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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2008


Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE A Time to Reflect and Plan

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Living Longer — Hospice and Palliative Care

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.

Margaret E. Parsons, MD

James McGregor, MD

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Growth in Group Practice Calls for a Bylaws Change

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Shall We Tango?

John Loofbourow, MD

Bill Sandberg

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7

Colorectal Cancer Tests

A Disingenuous Debate on Health Care Policy

Michael J. Lawson, MD

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STUDENT ESSAY WINNER Giving Organs, Giving Life

David J. Gibson, MD, and Jennifer Shaw Gibson

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Care Behind Bars: We Care

Celynne Balatbat

Chia-Chen Lee, FNP

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Remembering the Late American River Hospital

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Sampling Cancer Cases in Local Racial Subgroups

John M. Reed, MD

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Voices of Medicine

Monica Brown, MPH, PhD, and Dawn Nozicka-Ferris, MHSE, CHES

Del Meyer, MD

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Board Briefs

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Global Health Activism Among Medical Students

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New Applicants

Shabnam Hafiz, MS III

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Classified ads

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Four Related Posits on Universal Health Care

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The Death of a Young Pathologist in 1890

Gordon Love, MD, and F. James Rybka, MD

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

The cover was a scene that Dr. Robert C. Lentzner often enjoyed off of American River Drive, and he painted in 1971 in both oil and water colors. It is no longer there, having been replaced by home developments. This is the water color version; the original is 16 by 23 inches. “Water color provides a different way of expression, with the technique quite different from oil painting,” he said. “This particular scene hung in my office for many years. Patients enjoyed its tranquility.”

Volume 59/Number 3 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Used by permission. All rights reserved.

May/June 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.

Sierra Sacramento Valley Medicine


President’s Message

A Time to Reflect and Plan By Margaret E. Parsons, MD Some people reflect on their goals for the year at New Year’s. I have always thought more about the year as Spring breaks out with budding green leaves and new life; when you receive this issue Spring will be in full glory. Your SSVMS Board has also taken time to reflect and plan, with a board retreat in early March. Part of what makes our board effective is that every couple of years we take time to get to know a bit more about each other, our practices, our families, and “what makes us tick.” We can then work together to build on the strengths of our organization and plan for where we believe the Society needs to be moving. Historically, retreats have brought forth programs such as Adopt-A-School and been a time for organizational work, such as the combining of the separate county societies into our tri-county society. All of us concluded one of our greatest strengths SSVMS possesses is in our Executive Director, Bill Sandberg, and his outstanding staff. Bill has built a team that works effectively for us all every day. He is a man with a wealth of knowledge on health care in our region and the players and insurance organizations. He has skills and contacts to help guide members through insurance, practice, legal, and medical board questions — including the sort that none of us ever want to have to deal with. We are fortunate to have his strengths and resources at our helm. Accolades also go to Chris Stincelli, who I have come to know as someone who watches the details, helps keep the ship on course, and makes sure we don’t forget someone or something. Janice Emerson ably staffs committees and is part of the team for all of our work in public health and children’s advocacy. Le Pham keeps the details of membership organized — no small task. Melissa Darling runs the website

— and if you haven’t checked it out recently, you are missing some excellent information. Marti Hill keeps our finances and books in order and leads us to clean audits every year. And our SPIRIT and Adopt-A-School programs staffed by Kris Wallach are exemplary and her personal touch is evident — as those of you who have volunteered know. Membership and its value to all of you and to potential members was the topic of much of the board’s work at the retreat. Ensuring we provide the services our members need, and continuing to reach potential members as the face of medicine continues to evolve and change, was in our thoughts as we worked through the weekend. We discussed ideas to strengthen our magazine, the simplest of which was recognizing the three counties on the cover, as was done on the previous issue. More substantiative discussion about topics of articles and what you as members have told us that you want in past surveys was reviewed, and we know that Dr. John Loofbourow and his editorial board will continue to strive to make the magazine a strong asset. Letting members know of other member benefits, such as travel insurance, is always a goal. The work we do with CMA on legislative and regulatory issues will continue to be of importance. We in the Sacramento region are often leaned upon to testify at the capital on various health issues. SSVMS has also been working with the three counties on health issues; we have a responsibility to be a strong voice for patients and the physicians who care for them, and that will continue as one of our society’s priorities. How SSVMS and physicians are recognized

