Officers & Board of Directors Margaret Parsons, MD President Charles McDonnell, III, MD President-Elect Richard Jones, MD Immediate President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD District 4 Ulrich Hacker, MD 2008 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 Craighton Chin, 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 5 David Herbert, MD Robert Madrigal, MD Elisabeth Mathew, MD Stephen Melcher, MD Anthony Russell, 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 Marcia Gollober, MD At-Large Alicia Abels, MD Richard Gray, MD Robert Jacoby, MD Sanjay Jhawar, MD Robert Madrigal, MD Connie Mitchell, MD Anthony Russell, MD Kuldip Sandhu, MD Jeff Suplica, MD Gerald Upcraft, 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 AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor David Gibson, MD, Vice Chair Robert LaPerriere, MD John Ostrich, MD William Peniston, MD Gordon Love, MD F. James Rybka, MD John McCarthy, MD Gilbert Wright, MD Del Meyer, MD Lydia Wytrzes, MD George Meyer, MD Managing Editor Webmaster Graphic Design

Ted Fourkas Melissa Darling Planet Kelly



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.

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President’s Message

Working Together for Docs, Medicine, and Community By Margaret E. Parsons, MD This President’s Message is a lightly edited version of remarks made at the SSVMS Annual Meeting on January 18 . I am very proud to be recognized by my community of physicians and my hometown by the honor of becoming president of our medical society. This is an important responsibility. When I was in residency, Larry (Dr. Larry Bass, now my partner) and I would have conversations about whether or not I should return to Sacramento to practice. In the early to mid-90s, medicine was changing as managed care and larger medical groups expanded in this area. I knew that I wanted to return home to Sacramento and am grateful for the opportunity to practice with wonderful people in what I believe is a great medical community. The changes in Sacramento in the 90s were changes that have happened across the country. Medicine will always be changing. As President of the Medical Society I see a role in helping to make sure that SSVMS adapts to our membership’s changing needs and plans for the future. Sacramento is a community of all modes of practice: solo, small group, large multi-specialty group, large single-specialty group, hospitalbased physicians and a teaching university hospital. Working with our SSVMS board, practicing in the community, and working with the residents in the dermatology department, I get to experience many of these modalities. I have also had the viewpoint of being a patient or family member of a patient. Medicine is changing in other ways. Medical school admissions are at least 50 percent female,

which has changed the workforce. Women may practice on average four hours less per week during family years, but women are not retiring as early as the men. We make up for it later! All young physicians as a whole are choosing schedules that allow them time to parent or enjoy other interests and overall the physician work-hours have changed. Yet at the same time, we face a population that is living longer, and a baby-boomer generation hitting the years when they will have increased medical needs. The predictions are that we will be at least 15–20K short of physicians in the next five to ten years. How is society going to meet that need? In our community we are feeling some of this already; patients often talk of the difficulty of getting a primary care physician. Some specialties in particular are also facing workforce shortages. All of us here can talk about the difficulty in recruiting physicians to the area. And this is the same story I have heard in many other regions of the country. At the same time, physicians and all of medicine are being squeezed with flat or lessened reimbursement, yearly lobbying to stave off Medicare cuts, an abysmal Medi-Cal fee schedule. As witnessed by all the complicated negotiations at the state level, health care reform is a complicated problem. So here we are with a workforce shortage and yet a tight financial future of health care. As a medical society, we must help advocate for our patients by making sure we have physicians providing the wonderful care we can

January/February 2008




Our working together as physicians advocating for the practice of medicine and the health of our communities is what will keep medicine strong and rewarding.



provide in this community. SSVMS is an active part of CMA’s advocacy as we in this area are often called upon to testify at the capital, and I encourage all of you to help out on this when called upon. Locally, under the strong leadership of my predecessor, Dr. Richard Jones, and Executive Director Bill Sandberg, we have been working on a county community health coalition addressing the needs of Sacramento county residents. The Medical Society’s history of community care through CSERF and Spirit are evidence of our commitment to care for our community. I encourage all of us to participate at some level in our time here. And watch as we work with others with health care interests in improving community health. Our other member counties, Yolo and El Dorado, also have community engagement to help serve their counties’ needs. Medical school applications are up nationwide after some slow years. Also, many medical schools are bumping up their class size to meet the workforce physician shortage. UC Davis has expanded its class by 12 students with a program focusing on rural outreach. The increase in applicants bodes well that we will continue to have the best and brightest coming into medicine. With the move of UC Davis Medical School students in their first two years to Sacramento from Davis, I hope that student engagement in organized medicine will grow. Why is organized medicine important? We must advocate for ourselves, our patients, and our communities. We come from many specialties and modes of practice, yet most of our goals are common ones. Membership allows us to keep the organization fiscally healthy. Participation in committees and boards makes this organization strong and vital. Leadership in our community on other boards and organizations continues the legacy of physician leadership and the importance of health in the community. During his tenure as president, Dr. Richard Pan talked about the importance of SSVMS and physician leaders on community boards and

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hopefully school boards, park boards and other organizations. At its meeting this week, the Public and Environmental Health Committee discussed obesity and the CMA Foundation’s training for physician leaders on this tremendously important health issue. We also heard from El Dorado County on its high skin cancer rate of melanoma — now surpassing San Diego County. Hmmm. I think I hear a role for physician advocacy of shade structures at park board meetings! As we continue this 140th year of this Society representing three counties, we must insure that we are: • Relevant to membership as the face of medicine changes and grows • Relevant to the mission of the society and our member counties. • Relevant to our community as we stay visible and advocate for our patients I invite all of you to work with us at all levels in helping keep SSVMS strong and vital. I always feel so fortunate to be a physician, even on a day when paperwork and legislation and regulation are making me quite grumpy. The intellectual challenge of a tough case, the knowledge that I have discovered a cancer early in its course and helping save a life, and the “thank-yous” from patients for taking care of them, make medicine so rewarding. Our working together as physicians advocating for the practice of medicine and the health of our communities is what will keep medicine strong and rewarding. I look forward to working with all of you this coming year. Let us know your ideas, thoughts, and concerns so that our board can continue to do the work that the membership needs SSVMS to do. We are fortunate to have truly outstanding staff, led by our Executive Director Bill Sandberg, that help us accomplish the needs and mission of the society’s membership. In a year starting with Health Care Reform with a bill numbered ABX1-1, a six-month Medicare package, and stressed county budgets...I have no doubt a lot will be going on! mepmd@ix.netcom.com


Metaphoria By David F. Dozier Jr., MD Are there really snow elk in the cold storm light? Or are they instead a magnificent metaphor for powerful, unlooked-for, and transcendental elements of strength, persistence and resilience? A lovely, tranquil Sunday afternoon was shattered when my wife, Krystin, slipped on a hillside trail behind our home, while carrying a beloved 40-pound granddaughter, Gretchen, and in protecting the child, fell hard. The child was fine, but my wife’s right knee encountered a sharp embedded rock and dusty gravel. She sustained a 4-inch inverted chevron of a laceration, which bled profusely over leg and clothing. My 6 year-old grandson, Davey, who had been right there, came running back to the house, saying Grandma was hurt. My daughter, Rachel, and I had remained behind to do some office organizing. I ran out, carrying a box of varied BandAids, which turned out to be ridiculously too small, even in largest sizes. Leaning on my arm, Krystin limped back to our house. Rachel immediately conjured up a clean diaper, a gelpack from the freezer, and an Ace bandage, and was soon nicely cleaning up the blooddrenched right leg, sandal and clothing. Even though I’m a retired MD, emergency care was never my strong suit. I called the urgent care center closest to us, to say we were coming in (to which they curtly replied, “Well. It’s first come, first served”). While Krystin and I spent 2½ hours at the center for meticulous cleaning and suturing, with lots of wincing and shivering, Rachel found all the food we’d prepared. With my son-in-law Scott’s help they served all four grandchildren, checked on us several times by cell phone, and even took the kids back out for the promised (and, this time, uneventful) nature walk.

From Storyteller. Copyright © 1981 by Leslie Marmon Silko. Reprinted with permission of the Wylie Agency, Inc.

Kristin, from her initial reaction, constantly reassured Gretchen that she was all right, that it was just a little cut, and Gretchen, who appeared a little whimpery at first, was soon smiling. When I recall Rachel’s sensible care, reassurance and aplomb, Scott’s kind help, and my wife’s cheerfulness and stoicism, I think I’ve seen some snow elk. david_dozier@sbcglobal.net

January/February 2008




Homo plastinatus By John Ostrich, MD On the south side of Alta Arden Expressway, across the street from Macaroni Grill and just to the west of the Guitar Center, sits a building that used to be a CompUSA store. It is now home to an exhibit of “plastinated” human bodies and body parts created by a company called Bodies Revealed that is in turn managed by a company in Georgia called Premier Exhibitions, Inc. I visited the exhibit on the afternoon of December 29, and had to park next door at the Guitar Center lot, as the old CompUSA lot was full. It warmed the cockles of my not-yet-plastinated heart to think that so many of my fellow citizens were so interested in human anatomy that they would forego what was a meteorologically glorious day to root around in an abandoned mildew-ridden warehouse filled with preserved human remains. Plus they paid $24 for the privilege of doing so ($17 for juniors and $22 for seniors like me) to boot. And the place was indeed full.

How it all began The technology that made this exhibit possible was developed by German physician and anatomist Gunther von Hagens who began experimenting in the 1970s with what he has termed “plastination” of the human body. He created his first workable full body display around 1990, and estimated that it cost about $50,000 and took him about 1,500 hours of work to make that first solitary model. Since then, von Hagens has guided the creation of dozens of plastinated specimens and launched touring exhibitions called Body Worlds, which have been seen by tens of millions of people in cities around the world. (Body Worlds and Bodies Revealed are different exhibits by different companies.)



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Controversy has swirled around von Hagens from the start and has come from both religious and secular individuals and groups. It has been sharper and more barbed since von Hagens opened what is essentially a factory for the mass production of plastinated human and animal specimens in Dalian, China. In a New York Times article titled “China Turns Out Mummified Bodies for Display” published in August, 2006, reporter David Barboza, who was then based in China for the NYT, wrote: “About 260 workers in Dalian process about 30 bodies a year...[they] first dissect the bodies and remove skin and fat, then put the bodies into machines that replace human fluids with...chemical polymers. “In a large workshop called the positioning room, about 50 medical school graduates (sic) work with the dead...placing them in seated or standing positions or forcing corpses to do lifelike things such as hold a guitar or assume a ballet position.” For a show in Hamburg, Germany, von Hagens created a unique plastinated male with an erect penis and it was reported that in Hamburg “prostitutes and cab drivers were admitted for free” to that particular exhibit. (Don’t ask.) That particular model has not been displayed outside Hamburg, and whether it is now gracing one of the windows in the city’s famous red light district is unknown. Another popular item in the Body Worlds catalog is that of a young woman with an 8month-old fetus in situ. She is displayed leaning on her right elbow, her head is turned to the right and her left arm is raised to allow her left hand to cradle her occiput. She is flayed and skin free as are all the plastinated specimens and her anterior abdominal wall is removed exposing her own viscera and her gravid uterus, the ante-


rior wall of which is also gone so that one can see the normal appearing fetus, head poised just above the birth canal. The lady’s pose, wrote Megan Stern in a 2003 essay titled “Shiny Happy People,” is “taken straight from pornographic cliche”; Stern further complained that, in the show she saw, only two specimens were female and all the male plastinates “were displayed in heroic, ‘manly’ poses.” Perhaps the most famous of von Hagens’ displays is called “Rearing Horse With Rider” which is a fully dissected and “exploded” man riding a partially dissected plastinated steed. Another, somewhat more shocking, plastinate is “The Skin Man,” a gracefully posed, as usual skinless man who is holding his former integument draped over his left arm as he might hold a cape that he is about to pass to the young lady in the cloakroom outside the theater. The provenance of these corpses trouble a lot of critics. David Barboza reported that Premier Exhibitions invested $25 million to “insure a steady supply of preserved bodies from China.” He does not say, and perhaps he does not know, to whom that money was paid. All the exhibits enter their various venues licensed as “artistic” or educational in nature and so avoid, in general, the need to provide death certificate and other germane information to local authorities. Dr. von Hagens describes what he brings to the public as “edutainment.” He coined the term “plastinates” for his creations.

The Bodies Revealed Exhibit At Bodies Revealed on Alta Arden, there are eight rooms, each one highlighting a particular organ system. In each room there is at least one plastinate, and there are some cases that contain more detailed and carefully labelled dissected upper and lower limbs and major joints, head and neck specimens and some spectacular injected casts of the cardiovascular system and the placental circulation. In the room devoted to the CNS, a sign on the wall declares, “Girls’ brains account for 2.5% of their body weight. Boys’ brains account for 2%.” As I stood there contemplating what that fact might indicate in the grand scheme of things, I overheard a fellow attendee say to his female

companion, “Well, see, that saves us guys a little bit of blood so it can go to more important places.” So then I knew. One of the plastinates was posed kicking a soccer ball and another holding a golf club in follow-through position. The latter fellow looked to me to have a swing doomed to create a nasty slice, but what do those medical students in Dalian know about golf, after all? One specimen had blotchy gray lungs and the label on the wall stated the lungs were discolored by cigarette smoke. A nearby sign stated, in large letters: “LEAVE YOUR CIGARETTES IN THE HALL AND STOP SMOKING NOW!” All of the male plastinates are penis-free, but all have their testes hanging from their spermatic cords. The only complete female plastinate was a down-the-middle sagitally sliced lady whose remains were primarily designed to demonstrate internal genital anatomy. I rented an audio guide for $6 more, but I did not think it offered much more than the information already attached to the specimens and displays themselves. But what the heck, I got in for 22 bucks just for being 65 years-old, so that’s not a bad deal. At the end of the tour there is a room with a large table littered with pens and papers where you are invited to write down comments on blank sheets of paper that can then be inserted into a loose leaf binder, or one can fill out a standard questionnaire. Beyond that, there is a modest gift store where the usual t-shirts and caps as well as some catalogs can be purchased. I spent about an hour and a half, but can imagine that an interested layperson could spend longer, and one can double back to the beginning without having to pay again. Afterward, I went over to the Ancil Hoffman Park golf practice range and hit a couple of buckets of balls into the setting sun. I kept thinking about my fellow golfer back there in the old CompUSA building. Who was he and how did he get there? Had he ever even seen a golf club before he was plastinated and sent to The Positioning Room?

One specimen had blotchy gray lungs and the label on the wall stated the lungs were discolored by cigarette smoke.

John.Ostrich@kp.org

January/February 2008




On the Shoulders of Giants BloodSource celebrates its 60th year, and gets ready to move its operations.

By Michael J. Fuller, Chief Executive Officer, BloodSource Sixty years ago, Dr. James Yant and other physicians of the Sacramento Society for Medical Improvement (SSMI) recognized the need for a community blood program and forged the initial elements of what we know today as BloodSource. As with many other innovative and communitycentered programs the Medical Society founded, BloodSource was a bold step into the future of medicine. From its humble, albeit very visible, beginnings under the water tower on J Street to today’s international programs and respected reputation as a transfusion medicine leader, BloodSource most certainly exceeded the founders’ expectations. Today, BloodSource provides service to major healthcare systems in Northern and Central California and routinely supplies blood and components to hospitals and patients across the nation when there is a need. BloodSource’s leadership has been visionary from the beginning. Establishing best practices in transfusion medicine was the focus of our founders. They held scientific workshops and seminars for the leadership of state and national blood banking organizations, which were just opening up their own transfusion medicine practices. Medical direction has been a critical factor in the success and growth of BloodSource. From Dr. Yant’s and his colleagues’ tenure to the full-time medical directors of today, BloodSource has been recognized for quality and innovation. Dr. E.J. Watson-Williams, Scientific Director, was a champion of component therapy, which



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was a tremendous advancement allowing the support of numerous patients from one unit of blood. Dr. Vincent Caggiano brought the insight of the clinician to our blood center. His understanding of the need and use of blood and components in patient care, and his view of transfusion medicine through the lens of a physician with experience in the clinical setting, was instrumental in establishing long-standing and positive relationships with hospitals and physicians throughout Northern and Central California. Through his research experience and knowledge of hepatitis, Dr. Paul Holland, Medical Director and CEO from 1983 to 2004, implemented new blood safety screening tests. Those tests provided a significant margin of safety in the initial response to the AIDS crisis. His leadership guided BloodSource through that most critical period in transfusion medicine. Dr. Patricia Kopko is Executive Vice President, Medical Affairs and Histocompatibility Lab Director. Her investigations of Transfusion Related Acute Lung Injury (TRALI), funded by a National Blood Foundation grant, resulted in increased understanding of TRALI that redefined the collection and transfusion of plasma. Dr. Kopko is recognized as a leading expert in the field of transfusion medicine and histocompatibility. Her efforts have led to improved blood safety and care of patients who receive transfusions and transplants. The development of one of the nation’s first blood banking computer software systems started at BloodSource in the mid-1970s. In the 1970s, BloodSource was one of the first blood centers to bring automation to the donation


process. We pioneered the use of apheresis machines to collect specific components from donors. Our ability to consistently collect blood components has made BloodSource an international leader in automated collections today. Education has been a core commitment of our organization. BloodSource established a “Specialist in Blood Banking” (SBB) School in 1978. Approximately 25 students have now graduated from the SBB School and bring their special skills to blood centers and hospitals across the country. This successful educational experiment was the forerunner of BloodSource establishing programs in HLA and Immunohematology. Today’s Clinical Histocompatibility Scientist (CHS) and Clinical Immunohematology Scientist (CIS) programs are the first of their kind in U.S. blood centers. Students with an undergraduate degree in science enter a yearlong program to learn the specific science of CHS or CIS work in preparation for national or state exams. To date, eight BloodSource employees have completed the CHS program, passed their national exam and earned state certification; another employee has begun studies. One employee has concluded her year in the CIS program and another has begun studies. These programs help supply the professional staff needed in our BloodSource labs and will continue to do so into the future. BloodSource works closely with college and universities in Northern and Central California to develop programs that will focus student interest on transfusion medicine. We look forward to the day when transfusion medicine specialty programs in medical and nursing schools will bring students into the blood banking environment. Now in our 60th year, BloodSource is moving operations for only the third time in our history. Twenty-four years ago the BloodSource Board of Directors purchased property on Stockton Boulevard in Sacramento. Little could they know the decision to enhance operations in 1984 would provide a legacy redeemable in 2008 to further expand the growth of quality services. That critical decision 24 years ago

has provided the financial foundation to build new state-of-the-art blood testing laboratories including new homes for our world-recognized HLA and Reference Labs. Additionally, BloodSource will occupy a 95,000 square foot building across a parking lot from our new labs. This building will house administrative operations, Donor Recruitment, a donor collection site, autologous center, therapeutics apheresis suite, Public Affairs, Marketing, IT, Accounting and Human Resources. These facilities should provide the necessary physical plant for several decades to come — our new legacy, a far cry from the $1 per year space “under the water tower.” What does the SSVMS’s 1948 initiative

look like today? BloodSource employs more than 625 people who ensure blood, components and services are available when patients need them. BloodSource labs perform more than three million tests annually. A projected 225,000 donors will be drawn this year and, from this base, almost 1 million components will be produced to transfuse patients. The $80 million budget supports these and all of the other activities of BloodSource, including a volunteer program that boasts more than 1,000 volunteers. Several BloodSource programs are internationally recognized. Mentioned earlier, our

January/February 2008

This is the new BloodSource headquarters, at Mather Park in Rancho Cordova.




Histocompatibility Lab provides transplantation support locally and around the globe. Recently Dr. Kopko, working with Kathie Nelson, our 30year department Director and with transplant teams, established a new protocol allowing several patients to benefit from incompatible organs. Through a federally funded grant, Dr. Christopher Gresens, VP and Medical Director, Clinical Services, has extended BloodSource programs to Guyana, Mozambique, Tanzania, Kenya and Rwanda, as part of a national effort to enhance transfusion medicine operations around the world. He has helped nations such as Georgia, formerly a part of the Soviet Union, upgrade their blood banking operations. Our administrative relationships include creating a new business model to increase the collection of plasma for fractionation with a biotech company in Austria because new treatments for immunodeficient patients have

increased worldwide demand. As our founders would expect, BloodSource is again a pioneer and leading efforts to ensure availability to all in need. Why does BloodSource consistently occupy a leadership role in the transfusion medicine community? I am reminded of the story of Sir Isaac Newton, when asked why he thought he was able to see so far into the scientific future. He paused and explained, “I am able to see these things because I stand on the shoulders of giants.” BloodSource is able to provide leadership today and will do so into the future of transfusion medicine because, like Newton, we stand on the shoulders of giants — women and men, physicians of our Sierra Sacramento Valley Medical Society, who for 60 years have provided BloodSource with a strong foundation and a clear view into the future based on a dedication and commitment to our broader community. At the end of our 60th anniversary year, the amount of blood and components collected in the last 60 An Email to the Editor years would actually fill the J Street water tower — 3.3 million gallons! Eating Penicillin? We have come a very long way since those humble beginnings on A year ago, in the January/February issue, we ran an article by J Street. And when we review our Dr. Robert LaPerriere on bleu cheeses — called “Penicillin in the accomplishments at the next anniVein.” versary, our greatest compliment will Like many other publications these days, it was found on the be that we made it here because we Internet, in this case by someone in Buffalo, New York, who sent stood on the shoulders of giants, this email: today’s physicians of the SSVMS and a dedicated BloodSource staff. “I just found this article written by you and had a question. If I For 60 years of vision, leadership, were sick and needed to take penicillin, wouldn’t it be just as easy support and dedication, a sincere and to eat some bleu cheese? Is the penicillin in cheese just as effechearty thank you. tive? Thanks in advance for your reply.” Unfortunately, it’s not that easy. Dr. LaPerriere sent this reply: “This would not work. Penicillin is a concentrated, purified derivative of the substance produced by the Penicillin mold. It is not the mold itself that kills the bacteria, and not all strains of Penicillin mold produce the substance (“Penicillin”) that kills bacteria.” But Dr. Bob, suppose you ate bleu cheese while drinking red wine…