May/June 2008




and perceived by the community in various venues is important. We spent time both at our December Board meeting and the retreat reviewing the Sacramento Magazine “Top Docs” issue. Bill Sandberg and I met with the co-publishers Mike O’Brien and Joe Chiodo. We reviewed our concerns about the survey methodology and that there should be more information about how to select a physician than simply a list. Our discussion was productive and amicable, and we believe that their receptiveness to our concerns will help patients get more information they need. The Board’s weekend work provided a long list of ideas that we are now prioritizing and working through with staff. We hope to always build and strengthen the organization, and we welcome your input as members. Let us know if you have some ideas and if a survey comes your way, please take the time to give us the feedback we need. As a physician volunteer, I strive to not only build our organization, but to learn from the experience as well. Physicians are always learning and growing their skill set. Because the

Members Continue To Reduce Overhead Expenses Thanks To Membership SSVMS members renewing their workers’ compensation insurance this year don’t have very far to go to see how their membership can help save them money. Not only are rates going down again this year, SSVMS members will enjoy a special member discount not previously available. The special member discount is only available through Marsh, SSVMS’s sponsored insurance program administrator. The program is underwritten by Employers Compensation Insurance Company (ECIC), rated “A-” by the A.M. Best and Company. SSVMS members insured through Marsh will receive the new discount on renewal. If you are not insured through the SSVMS sponsored Workers’ Compensation Program, call Marsh for information on how you can access your discount. And depending upon where you have your group health insurance, you may be entitled to even larger discounts. See how today by calling Marsh at (800) 842-3761.

retreat was at the beginning of Spring, it was my time to reflect and ponder on the coming year. So I came away with some things to include on my year’s list and things to remember. Remember to Laugh. Bill Sandberg has a collection of video clips that refreshed us all at the retreat with their hilarity. Laughter is indeed healing. Keep to your word. I promised to lead the sessions of the retreat on time if the Board made sure to all be there and start on time. Wow! What a group — not once were we missing anyone when a session started. And so we finished on time or early every session — something we all appreciate, having been at CME sessions that get way off kilter. Get to know people you work with. Having time to get know each other has helped us all build bridges to have hearty discussions and work as a team. We all know this as a “takehome” value to our office lives. I do not need to know every detail of my staff’s lives, but enough to know how to maximize their strengths. Taking time for staff training or fun times is important and will help us care for patients more effectively. Exercise. I was pleased to see that just about all of our physician board took time to walk/jog either in the morning or at our end of day break. Just as we ask our patients to exercise, we need to care for our own bodies. Play and do something you enjoy. Barbara Arnold took in the view at the retreat and did some watercolors at break. (You have seen some of her work gracing magazine covers last year.) Taking time to play with our families is also never to be forgotten in our busy lives. Rest. Some of the board was truly in need of rest, recovering from the influenza outbreak. Time to sleep with no pagers or cell phones is the most wonderful thing when you are physically tired. Reflect, Review, and Plan. Well, that is what a retreat is about. SSVMS will be doing the ongoing work. And my Spring renewal time has me ready with my own list. mepmd@ix.netcom.com



Sierra Sacramento Valley Medicine


Executive Director’s Message

Growth in Group Practice Calls for a Bylaws Change By Bill Sandberg What is the biggest practice change we have seen in our medical community in the last 25-30 years? Chances are pretty good that most physicians who have been around for a while would say that it’s the growth in medical groups (in both size and number). That would be my answer, followed by the growth in managed care. And, of course, the changes are strongly related to each other. This growth has brought about the need to ask our membership to approve a proposed bylaws change scheduled for later this year. But, before we get to the bylaws, we need to understand the makeup of our membership. The bulk of our membership — 71 percent, or 1,181 of our 1,666 active members1 — consists of nine medical groups with 15 or more SSVMS members. The four2 largest physician groups in our membership are: The Permanente Medical Group (TPMG) with 679 members or 41 percent of total membership; UCD Medical Group (UCDMG) with 164 members or 10 percent; Sutter Medical Group with 141 members or 8 percent; and Woodland Clinic Medical Group with 64 members or 4 percent.3 Sutter Medical Group and Woodland Clinic Medical Group strive by policy to maintain 100 percent membership in Sierra Sacramento Valley Medical Society (SSVMS) and the California Medical Association (CMA), and pay the dues for their members. Physicians at TPMG and UCDMG are urged to join and the dues will be paid by their institution. The remaining 29 percent, or 485 members, fall within two categories: 17 groups with 5 to 10 SSVMS members, totaling 107; and 380 in