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mike.fuller@bloodsource.org


The First OIG Opinion on Hospital Pay for Call By Wendy R. Keegan, Esq. The author is an associate in the Sacramento office of Nossaman Guthner Knox Elliott LLP. Her practice focuses on healthcare law, regulatory compliance and policy matters. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency treatment to patients regardless of their ability to pay. However, EMTALA does not extend this obligation to physicians. Consequently, many hospitals find themselves between a rock and a hard place because of shortages of physician specialists and the increasing unwillingness of physicians to provide emergency care without compensation. Some hospitals have responded to this quandary by entering into transfer agreements with neighboring hospitals, while others have established minimum call coverage requirements for medical staff membership through hospital and medical staff policies. Still others have resorted to paying physicians for emergency department call coverage and uninsured patient services. Such call coverage agreements are not inexpensive or simple. According to the California Hospital Association, hospitals in California pay over $600 million a year in on-call coverage payments. Further, agreements between hospitals and physicians are tightly regulated by federal and state laws and, therefore, must be carefully structured. The Office of the Inspector General (OIG) recently issued its first opinion regarding application of the federal anti-kickback law to emergency department call coverage agreements,

providing welcome guidance to hospitals and physicians that have, or are considering, such arrangements. The anti-kickback law broadly prohibits the payment or receipt of compensation for referrals, and carves out numerous safe harbors for arrangements deemed to pose little risk of fraud and abuse. It is not necessary for an arrangement between a hospital and physician to fit within a safe harbor, but doing so may reduce exposure to possible civil monetary penalties, imprisonment and automatic exclusion from federal health care programs. The arrangement at issue in OIG Advisory Opinion 07-10 is typical of many call coverage arrangements that fall just short of meeting the four corners of an anti-kickback safe harbor, making the OIG’s reasoning and conclusion of particular interest. Under the arrangement, physicians participate in a monthly call schedule, respond to calls within a prescribed time, provide 1.5 days per month of coverage gratis, provide followup care to patients admitted through the ED regardless of their ability to pay, and participate in the hospital’s quality assurance programs. The hospital, in turn, pays physicians a per diem based on whether coverage occurred on a weekday or weekend and the extent of each specialty’s responsibility for uncompensated care responsibilities. An independent consultant reviewed the per diem stipends and concluded that they were consistent with fair market value. January/February 2008

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Finally, as icing on the cake, the OIG commented that all costs associated with the arrangement were absorbed by the hospital and were not passed on to federal health care programs.

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At the outset of its opinion, the OIG recognized that hospitals face increasing pressure to compensate physicians for call coverage and that there were legitimate reasons to do so, as described above. It noted, however, that the proliferation of such arrangements creates the risk that physicians might unlawfully demand compensation for call coverage as a condition for doing business at the hospital, or that a hospital might illegally use such arrangements to entice physicians to join or remain on the hospital’s medical staff or to refer business to the hospital. Thus, the OIG emphasized that the facts and circumstances of each call coverage arrangement must be evaluated to assure that compensation is fair market value for actual and necessary items or services, and that compensation is not determined in a way that considers the volume or value of referrals or other business generated between the parties. After considering the background and details of the arrangement in question, the OIG ultimately approved it, based on several key findings. First, the OIG found merit in the hospital’s position that the per diem payments to physicians were fair market value for actual services needed and provided because physicians were required to do more than just be “on call” — they were obligated to provide “substantial, quantifiable services” that justified the per diem payments under the arrangement. Second, the OIG determined that the hospital’s understaffed ED and its consequent outsourcing of emergency care was indicative of a legitimate, unmet need for on-call coverage and uncompensated care services. Third, several features of the call coverage arrangement minimized the risk of fraud and abuse, including that participation in the arrangement was offered uniformly to all physicians in the relevant specialties; call obligations were divided among participating physicians as equally as possible (so as not to reward high referrers); physicians were required to provide inpatient follow-up care to every patient admitted after being seen in the ED regardless of ability to pay (reducing the risk of “cherry-pick-

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ing” patients); and physicians were required to document services in medical records (thereby promoting transparency and accountability). Fourth, the OIG determined that the hospital’s call coverage arrangement promoted the hospital’s charitable mission by facilitating better emergency and uncompensated care to patients in the hospital’s community. Finally, as icing on the cake, the OIG commented that all costs associated with the arrangement were absorbed by the hospital and were not passed on to federal health care programs. Some questions remain in the wake of OIG Opinion No. 07-10, such as determining at what point it becomes appropriate to compensate physicians for providing ED coverage and uncompensated care; the extent to which the fair market value must be documented and supported (i.e., whether an outside consultant opinion is always necessary); and the level of substantial, quantifiable services, in addition to “being on call,” that should be a part of a call coverage arrangement. Further, the OIG’s opinion does not address the physician self-referral law (a.k.a. the Stark law), which is always a consideration when hospitals and physicians enter into arrangements. Nevertheless, for hospitals considering call coverage arrangements as a mechanism for assuring sufficient emergency department coverage and uncompensated care services, the OIG’s analysis and conclusions provide guidance as to how they might best be developed. wkeegan@nossaman.com

Say what?

Three old guys are out walking. First one says, “Windy, isn’t it?” Second one says, “No, it’s Thursday!” Third one says, “So am I. Let’s go get a beer.”


The Cupcake Effect By Chia-Chen Lee, FNP The author is a Family Nurse Practitioner and the Nurse Manager at the Santa Clara County Juvenile Facilities and Children’s Shelter.

The “cupcake effect” is a phenomenon we discovered in the Santa Clara County Juvenile Hall. A year ago, one of the minors in Juvenile Hall signed up for “sick call” (a request for medical evaluation) on two consecutive weeks. He wanted to be seen in order to make sure everyone knew that his birthday was approaching. “Can I just have a piece of cake? Please! This will be my second birthday in Juvenile Hall. I just want a piece of cake,” he said. He started asking for that piece of cake a couple of months prior to his birthday. Finally, one of the nurses called the kitchen and requested a piece of cake for him on his birthday. He had a smile on his face from ear to ear all day long! Consequently, the medical staff decided to honor every minor’s birthday. It was an amazingly moving experience for all of us. On a minor’s birthday, a dayshift nurse would call the unit to have the minor come to the clinic. The minor has no idea why he or she was being called to the clinic. The medical staff would welcome the minor by singing “Happy Birthday,” while presenting a cupcake with a single birthday candle. This usually generated a lot of joy and non-stop laughter in the clinic. One day, the medical staff called a birthday boy to the clinic as usual. This boy was well built at 6 feet, 180 lbs, and walked into the clinic with tattoos and needle tracks all over his arms. He projected an attitude right from the beginning, and said, “Why did you call me? What do you want from me?” We answered with a coordinated melody of

Happy Birthday. All of a sudden, his face turned soft, white, and then, he burst into tears. He tried to catch his breath, but was speechless. We all felt the air freeze and time stop. One could see his heart melt. He was so touched that he could not stop crying. He was not even able to eat his cupcake! We wiped the tears from our own eyes and realized “This is what we are here for.” A changed boy went back to his unit after saying “thank you” with the best manners and the tenderest look I had ever seen. One of the girls sobbed with tears when presented with happy birthday song. “I never had any birthday cake in my whole life! Why are you caring so much about me?” Another boy said, “This is the first time someone ever remembered my birthday!” The smallest caring action combined with a little human touch warmed their lonely hearts. A few sincere words can open the book of their life stories. Some have parents locked up in jail; or drunken parents incapable of parenthood whose child’s birthday was never of importance. A few have separated parents, each assuming the other will celebrate their child’s birthday. Some are always in between foster homes, without a long enough stay for a birthday celebration. A couple of minors said that they were going to have a birthday party when their mom gets her next pay check, but that precious pay check never came, I call it the “cupcake effect.” A little kindness, support, caring, and a human touch; an act that states, “you are recognized, you are someone special, and you matter,” brings out

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the best within a child. It is hope. The nursing staff began to notice better manners and bright hopeful eyes at medication time. Often we would be greeted with, “Nurse, can you please check to see if my name is in your book for a cupcake? My birthday is coming up in four days.” In the Santa Clara County Juvenile Hall, there are some teens with tough shells and poor manners. There are also well-behaved ones who made mistakes in the past. Bad or not, they all have a gentle, well-mannered, and sincere child

within. The birthday wishes, supplemented with delicious cupcakes have a tendency to break down these defensive walls. As a result, outlook and manners begin to change for the better. The simple recognition and acknowledgement of a birthday can have immense impact on their attitude towards life and towards their fellow citizens. Ultimately, the “cupcake effect” changed us all. Chia-Chen.Lee@hhs.co.santa-clara.org

The Language of Medicine By Nathan Hitzeman, MD

Let us keep company with chalazions, Barter with Bartholin’s glands, Muscle with mitrals. Safari with the hippocampus. Limbo with the limbus. Am I being particularly pituitary about all this?

And when we are done babbling about Babinskis, And whispering about never-ending Whipples, Done perusing pink puffers, And bailing out blue bloaters, Let’s rush to the cafeteria, And continue our conversations.

Please be frank about the frenulum, And don’t fall into Fallopians, Be positive about those negative findings, And appropriately negative about those positive findings. Tell them about the cerebellum. And why they oughtta take care of their oblongata.

Did you see that watermelon scrotum? Did you feel that ovarian orange? Did you smell that caseous sebaceous? Do you wish you hadn’t ordered the fish?

Medicine is an adventure. Let’s kindle crepitations, And excavate the ruins of cerumen. Let’s swim the canals of Schlemm, And get lost in the circle of Willis, Maybe find turtles in the cells of Hurthle!

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At the end of the day, we are in a hurry, To finish our McMurrays, And be apt with our Apleys. We lance and dance, Express and then dress, I try not to hesitate lest things start to fungate. At home, my spouse asks me how my day was. I want to say, “Simply sebaceous!”