the solo to small group range of 1–4 physicians. In the group of 380, 56 are in primary care, 21 in obstetrics and gynecology and 303 are specialists. Of the 380, 326 physicians appear to be in solo practice. Existing SSVMS Bylaws establish six membership districts — three in Sacramento County, one each for El Dorado and Yolo Counties and one for The Permanente Medical Group. The Board of Directors consists of 15 physicians, 12 of whom represent their geographical district, except for TPMG which is not a geographical district. The remaining three members of the Board are at large officers, not representing a specific district. Each district is automatically entitled to one director position regardless of total members in that district. Remaining positions are apportioned in each district by the total number of physicians in the district. The proposed bylaws change will prohibit any one membership district or medical group from obtaining a majority of the 12 district positions. Currently, TPMG (District 5), holds five director seats. District 2, bounded in the North by Arden Way and the South by Fruitridge Road, has three director seats. All other districts have one director. Over two years ago, TPMG’s leadership asked SSVMS to find a fair way to prevent TPMG from gaining a majority of the district positions, which has never been a goal of theirs. An ad hoc committee, several Board meetings and a Board planning retreat resulted in a thorough review of many options and choices

May/June 2008




2008 Medical History Lecture Series The Sierra Sacramento Valley Museum of Medical History will present three lectures this year at SSVMS, 5380 Elvas Avenue. On May 21, Pat Schrader will discuss “Physicians: Their Finances, Prescriptions, and Personal Lives From 19th Century Letters.” Original letters from 1830–1860 reveal physicians’ problems and clever solutions. Pat Schrader is a historical researcher specializing in 19th century social history relating to doctors, disease, and death. On August 27, Chris Enss will present “The Doctor Wore Petticoats: Women Physicians of the Old West.” Western towns looking for a local doctor during the frontier era often concluded advertisements with No women need apply. Yet highly trained women from medical colleges in the East took on the post of local doctor in small towns all over the West. Screenwriter Chris Enss has written a book on the fascinating lives of 10 of these women. On November 5, Faith Fitzgerald, MD, concludes the series with her 4th annual “Magical Medical History Tour,” cases of famous people, their illnesses, accomplishments and associated interesting things. Dr. Fitzgerald is an internist and Professor of Medicine and Assistant Dean of Humanities and Bioethics at the University of California, Davis. All the lectures start at 7 p.m., and are free and open to the public. To reserve a seat at any lecture, phone 916/452-2671.



Sierra Sacramento Valley Medicine

to accomplish the task. When all was said and done, the easiest solution was to simply amend the bylaws so that no one district or medical group shall obtain a majority of the district director positions. bsandberg@ssvms.org 1 As of March 2008, SSVMS has 1,666 Active Members, 400 Medical Students and 400 retired members, for a total membership of 2,466. 2 According to the 2007 Healthcare Directory, published by the Business Journal, TPMG has 1,183 physician shareholders in our area; UCD Medical Group has 804; Sutter Medical Group has 161 shareholders and Woodland Clinic Medical Group 48 shareholders. Mercy Medical Group is listed with 100 shareholders. 3 The nine groups and their SSVMS/CMA membership are: The Permanente Medical Group 679 (41%); UCD Medical Group 164 (10%); Sutter Medical Group 141 (8%); Woodland Clinic Medical Group 64 (4%); Radiological Associates 50 (3%); Mercy Medical Group 20 (1%); Sacramento Anesthesia 24 (1%); Pulmonary Medical Group 23 (1%) and Mercy Radiology 16 (1%).


Colorectal Cancer Tests Recent tests promoted by Raley’s and Channel 13 appear to be a step backward.

By Michael J. Lawson, MD There is growing public awareness of colorectal cancer (CRC), partly due to celebrity endorsements. But there has been little public discussion about the scientific pros and cons of CRC screening compared with breast cancer screening as regards risks, false positives and false negatives The current approach to CRC screening has focused on the removal of adenomatous polyps in an attempt to prevent the progression of the adenoma to cancer. There are no randomized controlled studies to show that this is an effective strategy, and the evidence is indirect. In absolute terms, the benefit of CRC screening should be considered before widespread policies are adopted. The risk of dying from CRC is 2.5 percent without screening. This risk may be reduced by 23 percent by biennial fecal occult blood test (FOBT) screening. Therefore, about 98 percent of patients will die of something else. No wonder there are concerns that not enough is being done for basic health care rather than costly preventative measures. Fatal cancers are often those that grow rapidly. There is an advantage to a screening program that provides several chances to diagnose and remove that neoplasm, rather than a once every 10-year test currently recommended by some for screening colonoscopy. Patients have been studied prospectively in dietary intervention trials and have been followed closely with frequent colonoscopies. Evaluation of five large trials failed to yield evidence of any significant reduction in CRC incidence, likely due to more aggressive interval neoplasms arising in subtle depressed lesions not appreciated until they reach a critical mass that can be too late for effective intervention.

The sensitivity of FOBT is only 50–60 percent for one-time use and their impact on mortality is modest. Although the sensitivity can be increased using rehydration, this leads to variability in the reaction with a high number of false-positives subjecting patients to unnecessary further invasive investigations. This invalidates the method as a screening procedure. FOBT testing using the guaiac smear is being replaced in many countries and some US facilities by a quantitative fecal immunochemical tests (FIT) that detects human hemoglobin using sensitive and specific techniques. These provide flexibility for the enduser, as a desired sensitivity/specificity ratio can be selected that is feasible for available colonoscopic resources. The EZ detect test recently offered by Raley’s, in a promotion with Channel 13, is a guaiacimpregnated paper placed in the toilet bowl. The prototype was developed 30 years ago and it suffers from the same problems as FOBT. The test has not been validated in blinded prospective clinical studies and would appear to be a backward step in CRC screening. The gold standard of successful screening methods is to reduce disease-specific mortality. We need to question our current approach and better define high risk patients using more sensitive and specific screening tests. Such risk stratification could be followed by tailored chemoprevention that can result in up to 90 percent reduction of recurrent advanced neoplasms in high risk patients. Michael.J.Lawson@kp.org

May/June 2008




Student Essay Winner

Giving Organs, Giving Life This is the winning essay in the high school competition.

By Celynne Balatbat In spite of all the advances in medical science, an average of 17 people dies each day while waiting for a life saving organ transplant. Millions of dollars have been spent on education and awareness, but a large and growing gap remains between the number of people waiting for an organ transplant and the number of organs available. In each state, the Uniform Anatomical Gift Act requires individuals to make an affirmative statement that he or she is willing to become an organ donor. This current system of informed consent has not encouraged donations, making alternative methods to improve organ donation imperative. To address this shortage, the most viable and logical option is a national policy of presumed consent. In a policy of presumed consent, everyone is considered an organ donor unless they have indicated otherwise on a national registry. Any dead or brain dead person’s organs belongs to the state for distribution and use. Such a policy would increase the rate of organ donation, as evident in nations using this policy, such as Spain, Italy, Sweden, Finland, and other European countries. While there is still a shortage in these countries, European nations have the highest donation rates worldwide. Numerous benefits can be reaped under a system of presumed consent. With the presence of better immunosuppressive drugs, the survival rate and acceptance of organs in transplant patients has increased. This increases the efficiency of using donated organs. Thousands of lives can be saved and countless others improved by increasing the supply of organs. Besides



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obvious gains in the number of lives saved, healthcare costs for many chronic illnesses can be reduced. Research shows that performing a successful organ transplant is cheaper than treating a chronic illness over time, such as in kidney or heart failure. Many of these patients require frequent hospitalization while awaiting an organ transplant and utilize valuable medical resources. Society as a whole benefits from higher rates of organ donation. Additionally, presumed consent lessens the burden on families after a relative’s death. Humans are notoriously passive when dealing with issues not immediately pressing despite future advantages, such as living wills, retirement planning, or even when considering organ donation. Studies have shown that when companies provide a retirement plan with default enrollment and the option to opt out, workers choose to continue using the plan. However, when the same retirement plan is offered without default enrollment, fewer employees sign up to use the retirement plan. Similarly, many people do not decide to become organ donors until a close friend or relative needs an organ, making that person more aware of the need for organs. Without a powerful event to prompt them, the same individuals may not have chosen to become organ donors. A policy of presumed consent would act as a stimulus to get more people to become organ donors. The ideal organ transplant donors are healthy, young individuals who sustain a tragic accident and are brain dead. To ask families to make a decision to donate their loved one’s organs at such a traumatic time adds another burden, often causing them to take no action.