2008 SSVMS Committees Below are the committee appointments for this year. Members interested in joining a committee should contact Bill Sandbereg or Chris Stincelli at SSVMS. Child and Adolescent Health Services Drs. Mary Jess Wilson, Chair, Charles Maas, Vice Chair, Fawzia Ashar, Marcia Britton-Gray, Lindalee Huston, Maynard Johnston, Robert Meagher, Richard Pan, Patricia Samuelson, Joseph Sison, Rachel Weinreb Editorial Drs. John Loofbourow, Editor/ Chair, David Gibson, Vice Chair, Robert LaPerriere, Gordon Love, John McCarthy, Delbert Meyer, George Meyer, John Ostrich, William Peniston, F. James Rybka, Gilbert Wright, and Lydia Wytrzes; Ted Fourkas, Managing Editor Emergency Care Drs. John Tucker, Chair, David Berman, Michael Carl, Peter Hull, Loren Johnson, J. Douglas Kirk, Robert Kozel, Norman Label, Rodney Loeffler, James Martel, Kelly Nations, Kenneth Ozawa, Pankaj Patel, Harold Renollet, Steven Schorer, Steve Tharratt, Lee Welter, David Wisner, John Wood Historical Drs. Robert LaPerriere, Chair, Francine Gallawa, Nancy Gilbert, Julian Holt, Roland Lippold, Joseph Masters, Margaret Masters, Otto Neubuerger, Kent Perryman, F. James Rybka, Irma West Judicial Drs. Joanne Berkowitz, Jose Cueto, Barbara Hays, Elisabeth Mathew, Richard Pan, Paul Phinney Medical Review and Advisory Drs. Howard Slyter, Chair, Joanne Berkowitz, Vice Chair, Denny Anspach, Jose Arevalo, Richard Axelrod, Peter Carruth, Mark Chang, Satya Chatterjee, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Louis Gallia, Michael Goodman, Kern Guppy, Okyanus Gurel, Ruth Haskins, David Haugen, Edward Hearn,

Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Robert Lentzner, Michael Luszczak, Charles McDonnell, George Meyer, Travis Miller, Gail Pirie, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto, Gerald Simon Membership Drs. James Sehr, Chair, James Farley, Vice Chair, Christine Fernando, James Hamill, Barbara Hays, Daksha Shah Professional Conduct and Ethics Drs. Joanne Berkowitz, Chair, Frank Apgar, Satya Chatterjee, Jamie Cobb, Kevin Elliott, Jon Finkler, James Hamill, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Connie Mitchell, Janet O’Brien, Ivan Rarick, Ronald Rogers, Linda Schaffer, Daksha Shah, Robert Treat, Glennah Trochet Public and Environmental Health Drs. Donald Lyman, Chair, Richard Sun, Vice Chair, Janet Abshire, Regan Asher, Donald Brown, Clinton Collins, Anthony DeRiggi, Jason Eberhart-Phillips, Sandra Hand, Bette Hinton, Robert Jacoby, Alexander Kelter, Robert LaPerriere, Charles Maas, Stephen McCurdy, Margaret McCusker, Robert Meagher, Connie Mitchell, David Root, Glennah Trochet Scholarship and Awards Drs. Byron Demorest, Chair, Ruenell AdamsJacobs, Frank Boutin, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kaplan, Paul Kelly, Abdul Khaleq, Lionel Lee, Mark Levy, Travis Miller, Caroline Peck, Patricia Samuelson Wellness Committee Drs. Michael Parr, Chair, Lee Snook, Captane Thomson, Robert Treat

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An Emergency Room in Buenos Aires By John Loofbourow, MD My Buenos Aires hotel room phone rang. The desk clerk stated that my sister wanted me to come to the lobby to see an injured woman who had fallen while entering an adjacent store. She had tripped on a 4-inch edge at the doorway, very common there, but easily overlooked because the sidewalk cement is of the same color as the floor inside. She fell into a glass display, cutting her chin, loosening a tooth, cutting her lip, and generally bruising her legs and ankles. There was no loss of consciousness. The store owner had provided some cotton balls to slap onto the laceration, and hustled her back to the hotel. The hotel desk clerk, a medical student just about to graduate, called for an ambulance. The injuries looked benign. I exchanged the useless cotton balls for a clean towel to stem the bleeding, and within a half hour the ambulance arrived. The attendants went through the usual reassessment, dressed the wound, filled out papers, and took us to the public hospital. The ambulance was a modified van, with basic equipment. We were informed there would be no charges because the ambulance service had a contract directly with the hotel and “everyone has access to emergency care, paid for through a payroll tax.” However, emergencies are sharply defined to exclude minor problems, which are turned away to await normal clinic hours. Perhaps in part for that reason, we were seen very quickly. The facility itself was cold, bare, and uninviting, but the care was fast and appropriate. No intake, no

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receptionist, no nurse triage assessment, no paperwork. I think it was assumed I was the patient’s husband. The delivery of care was old-style and hierarchic. Doc Big appeared very quickly, spoke good English, asked the history. (The injured woman is a nurse who has Hepatitis C from a needle poke in a dialysis unit, is otherwise in good health, age 74, no meds. Tetanus current. She had had a right hemicolectomy for cecal volvulus four months prior, but in this case, ”don’t ask, don’t tell” seemed acceptable.) Doc Big looked and explained that sutures were needed, and wished the patient a curious “goodbye-good luck,” and left. Doc Medium arrived and went through the process in almost exactly same way in quite understandable English. I simply listened and didn’t disclose my profession. Almost immediately thereafter, Doc Small arrived, with not so fine English, and repeated the process a third time. In this lovely backward world, no one wrote anything down. The only signature, my own illegible scrawl, was taken by the ambulance crew. I was asked to step out into the waiting room, and I confessed to being an E.D. doc who would be watching through the wall. The physician seemed a bit taken aback but said nothing. In about 20 minutes he came out, and gave instructions: keep dry, sutures out 5 days, use povidone iodine topically, change dressing 24 hours, Rx for Amox Clavulinate because a tooth had been moved slightly. The contusions and abrasions were felt to be insignificant, and the small lip laceration across the vermillion border required no


sutures, though these latter injuries would have been differently handled in a fee for service system. The antibiotic could be picked up at the adjacent pharmacy. I sat in the bare waiting area on one of four hard chairs. It had been only an hour since the injury. There is no Argentine HIPPA, and while the Small Doc did his thing, I overheard the details of two cases. Doc Big discussed the treatment of an M.I. with an anxious clutch of family in terms very like we would use in Sacramento. Because of lowered cardiac output, immediate angiography and possible angioplasty, stent or bypass would be required. The second case discussion addressed a patient with status epilepticus who wasn’t responding to the usual medical treatment, and would possibly require more aggressive measures including, if necessary, anesthesia. No other cases appeared. No vomiting, no coughs, nothing that would be called minor. I don’t know who makes such decision about ED visits, probably patients themselves who are aware of the rules. In yet another feature of underdevelopment, apparently the hospital and staff perceived no legal or political risk to such determinations. After Doc Small dismissed us, the patient asked to use the toilet; but there was none, so he took us into the hospital area showing her to an empty patient room. I later learned there was no toilet paper there so she resorted to a McDonald’s receipt! (I had a partial roll of STP, Sacred Toilet Paper, in my backpack, as usual, but she didn’t know that.) Rejecting the antibiotic, we returned to the ambulance entrance, and peered out into a fierce stream of traffic. I asked the policeman where to hail a taxi. He replied it would be impossible because adjacent to this public hospital was a fútbol (soccer) stadium and a big game had just ended. The four lanes going our way were clotted with cars and busses maneuvering and honking. The sidewalks were thick with pedestrians. He called for a radio-taxi but the first to be promised would be two hours. The rare empty cab among the flood of vehicles ignored our

appeals, and we were told they either had assignments or were afraid to pick up passengers there because it was a conflictive situation(?). Finally, the policeman stopped a colectivo (a car or bus that runs a specific route where each passenger who boards pays a set fee no matter what the destination). This bus would end its run at a place where we should find a taxi. So we pushed our way up onto the loading steps. But neither of us had the right kind of change. After searching frantically through pockets and possessions for several minutes, the owner-driver said to just forget it. He was only a few kilometers from the end of the run. On arrival there was still no taxi to be seen, so we walked about 6 blocks to the hotel, arriving door to door in less than 2 hours. I suggest only one thought about health care in a federal system: Where medical care is universal and free of direct cost, the program administrator must be free to limit care. Argentinos seem to stoically tolerate both the advantages and disadvantages of Peron-care and appear to feel that the inevitable aspects of universal care are not worth crying about. Would we be so tolerant? We may find out.

There is no Argentine HIPPA, and while the Small Doc did his thing, I overheard the details of two cases.

john@loofbourow.com

Health Notes MRSA Reporting There is widespread interest in Community Acquired MRSA with many articles and reports in the media. In addition, the Legislature has held hearings about the issue. The California Department of Public Health is working on regulations that would make severe MRSA infections that result in ICU admission, hospitalization or death, reportable. They concluded that this limited reporting would be the best way to evaluate the impact of MRSA in California. Although MRSA is not reportable in California, this may change in the near future.

— Glennah Trochet, MD Public Health Officer, Sacramento County

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Annual Meeting Incoming SSVMS President Margaret Parsons attended medical school at Tulane University in New Orleans — so it’s no surprise she chose Mardi Gras as the theme of this year’s Annual Meeting, on January 18 at the Sheraton Hotel. Sacramento neurologist Dr. David F. Dozier, Jr., received the society’s highest honor, the Golden Stethoscope Award. He was recognized as embodying the spirit of unselfishness, compassion and empathy that are the hallmarks of a physician chosen for this award. His father, Dr. David F. Dozier, Sr., received the award in 1970. The Medical Honor Award, given for achievements that have brought a contribution of great significance to medicine or community health, went to Dr. Richard Pan, a pediatrician at the UC Davis Medical Center and 2004 SSVMS President. Dr. Pan has been a leading advocate for insuring all children in our region. County Supervisor Richard Dickinson was presented the Medical Community Service Award for his leadership in local health care policy. He is an advocate of expanding health care coverage for all children, a leading proponent of maintaining county health services for the indigent, and a staunch advocate and ally with medicine to improve health in Sacramento County. Lisa Smith was the recipient of the Dedicated County Alliance Member Award, and Marilyn Skinner was presented the Dorothy Dozier Helping Hands Award. BloodSource presented SSVMS with its highest award, the Bennett Sculpture, in recognition of the Society’s support of the organization.

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1 Michael Fuller, the Chief Executive Officer of BloodSource, presented SSVMS with BloodSource’s top award.

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2 Dr. Paul Kelly, the 2005 Golden Stethoscope Award recipient, and his wife, Linda. 3 Dr. Margaret Parsons with Bonnie Ferreira, Executive Director of Healthy Kids Healthy Future, who accepted the Medical Honor Award on behalf of Dr. Richard Pan. 4 From the left are Dr. Margaret Parsons, SSVMS President; Dr. Charles McDonnell, President-Elect; Dr. Robert Madrigal, Incoming Director; Dr. Richard Jones, Immediate Past President; and Dr. Anthony Russell, Incoming Director. 5 Marilyn Skinner, who received the Alliance’s Dorothy Dozier Helping Hands Award; Katie White, President of the Alliance; and Lisa Smith, recipient of the Alliance’s Dedicated County Member Award. 6 Dr. Margaret Parsons with Roger Dickinson, Sacramento County Supervisor, who received the SSVMS Medical Community Service Award. 7 Dr. Byron Demorest, Chair of the Scholarship & Awards Committee. 8 Dr. David Dozier, Jr., the 2007 Golden Stethoscope Award recipient, and wife, Krystin.

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9 A group picture of the Meeting. In the foreground is Dr. Margaret Parsons’ table. Photos by Kurt Fishback Photography

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Voices of Medicine Insurance leeches, the way doctors think, and the weaponry of numbers.

By Del Meyer, MD

Medicine’s Parasite In the The Bulletin of the HumboldtDel Norte County Medical Society, October 2007, Dr. Emily Dalton discusses “Leeches in Medicine.” “According to Stedman’s medical dictionary, a parasite is an organism that lives on or in another and draws its nourishment there from. Leeches suck nutrients from the host — not enough to cause death — yet they have no beneficial effects for the host…. Insurance companies are the parasite of our times, and like the leeches, it is time for insurance companies to get out of healthcare. “Twenty percent of the money spent on health care premiums gets pocketed by the insurance companies. They collect the money and they dole out medical care (also known as the “medical loss ratio”) in capricious and self-serving ways. Insurance companies create barriers to care by denying payment to doctors and by denying medical care to patients… “The insurance model does not apply well to medical care. Insurance works best for catastrophic problems that are unlikely to actually happen. For situations such as home-destroying disasters or automobile crashes, the insurance model works well. Most people do not have damaging house fires or severe auto accidents on a regular basis. People get covered for losses that could be financially ruinous, insurance companies make their profits, and it all works out fairly well. Healthcare is different! Healthcare is something that everyone needs on a regular basis. Preventative care, treatment for minor illnesses, and treatment for catastrophic

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illnesses are basic human necessities.* Serious illnesses will occur for each one of us at some time in our lives. We deserve better than to be at the mercy of a cold-hearted insurance company when that time rolls around. “The insurance model is a poor way to structure the delivery of efficient and sensible healthcare. The time has come for medicine to become leaner and more efficient, which can only be accomplished by eliminating the parasitic growths that insurance companies have become, and replacing them with a single payer system.” Go to www.humboldt1.com/~medsoc/images/ bulletins/OCTOBER%202007%20BULLETIN_ for%20web.pdf for the original article. *[If Dr. Dalton had continued the analogy so nicely made with houses and autos, the article would have ended on a positive, instructive and optimistic note: “Serious illnesses will occur for each of us at some time in our lives. But only serious illnesses are insurable. Treatment for preventative care, minor illnesses and routine health care should be paid out of pocket, like car maintenance and home repairs. Then health insurance would be appropriate and affordable just like car and home insurance.” — D.M.]

Art and Science of Medicine Dr. John Toton reviews the book, “How Doctors Think,” by Jerome Groopman, MD, in Sonoma Medicine, the Magazine of the Sonoma County Medical Association. “In How Doctors Think, the much-published Dr. Jerome Groopman uses multiple case histories (all of them initially misdiagnosed or mistreated) to highlight the perceived inability of doctors to think and communicate effectively with their patients — an issue of great


importance in these times of medical stress and change. Groopman is a reluctant apologist for this issue, and he argues for corrections that he feels are needed. The case histories he presents are a sad journal, particularly since — from his perspective — all were preventable. Groopman also chronicles his own experiences with ‘aggressive back surgery’ and a long effort to diagnose scaphoid-lunate ligament injury as the source of his own chronic wrist pain. “After much patient suffering or risky delays, the cases Groopman describes are almost always resolved by ‘open communication,’ including listening, open-ended questioning, systematic thinking, patient activation and engagement in the process, and exclusion of good patient-bad patient prejudices… “Groopman accepts that we are in a time of rapid change in how we practice the art and science of medicine. The ’older’ generation, he explains, acquired their skills primarily by the Socratic method of sharing knowledge, questioning and responding, learning from our experience and that of our mentors, and on-the-job honing of these skills. We trust our experience; we learn from our errors. We search for the ONE diagnosis that seems to fit the data and explain the symptoms (Ockham’s Razor). We always look for patterns and similarities so we can shortcut to the diagnosis. From there, it’s just a short leap to developing ‘confirmation bias,’ often based on recent experiences, leading in turn to ‘diagnostic momentum.’ As a result, we sometimes give short shrift to atypical symptoms, especially with alcoholic, diabetic, or other stereotypical patients. “The ’younger’ generation is in transition, but with much the same burden. They are taught to depend on algorithms, ‘diagnostic certainty,’ evidence-based diagnosis and treatment, computerized records and formulas, all available in one nice BOX (PalmPilot or Blackberry). They may be worshiping the science and ignoring the art of medicine…” For the complete review, go to www. scma.org/magazine.scp.Fall07/toton.html

The Numbers Game Thomas H. Lee, MD, writes on “Dangerous

Numbers: Misconstrued Data Hazardous To Health Care” in Vital Signs, official publication of the Fresno-Madera Medical Society and Kern County Medical Society “$2 trillion. Forty-four million uninsured. Sixteen percent of gross domestic product. Respectively, that’s how much the U.S. spends on health care each year, how many people are uninsured and the portion of the GDP that health care consumes. To those of us who follow health care, these numbers are more than just familiar — they are macroeconomic symbols of our woeful health care system. As health care reform continues to burn near the top of political issues in the U.S. presidential race, these numbers increasingly are being used as weapons. Weapons against insurers, pharmaceutical companies and providers. “These numbers can be somewhat misleading. For example, just a few weeks ago, the New York Times published a controversial article — ‘Sending Back the Doctor’s Bill’ by Alex Berenson — about how many health care economists believe that both political parties were missing the real source of cost savings: physician incomes. The article argued that physician incomes were more than double those of their European counterparts and that health spending could be reduced significantly if doctors were paid less and were salaried rather than being paid per procedure. “Not surprisingly, the article drew plenty of criticism, including some from noted economist Uwe Reinhardt. Reinhardt counter argued that physician take-home incomes represent only 10 percent of health care spending and that even a 20 percent reduction in incomes would reduce national health care expenditures only by two percent. “Regardless of how you think physicians should be compensated, health care reform inevitably will be determined by the politics and economics of change…. Numbers increasingly will be wielded as fact, argument and weapons of ideology…” The entire article is on page 8 of www.fmms.org/pdf/Oct07_VS_FINAL.pdf

As health care reform continues to burn near the top of political issues in the U.S. presidential race, these numbers increasingly are being used as weapons. Weapons against insurers, pharmaceutical companies and providers.

DelMeyer@HealthCareCom.net

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Why Who Wins the 2008 Election Doesn’t Matter By David J. Gibson, MD, and Jennifer Shaw Gibson Here is a radical if not subversive concept concerning elections in today’s hyper-partisan environment: Elections are not about winning. They are about gaining the permission of the electorate to govern. It should not be a surprise that voter turnout is lower in the U.S. than in other industrialized country — the most expensive campaigns are generally the most negative and depress voter interest. Wedge issues by definition cannot accommodate compromise and therefore have no place in public political dialogue. They serve only the interests of demagogues on both sides of these issues. What substantive issues are being avoided by politicians in this election cycle? The following are but a few we should be discussing:

U.S. has lost control of its financial future America has become a developed debtor country. As Niall Ferguson, the professor of history at Harvard University, noted recently in an op/ed column in the LA Times, the problem for America is that its electorate now thinks the world owes them a living. As we are witnessing in this political season, politicians pander to this assumption by making a series of more or less incompatible promises: that expenditure on healthcare and education will always go up; that direct taxation will never go up; and that the assets against which voters borrow will never go down. The only way to fulfill these promises is to pump

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out ever more printed paper — bank notes, bills, bonds, stocks and the rest. The emerging exporter countries buy these. The net result for America is a creeping transfer of financial ownership to foreign investors. This process of acquiring liquidity through the sale of paper to foreign investors is about to enter a doomsday scenario. China has stockpiled £700billion worth of foreign currency, and has only to decide to slow its accumulation of dollars to weaken or destroy America’s economy. We are now hearing clear warnings from China that it will be switching away from dollars into higher valued currencies such as the Euro in the future. Such a move will likely precipitate a liquidity crisis that will crush America’s economy. It matters not how many troops, missiles, bombers or aircraft carriers America’s military possesses. At the point of divestment by foreign exporting investors, our economy will implode without a shot being fired. This is the clear and present danger we now face and the reality our children are inheriting.

Our consumer-based economy is not sustainable For the past generation, America’s economy is consumer-based. Consumer spending, not saving and investing, has sustained our economic prosperity. Unfortunately, this consumer-based economy is not sustainable. According to the 2007 Retirement Confidence Survey conducted by the Employee Benefit Research Institute (EBRI), about 60 percent of people age 45 and older have less than $100,000 in retirement savings (about 40


percent of the those 45 and older have managed to save less than $25,000). In fact, of all the workers surveyed, more than one-third has less than $10,000 in savings. Despite the apparent lack of adequate savings, roughly 70 percent of all EBRI survey respondents say they are somewhat or very confident of having a comfortable retirement. One fundamental investment that individuals in middle years and older have traditionally held in their portfolio has been equity in their home. The graph below, taken from Investor’s Business Daily, demonstrates that while homeownership rate climbed to a high of 69.2 percent in 2004, the equity homeowners hold in their houses slipped in recent decades, approaching the 50 percent barrier this year. For the past decade and a half, homeowners have been extracting equity from their homes in the form of second trust deed financing to support their consumerist life style. All of this sets up the economy for the perfect storm that will occur during the next administration’s time in office. The trust funds for both Social Security and Medicare have been eradicated with over $4 trillion in borrowing to pay for prolific spending by the federal government. Most individuals retiring over the next

20-years have little if any savings. No one in public life is warning the country of the crisis that is now unfolding.

Health care will not be reformed in the next four years The largest industry in America cannot be fundamentally restructured without the consent of the electorate and the tax payers (the two are not synonymous). Thus far, the political debate has centered on the current system’s shortcomings. As a result, health care reform is at the top of the 2008 election agenda. Near-universal coverage is being promised by most serious presidential contenders. There are at least three problems with the current health care reform debate. The first involves the lack of candor concerning what reforming the system will require. National polling consistently demonstrates that reform proposals that threaten — or which can be made to appear to threaten — the plans that insured Americans (who are taxpayers and tend to vote more reliably than the preponderant non-tax paying uninsured) currently have will likely face a backlash similar to the Clinton debacle of 1993. This reality has doomed Schwarzenegger’s “year of health care reform” in California.

There are at least three problems with the current health care reform debate.

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Clearly, no current candidate from either party has any grasp of the imminent problems facing the country.

Secondly, the debate has been superficial. Changing the structure of the underwriting system for health care is easy. Restructuring the cost per unit of service and the number of units of service delivered is the hard part of the reform process. In reality, how the underwriting system is structured is of little consequence — no underwriting system can support the current inflationary trend in health care. Finally, the government cannot fund universal coverage. In fact, the cost of existing health care entitlements has bankrupted government at all levels, from the local school board to the federal. At the national level, the magnitude of the unfunded health care retirement liability for government employees is just coming into focus. Recent estimates by various benefits consulting firms of the total amount of public sector unfunded retiree health care obligations have exceeded $1 trillion. To put this in perspective, according to the Federal Reserve Board, the total amount of outstanding municipal securities in the United States as a whole at the end of the first quarter of 2007 was $2.5 trillion. All of the above does not include the economic tsunami that both Medicare and Medicaid now represent. Medicare Part A expenditures alone are expected to grow 85 percent to $385 billion, and the projected annual shortfall between tax revenue and spending will grow to nearly $45 billion in 2016. The Medicare Trustees this year estimated that filling this shortfall in Medicare will require an income tax increase of 22.7 percent by 2030.

Health Notes Disposing of Needles Needle disposal in capped solid plastic or glass containers is acceptable in household trash. However, unless something is done, in September 2008 it will be legal statewide only at official refuse collection sites.