Presumed consent coupled with education, places less burden on the family because the decision has already been made. The policy follows ethical procedures because families still have the ability to decide to not donate their relative’s organs. In addition, other steps would be taken during a person’s life to ensure the protection of their rights. Information explaining presumed consent and the available options could be presented at the same time a person must renew their driver’s license. However, they are simply given the option to opt out, not the added paperwork where they must consent to donating their organs. Alternative methods to increase organ donation include the freedom to purchase and import organs. Experts have also proposed smaller improvements within the current system such as improved procurement procedures. They propose that changing the method of dealing with families after the death of a relative could possibly cause more families to agree to organ donation. However, both alternatives will not accomplish the goal of improving the organ supply, more effectively than presumed consent. The freedom to purchase and import organs

is inherently unfair, putting many people at a disadvantage. Many individuals already struggle to receive equal access to healthcare because of the high cost of insurance. Allowing a market for organs to exist only magnifies this disadvantage. The second alternative may improve the utilization of organs, but will not address the shortage as directly as presumed consent. Unlike these two alternatives, presumed consent can significantly increase the rate of organ donation without influencing access based on the ability to pay. As we struggle with escalating national healthcare costs, finding ways to increase efficiency and provide more cost effective treatment is very important. Transplantation in the correct clinical setting not only improves a patient’s survival, quality of life, and ability to remain productive, but can be more cost effective. However, those benefits can only be attained with an increased supply of donated organs. With a growing population of patients with chronic medical problems who can potentially benefit from transplantation, an initiative such as presumed consent will accomplish important societal goals.

On the Author, the Contest, and Buying Organs Celynne (pronounced like the island, Ceylon) Balatbat is a 15-year-old junior at Loretto High School in Sacramento. Her parents moved from the Philippines when she was an infant. She grew up in Colusa, and enrolled in Loretto High School, commuting daily for several years until her family moved to Sacramento. She is interested in Health Policy, and is considering a career in law, or in her father’s profession, medicine. Her other interests include reading, and golf, and she is active on the Loretto golf team. This is the second annual SSV Medicine essay contest. The decision on best essay was difficult this year; there were more entries and a number of fine essays. The topic was organ transplant. Most authors favored some sort of presumed consent to organ donation, to replace the current system of presumed dissent. No author argued in favor of legalizing the purchase of organs. Therefore the following may be of interest:

According to Benjamin E. Hippen, of the CATO Institute, in Iran the waiting list for kidneys was eliminated after the legalization of organ vending. If a patient needing a transplant cannot find a willing and compatible relative donor, and waits for six months without receiving a kidney from a deceased donor, then the Dialysis and Transplant Patients Association (DATPA) identifies an immunologically compatible kidney vendor for the recipient. DATPA is staffed by volunteers with ESRD and receives no remuneration for matching kidney vendors with recipients. Only Iranian citizens can act as donors and recipients. Vendors are paid in two ways: The Iranian government provides a fixed compensation to the vendor of approximately $1,200 plus limited health insurance coverage. The vendor also receives remuneration either from the recipient or from one of a series of designated charitable organizations, usually between $2,300 and $4,500. — J.L.

May/June 2008




Remembering the Late American River Hospital By John M. Reed, MD American River Hospital admitted its first patients in 1962, and many thousands were cared for there. In 2000, American River Hospital closed its doors for good. The building and surrounding 15 acres were sold to a real estate developer who demolished the building, and built about 50 very nice homes. Today, the area is a pleasant residential neighborhood. But sadly for those of us who spent our professional careers at American River, not a trace or a reminder of the old hospital remained. This has now been corrected — we have placed a commemorative plaque on the site where the hospital stood. It is not hard to remember 1962. The world had just dodged a nuclear bullet in the Cuban Missile Crisis, and the Beatles were the rage. In the medical sphere, designations like intensive care unit, oncology unit, discharge planning, home style delivery, and ambulatory surgery had yet to appear. The 38 years of American River Hospital’s existence coincided with the most explosive growth and change in medical practice ever. The hospital accepted and met this great challenge. By the late 1950s, growth in the Carmichael and north areas of Sacramento made it apparent that a suburban hospital was needed. Many physicians maintained offices in this region, and the downtown hospitals were often

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Sierra Sacramento Valley Medicine

short of beds. I’m told that traffic was not much better than today! So a group of seven physicians bought a 10-acre parcel in Carmichael and started planning their new hospital, American River Hospital. Eventually, it would grow into a major medical facility offering the best of care available. The challenge for a suburban hospital is unique. It does not have the major financial resources of metropolitan hospitals, and it does not have the luxury of being the only facility available, as in small towns and rural areas. Yet it is judged and evaluated by the same standards as the larger central hospitals — and properly so. American River Hospital always accepted this, and became a major part of the Sacramento area medical community. In those days, unlike now, almost all physicians belonged to SSVMS. Over the years, American River Hospital physicians participated fully in all the society activities, including many committee chairmanships and as CMA delegates. Between 1962 and 2000, nine society presidents were physicians with strong ARH associations. At 180–210 beds, with a peculiar physical plant and in a very residential neighborhood, American River Hospital was nothing short of remarkable. Usually, lists are boring. But, in addition to all the usual services expected in any hospital, here is a partial list of what American River offered at her prime: intensive care unit, cardiac care unit, psychiatric unit, pediatric unit, oncology unit, cath lab, pulmonary lab, GI lab, rehabilitation unit, ambulatory surgery, obstetrical service with 30,000 plus deliveries,


home-style obstetrical service, nuclear medicine, CT scanning, geriatric unit, total joint replacement surgery, discharge planning for home care — and much more. Always certified by the Joint Commission, as medicine forged ahead with new knowledge and technology, American River Hospital embraced it and kept pace. American River Hospital was lucky with its owner/management partners. The physician group sold to the Eskaton organization in 1968; later in 1986 there was a merger with the Alta-Bates Health System. Mercy Healthcare Sacramento became the owner in 1991, until the hospital was closed in 2000. Of course there were disputes and tensions, but they all provided sound, even visionary, leadership. For example, the addition in 1972 allowed for a modern laboratory, radiology unit and emergency room, all essential for subsequent growth. By 2000 though, the continuing explosion of technology and clinical techniques, the new and ever changing reimbursement systems, and the perpetual search for funding, all took their toll on the smaller suburban hospital. Clearly, consolidation of the new expensive services and equipment was necessary. So American River Hospital closed its doors, after 38 years of service. Of course, the physical plant, superb equipment, and state of the art technology are essential for the modern hospital. But as everyone knows, the key to excellence is the quality of the people who work there. And in this area, American River Hospital was unsurpassed. A sense of cooperative professionalism was apparent. There was a continuous motivation toward improvement and progress, and a sense of a close knit team working together. How this feeling came about is unclear, but it was always there, and newcomers soon became a part of it. And it applied to all — physicians, nurses, technicians, clerical staff, administration, maintenance — all. When we began contacting former employees about the memorial project, this is what we heard, again and again: “It was the best job I ever had!”

The commemorative monument was installed recently. On June 7, from noon to 3 p.m., we plan a dedication celebration. Everyone is invited, especially if you worked there, were a patient there, or were born there! The monument is located on Gibbons Drive, just across from Gibbons Park, actually on the former American River Hospital property. Please come! johnreed@omsoft.com

A commemorative plaque marks where American River Hospital used to stand. From the left are: Harvey Goldberg, MD; Mary Goldberg; Barbara Drysdale, RN; Patricia Pratt, RN; John Reed, MD; Dawn Reed and Diana Lenon.

May/June 2008

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Voices of Medicine Re-scripting medicine, successful Electronic Health Records, a plea for the hearing impaired.

By Del Meyer, MD

I am happy being a doctor, I am well compensated, I am… Kate McCaffrey, DO, discusses “Re-scripting Our Profession” in the President’s Message column of The Bulletin of the Humboldt-Del Norte County Medical Society, March 2008: I have been re-scripting my self-talk lately. It helps being around optimistic medical students who aren’t jaded by the storms of practice and the insurance sharks. Instead of saying, it’s hard practicing medicine I say to myself, I am happy being a doctor, my patients and colleagues respect me and I am being compensated well for my efforts and expertise. I have committed to re-scripting my thoughts for one month. As a scientist, I like to test my hypotheses. I’ll let you know how the rescripting goes and what changes, if anything! On the larger scale, I think our profession needs to re-script itself. The public still has the highest regards for doctors. When we complain, we erode this reputation. If any of you has had the unfortunate experience of being injured or ill, you know how important the opinion of your physician can be… As the Touro University medical students arrive in Humboldt and Del Norte this June, I will think about how I am portraying our profession with my words. Yes, it is broken, but am I living in the problem or in denial or am I living in the solution? Am I calling and emailing my representatives? Am I involved locally? I will become aware of my version of the torch I am passing on to the next generation. How can I involve them in the local and state political process early in their careers? What hope and reassurance can I give them that they still entered one of the

most important and revered professions in the world?... The entire column can be read at www. humboldt1.com/~medsoc/images/bulletins/ MARCH%202008%20BULLETIN_for%20web.pdf