— Glennah Trochet, MD Public Health Officer, Sacramento County

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A failed political paradigm Since the passage of the 16th Amendment to the Constitution in 1913, the paradigm for the successful politician has been essentially unchanged. Once elected, politicians use tax payer money to purchase goodwill of the electorate, to ensure longevity in office. Most of this spending has been financed through borrowing by government at all levels. With the ability to borrow now limited and the magnitude of the already-promised entitlement funding overwhelming, we face the reality of a perfect storm in public policy. Future politicians will of necessity be taking prized goodies away from their constituents. They will need to increase tax rates to near confiscatory levels, decrease spending by reneging on prior entitlement commitments, or a combination of both. The new politician will look much like Tom McClintock here in California, a policy wonk who understands the precarious future facing public financing of government. America has no experience with this type of politician. How does a politician get elected by taking away programs and increasing tax rates simultaneously? Clearly, no current candidate from either party has any grasp of the imminent problems facing the country. The current outrageously expensive political season is not about governing, it is about winning. The result: It does not matter who wins. Inconsequential social issues that should not be part of the public debate will be influenced but the winner will have neither the political capital nor the mandate from the electorate to govern in these perilous times. DJGibson@winfirst.com

David Gibson is 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.


Cancers of the Oral Cavity and Pharynx in our Region By Monica Brown MPH, PhD; Katrina Bauer, MS, CTR; Vincent Caggiano MD The first two authors work for the Public Health Institute/California Cancer Registry; Dr. Caggiano is with the Sutter Institute for Medical Research/ Sutter Cancer Center. Cancers of the oral cavity and pharynx accounted for 1,687 (2.5 percent) new cancer cases in the Sacramento region1 from 2001– 2005. Typically these are cancers of the poor, the elderly and the uninsured and are associated with long-term tobacco use; alcohol abuse and, for as many as 15 percent of the population, infection with the Human Papillomavirus (HPV). The average annualized age-adjusted incidence rate for oral cavity and pharyngeal cancers was 10.3 per 100,000 persons in the region during this period. Incidence by county ranged from 14.3 in El Dorado County to 9.0 per 100,000 in the combined counties of Alpine/ Amador/Calaveras. Although the incidence of these cancers has been and remains higher in the Sacramento region than in the state, we’ve seen a steady decline in incidence since 1988. The epidemiology of oral cavity and pharyngeal cancers in our region reflects that seen elsewhere. Men were diagnosed with oral cavity and pharyngeal cancers 2.4 times more often than women; at a median age of 63 and 67 years respectively. Non-Hispanic whites had the highest incidence while the lowest was among Asian-Pacific Islanders. In the oral cavity, tumors were most often seen on the tongue (2.5 per 100,000), followed by the salivary glands and lips (1.6 per 100,000 each). This does not include cases of melanoma of the lips, of which there were less than 5 cases

during this period. In the pharynx, the tonsils had the highest incidence (1.6 per 100,000). Early diagnosis of all cancers — and oral cavity and pharyngeal cancers are no exception — can result in expedient appropriate treatment, less disfigurement from treatment, increased functionality after treatment, better prognoses, higher quality of life and longer survival. Unfortunately, for both oral cavity and pharyngeal cancers near equal proportion of cases were diagnosed in the localized stage (41 percent) as those diagnosed in the regional stage (45 percent). Not surprisingly, those in the highest socioeconomic group were more likely to be diagnosed at the localized stage (46.8 percent); ethnic minorities were more likely to be diagnosed with tumors in advanced stages. Survival after diagnosis with oral cavity and pharyngeal cancer, like most cancers, was dependent on stage at diagnosis. The 5-year relative survival for persons having oral cavity cancer was 81 percent for those with localized tumors but 41.2 percent for those with regional tumors and 27.4 percent for those with distant metastases. Five-year survival was bleaker for those diagnosed with pharyngeal cancers: 63 percent for those with localized tumors, 48.7 percent for those with regional tumors, and 22.5 percent for those with distant metastases. Oral cavity and pharyngeal cancer are debilitating and often fatal diseases. The incidence of these cancers remains higher than most other areas of California possibly because of our higher smoking rates. The decline in incidence in our region

January/February 2008

Although the incidence of these cancers has been and remains higher in the Sacramento region than in the state, we’ve seen a steady decline in incidence since 1988.

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is nonetheless promising — although differences in cancer screening by dentists, failure to report cases to the California Cancer Registry or limited access to dental care could produce similar results. For example, the county with

the highest incidence, El Dorado County, has the third highest median household income among counties in the region; consequently, it’s likely that residents of El Dorado County have access to effective and timely dental care and better reporting of cases. Physicians play a major role in preventing and detecting these difficult cancers. Advise moderation in alcohol use, direct smokers to smoking cessation programs, and refer patients for appropriate biopsy of any suspicious lesions in head and neck region. MBrown@ccr.ca.gov 1 The Sacramento region covers the counties of Alpine, Amador, Calaveras, El Dorado, Nevada, Placer, Sacramento, San Joaquin, Sierra, Solano, Yolo and Yuba.

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In Memoriam

Harvey Rose, MD 1932–2008

Harvey Rose died on January 1, 2008. It is hard to quantify the magnitude of the impact he had on the practice of medicine, and particularly, the practice of pain medicine. I first met Dr. Rose in the late 1980s. I had recently left the University of California, Davis, and ventured into the realm of private practice as a hospital-based anesthesiologist and then into the new and developing world of pain medicine. I was approached by Bill Sandberg and asked to contribute to an article called “The Painful Dilemma� which was spearheaded by the Medical Society under the prodding of Harvey Rose. He had the insight and foresight to recognize that physicians needed organized medicine to advance medical care and that one physician alone could not do it without help from others. He was the driving light behind this sentinel work, which is still one of the most copied works from our Medical Society in its entire history. I began to see Harvey at every dinner or event where pain or its treatment was discussed. He never shied away from controversy no matter who the presenter was, be it the Bureau of Narcotics Enforcement, the Medical Board of California, or any federal, state, or enforcement agency. He had been thrown overboard of peer review and under siege from the Medical Board before and he feared not. Harvey was committed to his patients, not afraid to take personal risk in this pursuit, and was a physician warrior in his quest to change our approach to suffering patients. He did this and more. I had heard stories, almost mythical, of his approach to a legislative solution to the treatment of pain. He convinced Senator Leroy Greene to sponsor legislation which became the

Intractable Pain Act for the State of California. Not only did the Sacramento-El Dorado Medical Society, as it was then named, get behind this but so did the California Medical Association. By his drive and fortitude, this county medical society and this state medical society lived up to their stated mission of serving our patients by practicing the art and science of medicine. The impact of this act was to assure countless patients over many years of needed relief by allowing some physicians who were interested in this type of practice the necessary protection from enforcement to do so. Over the years, I saw Harvey at the CMA Houses of Delegates, pushing for resolutions, providing insight Harvey Rose, MD to the rest of us about pain medicine, and constantly being present to advocate for his patients. He thought nothing of calling local radio or press and discussing his views. He recently was on KFBK on the Tom Sullivan Show, discussing pain management. This was at a time when he was suffering from advancing cancer and receiving chemotherapy. Harvey had plenty of time to arrange for care of his practice since he knew about his diagnosis and prognosis many months ago. This absolutely did not stop him from advocating and practicing. I was called by Harvey, when he was in the hospital and so dyspneic that he could barely talk. He called me to make sure that I followed up on a Bay Area referral for one of his patients. Not a word about his condition or his near death, only about his patients. I had to go to the hospital myself to visit Harvey to find out anything about his declining condition. That was Harvey, selfless. He embodied the

January/February 2008

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very qualities of being a physician that we all strive to reach but rarely achieve. Near the last days of his life he longed to have the control over his end that he had lost as a consequence of his disease. Harvey believed that patients should be able to decide, when adequately informed, how to conduct their life, medical care, and end of life care. He knew that most patients who opted for physician-assisted suicide were undertreated pain patients. Bill Clinton’s campaign guide for President was, “It’s the economy, stupid.” Harvey Rose changed that to define the real issue in his own campaign, and it became his favorite slogan: “It’s the pain, stupid.” It was by his constant vocal and passionate advocacy that many of us are able to treat patients today. We are peer reviewed, denied, threatened, dropped from provider panels, and essentially marginalized. We are accused of practicing medicine that is not evidence-­based

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by its current insurer-friendly definition. Harvey Rose lived through all of this, through the managed care onslaught, at risk medical care, capitation, HMO panels, and all of it. He did not complain about it. He just soldiered on and took care of his patients. Never stop, never give up. He taught me the importance of listening to patients and individualizing care for each patient because no two patients are alike. The best medical care for a patient resulted from the special interaction between physician and patient that we hold sacred. Harvey did not let anyone or anything intimidate him or direct him away from his primary directive, patient care. For these reasons and many more, Harvey Rose is the Father of Pain Medicine in our community, our state, and our nation. I can only hope that we can strive to be as dedicated as Dr. Rose. God rest his soul. Let his life be an example for us all. — Lee T. Snook, Jr, MD


Posit on Mandated Medical Translation Services “A government mandate to provide medical interpreters for non-English speaking people is demeaning and counterproductive for patients, for medicine and for a coherent, cohesive society.”

Among 153 responses, 84 agreed, 64 disagreed, 5 expressed no opinion. While a majority of those who responded agreed with the posit, the majority of commentators felt mandated translation was appropriate, and not demeaning. Posit statements are intended solely to encourage discourse among members, and do not reflect the opinions of the SSVMS Board, or editors. Edited comments appear below, while unedited comments can be viewed on-line at SSVMS.org. “There is no way to get an adequate hx from a patient that does not speak the same language as the provider without a qualified medical interpreter. Numerous errors are made when family members or other non-qualified persons are used. It is demeaning to NOT use a medical interpreter.” — Dineen Greer, MD “Basically it’s for one’s self interest. One cannot provide any standard of care at all without a translator. However, the cost of, e.g., Language Line, through AT&T is about $3/minute, ought to be the responsibility of the patient.” — Colin Paul Spears, MD “Interpreters insure a minimum level medical care is provided which is good health for all of society: consider the public health implications of poorly or untreated TB.” — Sufen Chiu, MD “Your posit is worded in a ’too kind and benign manner’; just call it like it is: ’baloney.’ Forego…have the patient bring an English speaking family member or friend.” — Donald Hummel, MD

“The mandate [is not] demeaning; however, it is counterproductive to a cohesive society… I consider myself an open-minded and tolerant individual, but I live in a country where the language we speak is English. If I move to France …I will learn the language-French. There are studies which show when Hispanics do not learn English they are less likely to succeed… We need to encourage them to become part of the country they have joined without eliminating their own personal cultural differences.” — J. Rabinovitz, MD “Considering how many languages there are, this is just simply impossible, mandate or no mandate.” — Amy Black, MD “What is demeaning to non-English speaking patients is having a physician who … uses a child or other family member to interpret. It often happens that intimate and private questions are asked that are too embarrassing to the patient to answer honestly in front of a child or family member; or the person being used does not understand the medical vocabulary and can’t translate adequately… If we, as medical professionals, had risen to the challenge and begun using medical interpreters on our own there would not have been a need for a government mandate.” Glennah Trochet, MD “Kill this turkey by mandating the govern— ment pay full costs for the service.” — Deane Hillsman, MD “A government mandate may be misguided, but it is not demeaning. …Elected officials and regulators are …trying to do the right thing in the

January/February 2008

“Numerous errors are made when family members or other nonqualified persons are used. It is demeaning to NOT use a medical interpreter.”