Electronic Health Records “Nine Strategies for Successful EHR Adoption” by John C. Whitham and Steve Davis, DO, appears in the January 2008 issue of Vital Signs, published by the Fresno-Madera Medical Society and Kern County Medical Society: …If you are going to implement an EHR system, following are 9 guidelines to managing the art of successful system adoption: 1. It is imperative to minimize the impact to a physician practice’s cash flow…. Regardless of how well the system works or how spectacular the other components are, if income to the practice stalls, the physician’s perception is that the whole implementation is a disaster. Practices will always assume it is the implementer’s fault, no matter the circumstances… 2. Include an evaluation of the practice’s billing, business, and clinical processes and practices in your preimplementation evaluation. Each practice has its own unique processes and business and clinical practices, and the practices need to understand that a new system will not allow them to always do things the way they have always been done... 3. Make sure that the practice’s lead physicians are “leading” staff and other physicians to effectively manage change and that their motives are understood. Each practice needs to

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We sufferers are able to recognize that hearing aids do help, but they are not a panacea, particularly in areas that have poor acoustics or are occupied by large crowds.

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have good leadership to get the rank-and-file to follow and be enthusiastic… 4. The practice management system is a tool for billing, not a system that “does” the billing… 5. If an office is unreliable and difficult in the training and implementation process, then they will be unreliable and difficult in using the new system… 6. Find the reliable and enthusiastic individuals within the practice to be the superusers for the practice.… 7. Allow adequate opportunities for “practice” between training and go live… 8. Develop a post-implementation followup process for both the practice management system and the electronic health record… 9. Understand that the electronic health record implementation is difficult… John C. Whitham is a partner who chairs the Clinical Integration Practice in the JHD Group. Dr. Steven Davis is medical director of Physician Associates Clinical Integration Services (PACIS), and a Board Member of Physician Associates, an 800-member IPA based in Pasadena, California. Details of the nine strategies appear at www. fmms.org/pdf/Jan08_VS_FINAL.pdf

Can You Hear Me Now? Basil Meyerowitz, MD, who is hearing impaired, writes “A Plea to the Hearing Intact: Advice to the Auditory Challenged,” in the San Mateo County Medical Association Bulletin of March 2008: …Those that don’t have this disability often don’t recognize our plight and do not try to alleviate the problem…and some treat the hard of hearing as if they are intentionally plotting to not hear (although, in some circumstances, it may be an advantage not to hear some things, but this is rare indeed). We sufferers are able to recognize that hearing aids do help, but they are not a panacea, particularly in areas that have poor acoustics or are occupied by large crowds. And sometimes, hearing aids work a little too well! For example, wind noise is greatly enhanced, and raindrops falling on an unfurled umbrella sound very

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loud indeed. A hearing aid’s basic principal is to maximize sound waves as they reach the ear. However, hearing aids accentuate ALL sound waves (even extraneous ones), which frequently overwhelm the voices of those one wishes to hear. It is possible to adjust one’s hearing aids to try to pick up selected sounds, but this is difficult to engineer: For example, when sitting in a restaurant, background noise is impossible to filter out. At public meetings or lectures, if the sound system is good — although most often it is not — it is relatively easy to follow the speaker. However, some lecturers and lay speakers are not always familiar with the proper use of microphones. Moreover, even in normal discourse, too many people are careless with their speech. A good many speak softly or indistinctly; some speak very quickly without enunciating their words. At mealtime, speech is often garbled by food in the mouth of the speaker… Tips for the Hearing Impaired… When conversing in person or by telephone, it’s a good idea to immediately announce that one is hard of hearing and to request the speaker to please speak louder and a little slower. Conversations on cell phones, even in the best of circumstances, are often awkward. Instead, request using a landline phone. A speakerphone permits the listener use of both ears at the same time… There are innumerable web sites that offer advice to the hearing impaired…or for those that want or need to have a sensible dialogue with somebody that is hard of hearing. One that I found… [is ] The Hearing Exchange (www. hearingexchange.com)… Perhaps my plea should be directed to unite those of us with hearing problems (and it appears there is no shortage of fellow sufferers) instead of those that do not. We need to have our disability taken more seriously. The complete article is at www.smcma.org/ Bulletin/BulletinIssues/March08issue/BULLETIN0803_Meyerowitz.pdf DelMeyer@MedicalTuesday.net