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“…it is not an unfunded mandate anymore; funds are available and even Medi-Cal has a task force to establish the amount and mode of payment with their first meeting as early as next week.”

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context of our culture of over-entitlement, one of the most damaging social pathologies of our time. We demean ourselves as a society by feeling that we deserve the best of everything, at the expense of someone else.” — Paul Phinney, MD “Not so much demeaning, as another example of the government interfering where it doesn’t belong.” — Richrd Gray, Jr., MD “It may be expensive for doctors, but it’s not demeaning to patients or medicine.” — Ann Gerhardt, MD “I don’t know that I would use such harsh words but this is truly counterproductive.” — Elizabeth Mathews, MD “I [reject] strongly…any government mandate that interferes with patient/physician communications.” — Paul Kelly, MD “Medical interpreters are BADLY needed and can only help to improve communication between patients and doctors.” — Laura Kurek, MD “If I were in Russia, I would not dream of seeing the doctor without a friend or family member to translate for me.” — Ron Rogers, MD “How can it be demeaning and counterproductive to provide an explanation about diagnosis and treatment to a patient through a interpreter? …Call it a government mandate or just call it good medicine.” — Jose Cueto, MD “Do these lawmakers ever think of how a solo practitioner is going to comply with this mandate? What happened to personal responsibility?” — Bill Au, MD “…the quality of service, the results of the treatment, the outcome, and …the patient’s satisfaction is …greater …where an interpreter …[is] provided. …patient unders[tands] what the treatment plans are with its pros and cons … it is not an unfunded mandate anymore; funds are available and even Medi-Cal has a task force to establish the amount and mode of payment with their first meeting as early as next week.” — Satya Chatterjee, MD “I believe nearly all government mandates regarding health care are misguided and unworkable. I would not have chosen the word demeaning but agree strongly with the idea that it would be counterproductive….” — Don Hause “The concept is fine. The problem is that it is

Sierra Sacramento Valley Medicine

an unfunded mandate.” — Edie Zusman, MD “A mandate isn’t the right [way] to pursue this appropriate purpose…it’s not demeaning or counterproductive — it’s expensive and without reimbursement for it.” — Jack Lewin, MD “An unfunded mandate that requires a physician to pay more for the interpreter than what the physician receives in reimbursement is unacceptable!” — Arjun Sharma, MD “A just and moral society is obligated to offer quality medical care to all who seek it. Only by ensuring that patients can communicate adequately with their healthcare providers can we fulfill this obligation.” — Chris Gresens, MD “Who pays? The interpreter fees are more than medical reimbursement.” — W. Randy Martin, MD “What’s wrong with family? Who pays? MD office?” — John Young, MD “If patients do not speak English, a medical interpreter should be absolutely necessary and it should not be demeaning in any way….” — Dawn Sung, MSII “Cultural and language barriers have been identified as important contributing factors to the quality of care. Without this mandate, many providers will not bother to provide interpretation services leading to errors, misunderstandings, and substandard care.” — Olivia Kasirye, MD “I oppose such government mandates unless there is funding to cover the costs of this service. …I don’t think providing translators is either demeaning or counter-productive. … Even if you believe that everyone coming to the USA should speak English, it is not going to happen overnight and we have to be currently prepared to take care of folks with no English ability.” — Joanne Berkowitz, MD “There are already too many “government mandates.” — Roseanne Pevek, MD “Quality and comprehensive medical care and treatment require precise communication… an interpreter negates the possible confusion that can and does occur…. When possible I request a family member. If this is not possible a certified interpreter always helps…, especially in urgent and emergency situations.” — Michael Klein, MD


“People need to take a certain amount of responsibility for themselves. For non English speakers to bring their own interpreters is not unreasonable.” — J. Asling, MD “I agree. And (it) burdens providers with unfair cost.” — Kuldip Sandhu, MD “This ’mandate’ is racist ethnic vote pandering by the pro-illegal immigrant Democratic Party…. U.S. Citizenship “requires” a working knowledge of English…. (N)o other ethnic group …has ever demanded interpreters. I suggest the Medical ’Profession’ demand that Congress mandate that English is the language of governance of the United States. …I have two immediate family members who are naturalized U.S. Citizens. They did it the legal way…My wife, when naturalized, was selected in her group of 1,000 to lead the Pledge of Allegiance because… she was the only one who could speak sufficient English to do the job. Thank God, the Irish speak English: I’d hate to have Gaelic interpreters federally mandated!” — Cleve Baker, MD “…Mandating interpreters for non-Englishspeaking patients is an unnecessary intrusion into the practice of medicine and decreases a cohesive society based on the ability of its citizens to communicate through a common language.” — Rick Feldman/Wendy Forrest, MD “The use of interpreters for non-English speakers actually improves quality and efficiency of care in my experience. I disagree with a government mandate however...who will bear the cost of it all?” — Samuel Bartholomew, MD “I am horrified that people come to America then don’t make any effort to speak English. ...(Yet)it is difficult for the physician AND the patient to complete the encounter satisfactorily if they cannot speak. It is a service for humanity that our government is trying to ‘mandate’… full communication…” — Evalyn Horowitz, MD “I agree there is a need to communicate with the patient particularly about procedures and risks. However, to presume that the burden should be mandatory and fall solely on the practitioner disconnects the patient from their responsibility…. The mandate also places an unfair financial burden on the physician…. It will be a hindrance to encouraging bright young

people to pursue medicine because of the onus to provide uncompensated care.” — Forrest Junod, MD “Let the government supply the interperteers!” — Alan H. Galbreath, MD “…I HATE having to provide translators at my cost, primarily for Medi-Cal patients where I’m getting paid nothing already. Curious, since the OFFICIAL language of the State of California is English. It is about time that the CMA sued the State over this issue….” — Steve Polansky, MD “…Translation in extreme circumstances …is reasonable; however, translation …is probably counterproductive…non English speaking patients are allowed to continue relying on translators and don’t develop English as a second language. …I support a system such as France uses, in which all citizens are required to learn French (English in our case).” —Travis Tollefson, MD “English is our language as a country and society. …A ’mandate’ is intrusive.” — Greg Herrera, MD “Communication in medicine is basic. If we have admitted folks into this country who do not speak English we must be able to communicate with them when they come for medical care. My preference would be to have patients bring an interpreter. If not feasible, an interpreter should be provided. I see nothing demeaning here.” — Irma West, MD “It is a no-brainer that interpreters are necessary to convey historical information to a physician from a non-English speaking patient…. It is up to the physician to assure the appropriate doctor-patient relationship…. If the interpreter is intrusive on this relationship, the physician should …limit the interpreter’s function to the essentials.” — Charles Halstead, MD “If the government mandates that providers supply such a service, they should also provide reimbursement for the legislatively mandated services.” — Seth Rosenthal, MD “There should be mandatory interpreters for quality and proper medical care.” — Vong Lee, MD “Like all government mandates, [the government] should support the cost of the mandate.” — Richard Meyers, MD

January/February 2008

“…Mandating interpreters for non-Englishspeaking patients is an unnecessary intrusion into the practice of medicine and decreases a cohesive society based on the ability of its citizens to communicate through a common language.”

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Board Briefs November 13, 2007 The Board approved the nominations from the Scholarship and Awards Committee for the 2007 Sierra Sacramento Valley Medical Society awards: Golden Stethoscope Award to David F. Dozier, Jr., MD; Medical Honor Award to Richard J. D. Pan, MD; Medical Community Service Award to Supervisor Roger Dickinson. The Board approved the resolution, History Day Student Recognition, recognizing Ashleen Kishore, Khanh Nguyen and Nazeela Sabir for their dedication and exemplary work in their project related to the field of medical science. The Board approved the recommendation from the Public and Environmental Health Committee to send a letter to the Sacramento County Board of Supervisors encouraging their support of the development of the Orangevale Cohousing Project, Sycamore Village. The Board approved the Membership Report: For Active Membership — Arun P. Amar, MD; Diane Apostolakos, MD; Maheswari J. Balasubramanian, MD; Christie L. Carroll, MD; Michael G. Chez, MD; Stacy D. D’Andre, MD; Jon F. Foy, MD; Jesus A. Garcia, MD; Francisco J. Garcia-Ferrer, MD; Peter S. Gemmell, MD; John S. Humphrey, MD; Stephen J. Jerwers, DO; Sarah S. Jones, MD; Michael Z. Li, MD; Dawn A. Mudie, MD; Kelly H. Pham, DO; Mark A. Rezac, MD; Seth p. Robinson, MD; Kelly A. Sharrar, MD; Scott W. Siegner, MD; John F. Thompson, II, DO; Travis T. Tollefson, MD; Wesley J. Tsai, MD; Tamas J. Vidovszky, MD. For a Change in Membership Status from Resident to Active — Karen T. Hopp, MD. For Annual Renewal of Postgraduate Leave of Absence — John T. Cornelius, MD. For Retired Membership — Il Hui Lee, MD; Robert C. Lentzner, MD.

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For Resignation — Polly F. Baldwin, MD (transferred to Santa Barbara); Leigh A. DeLair, MD (moved to Kentucky); Amy A. Jibilian, MD; Thomas J. Leavitt, MD (moved to Idaho); Robert H. Mertz, MD (moved to Seattle, WA); Steve Y.H. Shih, MD; Chiu H. Tung, MD (moved to Modesto). For Termination of Membership for Non-payment of Dues — James P. Dickens, MD.

December 10, 2007 The Board: Approved the Third Quarter Financial Statements and Investment Reports. Approved the 2008 Budgets for the General Fund, Building Fund and the Community Service, Education and Research Fund (CSERF). Approved the 2008 Committee Appointments. Approved the Membership Report: For Active Membership — Saraswathy Balasingam, MD; Mark T. Dillon, MD; Sherellen B. Gerhart, MD; Anubha Khanna, MD; Hank M-H. Linn, MD. For a Change in Membership Status from Active to Active 65/20 — Jonathan R. Beck, MD. For Resignation — Hsichao Chow, MD (moved to Oregon) and Ansumana A. Gebeh, MD (transferred to Los Angeles Medical Association). For Termination of Membership for Non-Payment of 2007 Dues — Ketan P. Ajudia, MD and Tanya Maagdenberg, MD.

January 14, 2008 The Board: Elected the 2008 Secretary, Glennah Trochet, MD and Treasurer, Stephen Melcher, MD. Also welcomed the new incoming Directors, Robert Madrigal, MD and Anthony Russell, MD. Received an update on BloodSource activities from Michael Fuller, CEO.


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. — Glennah Trochet, MD, Secretary BALASUBRAMANIAN, Maheswari J., Internal Medicine, Madras Med Col, India 1999, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 BIJAN, Bijan, Radiology/MRI/Nuclear Medicine, Hacettepe Univ, Turkey 1990, Elk Grove Open MRI, 9281 Office Park Cir #115, Elk Grove 95758 (Mail: PO Box 163361, Sacramento 95816) (916) 705-8984 CARROLL, Michael P, Medical Oncology, Stanford Univ 1984, Sutter Medical Group, 1020 – 29th St #680, Sacramento 95816 (916) 7332803 CHEN, Emery L., General Surgery/Surgical Endocrinology, New York Med Col 2001, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 CHEZ, Michael G., Child Neurology/Epilepsy, Indiana Univ 1985, Sutter Neuroscience Medical Group, 2800 L St #340, Sacramento 95816 (916) 454-6661 D’ANDRE, Stacy D, Hematology/Oncology, UC Davis 1995, Sutter Medical Group, 1020 – 29th St #680, Sacramento 95816 (916) 453-3300

DILLON, Mark T., Orthopedic Surgery, Univ Michigan 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4844

MARCIN, Erin B., OB-GYN, UC San Diego 1992, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055

GERHART, Sherellen B., Internal/Geriatric Medicine, Univ Texas, San Antonio 1998, PO Box 1264, Placerville 95667 (530) 344-1207

NAKANO, Stacey A., Family Medicine, UHS, The Chicago Med School 1993, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 973-5243

GORSKI, Dale J., DO, Internal/Family Medicine, Col Osteopathic Med of the Pacific 1984, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 662-3961

RAINER, Annelies K., Psychiatry/Family Practice, Univ Vienna, Austria 1987, 709 Woodside Lane East #1, Sacramento 95825 (916) 929-9469

KHANNA, Anubha, Pediatrics, Gandhi Med Col, India 1995, Sutter Medical Group, 9281 Office Park Cir #120, Elk Grove 95758 (916) 691-5999

TSAI, Tony, Ophthalmology/Retina/Ocular Oncology, Washington Univ 1998, Retinal Consultants Medical Group, 3939 J St #106, Sacramento 95819 (916) 454-4861

LAURENSON, Kimberly E., Family Medicine, UC San Diego 1997, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5243

WEI-SHATZEL, Julie R., DO, Family Medicine/ Aesthetics, Des Moines Univ 1998, 3104 Sunset Blvd, #2B, Rocklin 95677 (916) 624-0300

LIN, Hank M-H, Radiology/Musculoskeletal Imaging, Johns Hopkins Univ 2001, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

ZHANG, Cong (Christine), Medical Oncology, Beijing Second Med Col, China 1992, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631

LOMBARDI, Donald P, Medical Oncology, Univ Rochester 1986, Sutter Medical Group, 1020 – 29th St #680, Sacramento 95816 (916) 4533300

Health Notes Pythium insidiosum in Rio Linda Neighbors in Rio Linda were concerned because in 2005 a dog died of pythiosis and recently a horse in the same neighborhood was diagnosed with the disease. The owner of the dog who died believes that there may be other animals with the infection in the neighborhood. According to UCD, 10 dogs in Northern California have been diagnosed with Pythiosis between 2002 and 2007. Pythiosis can occur in humans. Most cases have been diagnosed outside the US. This is not a reportable disease. I sent out an inquiry to physicians in the community to find out if anyone had diagnosed Pythiosis in a human locally, and no human cases were reported. The organism lives in warm, wet places. In humans it causes dermatologic lesions, arteritis and eye infec-

tions. There have been many animal infections reported in the Gulf states. Human infections have been reported in Africa, Brazil and Thailand.

Local STD alert The incidence of Chlamydia and Gonorrhea infections here are significantly higher than the state as a whole. Sexually active women between the ages of 15 and 24 have the highest rates of these two diseases; among women age 15–19 our incidence for Chlamydia infection is approximately 549.9 per 100,000; this is higher than the state rate of 363.5 per 100,000.

— Glennah Trochet, MD Public Health Officer, Sacramento County

January/February 2008

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Classified Advertising

Positions Available PART-TIME PHYSICIANS for urgent care center. Hours flexible. BC/BE in FP, IM, EM preferred. Competitive compensation and malpractice paid. Kim Marta, MD. The Doctors Center, 4948 San Juan Ave., Fair Oaks, CA 95628. (916) 966-6287. BUSY PRIMARY CARE CLINIC in Midtown area seeks PT and FT MDs. Multi-lingual staff. Competitive Compensation. Please call (916) 275-3747 or fax resume to (916) 760-0837. Part-Time Internist/FP needed to help with screening and medical management of obese patients during rapid weight loss. Weekday evenings. Must be familiar with diabetes, hypertension and lipid management. We pay malpractice insurance premium. Please email: julie@weightmanagement.net or fax CV to (415) 771-3528, Att: Medical Director.

PHYSICIANS NEEDED California Harness Racing Association needs physicians to be in attendance at races at Cal Expo in case of harness driver injuries. While this is a rare occurrence, an ambulance and fully trained EMT’s are on site and will provide medical care in all but the most serious cases. Racing is on Thursday thru Sunday evenings thru July from approximately 6 PM to 10 PM. Physicians may choose selected dates or commit to a weekly schedule. Meals and a negotiable stipend will be provided. For more information, please call David Ferrera, M.D. at (916) 662-5098

Office Space Medical Buildings-Mercy San Juan Hospital. South Sacramento locations also available (916) 223-9969

Membership Has Its Benefits!

Free and Discounted Programs for Medical Society/CMA Members Auto/Homeowners Insurance

Mercury Insurance Group 1-888-637-2431 www.mercuryinsurance.com

Billing & Collections

Athenahealth 1-888-401-5911

Car Rental

Avis: 1-800-331-1212 (ID#A895200) Hertz: 1-800-654-2200 (ID#16618)

Clinical Reference Guides-PDA

EPocrates 1-800-230-2150 / www.epocrates.com

Collection Services

I.C.System 1-800-279-6620 / www.icsystem.com

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

MBNA 1-866-438-6262 / Priority Code: MPF2

Office Supplies

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

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Infinedi – Electronic Clearinghouse 1-800-688-8087 / www.infinedi.net

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Sierra Sacramento Valley Medicine


Tuberculosis: Its Long History of Affliction By Irma West MD Worldwide, about a billion people, mostly young, died of tuberculosis during the last epidemic — which lasted more than two centuries. That does not include previous mortality from the disease, which has been with us since the Stone Age. Tuberculosis-like hunchback deformities of the spine were reported in the remains of a young man who died near Heidelberg about 5000 BC. There were similar findings in Denmark and Italy. As early as 2400 BC, Egyptian mummies showed characteristic lesions, and artists drew pictures of hunchbacks in their tombs. Hippocrates described a deadly lung disease he called phthisis (wasting) about 460 BC and advised his colleagues to avoid attending victims, for they would soon die and sully the physician’s reputation. There were epidemics among pre-Columbian Huron Indians in Canada. Mycobacterium Tuberculosis was found in a mummy of a young Inca boy from about 700 AD. Aztec language has three words for tuberculosis. Mayan artists carved hunchback figures. The prehistoric Ainu of Japan were infected. Yes, there was a 200–300 year tuberculosis epidemic in Europe and America, fueled and sustained by the industrial revolution that brought increasing numbers of young workers from the countryside into filthy, crowded slums in the big cities. The epidemic began in England, peaking in 1750. In Western Europe, the peak was 1800. In America it was 1890. Some African countries may have yet to peak. The annual mortality for England in 1815 was estimated at 500 persons per 100,000 population, dropping to 300 in 100,000 in

1850 and to 15 in 100,000 in 1960. The death rate for New England in 1800 was 1,000 in 100,000. In the United States it was 113 in 100,000 in 1920, when tuberculosis continued as the leading cause of death. The World Health Organization reports 5.5 in 100,000 as the rate for the Americas in 2005. Different manifestations of tuberculosis once were considered separate diseases. Scrofula (meaning brood sow), was a swelling of the cervical lymph nodes. It was called King’s Evil subject to cure by the touch of a King or Queen. Victims were trampled to death during one of Queen Anne of England’s touching sessions about 1700. Percival Pott, a British surgeon, in 1750 described the hunchback deformity of the spine, since called Pott’s Disease. Paracelsus, a Swiss physician, visited the mines in Cornwall and wrote the first report on miner’s phthisis in 1530. The bovine strain of tuberculosis is more likely to cause scrofula, bone disease, meningitis, intestinal destruction and lupus vulgaris, a deforming lesion of the face. Pulmonary tuberculosis (consumption) is usually caused by the human strain. Contributors to understanding tuberculosis included Francisco Sylvius, a professor of medicine in Holland, who first described the tubercle in 1679. Jean Villemin, a German physician, in 1850 proved that human tuberculosis could be transmitted to cattle and guinea pigs. Dr. Robert Koch identified Micobacterium tuberculosis in 1882. January/February 2008

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The photo for this postcard was probably taken nearly a century ago.

Theobold Smith in 1898 determined both human and bovine strains cause human disease. His finding led to testing of cattle and pasteurizing of milk, which reduced deaths from milkborne tuberculosis in New York by 67 per cent between 1910 and 1915. Herman Brehmer built the first tuberculo-

Sierra Sacramento Valley Medicine

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sis Sanitarium at Gorbersdorf in the Bavarian Alps in 1854 and its popularity soon spread as a place where patients could receive bed rest, good food and fresh air. Another popular treatment was moving to mountains or warmer climate. In 1900, one-third of the population of Colorado had tuberculosis. The National Association for the Study and Prevention of Tuberculosis (now the Lung Association), the first voluntary organization in the United States aimed at a specific disease, was founded in 1904. Its free screening programs using chest x-rays and the skin test, introduced by Charles Mantaux in 1908, were widespread in the 1930s and 40s. The BCG vaccine introduced by Calmette and Guerin of France in 1908 was controversial. Waksman in 1944 discovered that streptomycin was active against tuberculosis. Other effective antibiotics followed. From 1950 to 1980 tuberculosis plummeted in developed countries only to level off or increase due to HIV and drug resistance. Nations with adequate


public health and medical services can keep tuberculosis under control, but the battle against it may be lost in poor countries. imariewest@aol.com References: 1 American Lung Association. “A Century of Milestones. 19042004” 2 Dormandy, T. “The White Death: A History of Tuberculosis.” New York University Press. New York, 2000 3 Fishman, A. “Pulmonary Diseases and Disorders.” McGraw-Hill Book Co. New York, 1980 4 Murray, J. “A Century of Tuberculosis,” American Journal of Respiratory and Critical Care Medicine, June 1, 2004 5 National Tuberculosis Center. Brief History of Tuberculosis, 1996 6 Ryan, F. “The Forgotten Plague: How the Battle Against Tuberculosis was Won — and Lost.” Little Brown, Boston, 1993 7 Sarrel, M. “A History of Tuberculosis.” N.J. InTouch (no date) 8 Cynthia Stout. “Tuberculosis.” Denver Post, May 30, 2007 9 World Health Organization. “Tuberculosis.” March 2007

These illustrations of the effects of tuberculosis are from a 1903 book in the Sierra Sacramento Valley Museum of Medical History. It is Portfolio of Dermochromes, by a “Professor Jacobi of Freiburg Im Breisgau,” adapted in English by J.J. Pringle, MB, FRCP, of Middlesex Hospital, London.


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January/February 2008