Global Health Activism Among Medical Students By Shabnam Hafiz, MS III, UC Davis School of Medicine As the Sacramento Convention Center flooded with global health advocates, on April 3-5, I was not surprised to see the rising interest in today’s medical students and physician leaders in global health, as awareness of the scarcity of healthcare in third world countries becomes more apparent. The 17th Annual Global Health Education Consortium was hosted here in Sacramento with the support of the UC Davis School of Medicine and led by its founder and conference chair, Anvar Velji. The conference was a great success and most impressive features were the idealism and enthusiastic participation of physicians-in-training — medical students. It was a testament to the desire in so many of us seeking change in the status and access of medical care around the globe. When I say “us,” I speak for over 300 medical students among 500 participants who came from across the country and around the world to share their interests, projects, and innovative ideas; their attempts at changing the face of health care on a global level. Many physicians who have long led the movement were taken aback by the energy of the students; they had never experienced such an impressive and widespread involvement from any part of the medical community. At the conference, students not only heard from experienced and respected physicians in the field, but also shared their own experiences during panels with their peers, and through poster presentations covering a broad spectrum of matters that make up “global health.” The level of scrutiny in evaluating and managing healthcare in various regions of the

world made clear the importance of what we are trying to do today in the field of global health. At the 17th annual conference, “ethics” was the main theme behind the discussions. Many students shared their concerns that global health not be simply “medical tourism”; certain popular or attractive countries have gained popularity for project destinations when so many other regions of the world have far more desperate needs for outside help. Several students had evaluated bigname programs such as Unite for Sight as to how and where they deliver care and whether or not it was truly serving a population still in need. I was surprised to see the degree of analysis that medical students used in evaluating the justification for and quality of programs. It seems like a major shift from simply deploying projects to ensuring that quality programs are being established with meaningful and long-lasting outcomes. Rohan Radhakrishna from UC Berkeley presented his award winning project in Northern Uganda following the “night commuters,” children who sequester themselves each night to avoid being captured and conscripted or worse by armed gangs. His focus was on why they continued to fear their homes at night even after violence had subsided in their region. Not only did he evaluate the children, he returned a year later with a plan of action that would address the needs of these children and help resolve this particular problem in Uganda. This is only one example of what is being done by the global health community, among

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dozens we heard about at the conference. It no longer suffices to travel to a region, do some preliminary research or provide temporary care without having a plan for resolution. Projects like this are happening all over the world from Kazakhstan to Darfur to our backyard here in Sacramento; students are sharing their thoughts and innovations regarding how to assess the situation, set up a project, and evaluate the outcome, how to surmount obstacles. Overall, I was impressed by the attendance of so many students from around the country and their enthusiasm in the advancements of global health. The conference opened my eyes to the endless aspects of healthcare being addressed in the local and global community and the importance of establishing programs that will have a lasting impact. It is refreshing to see everywhere, and here at UC Davis, students addressing global health problems. I hope that we will continue to pave the way as we try diligently to close the gap in healthcare across the world. I hope we continue to acknowledge that healthcare is an important concern in our country but also continue to advocate for its need outside of our borders as well. shafiz@ucdavis.edu

Medical students involved in global health and hundreds of other dirt-under-the-nails global health activists were brought together by the silent plight of millions of the earth’s people. Fifty student global health projects were the subject of displays and discussion. Three days of speakers, too many to list individually, were an eclectic collection of luminaries including UCD’s Claire Pomeroy, Joe Silva, Faith Fitzgerald (no one breathes when she speaks!), Fred Meyer, Sergio Aguilar G., Michael Wilkes.and Blanca Solis; Permanente Medical Group CEO Robbie Pearl; and former minister of health for Mexico, Julio Frenk, now the holder of the Gates-Buffet-Slim philanthropic purse strings. In a classic multispeaker and discussion format they spoke to and with participants whose vision and activities are focused on the world. Despite the stellar collection of speakers involved and experienced in global health, the most impressive feature of the conference was the students. Their enthusiasm, cultural, linguistic, and personal diversity, was new DNA to the body of global health. Their hard-headed idealism was evident in their projects, faces, and their personal effort to explore and to move the medical earth beneath our feet. Albert Schweitzer and Paul Farmer, move over; there are those who will join you. 17th Annual kudos to Dr.Velji, UCD, Kaiser/PMG, and Karen Lam of the Global Health Consortium. — J.L.

Health Notes An Outbreak of Chickenpox From February 12 to April 4, 68 cases of chicken pox were reported, which began with an outbreak in two schools. Most cases were mild, in children who received only one dose of the varicella vaccine. It is recommended that ALL children receive two doses of varicella vaccine by 6 years of age, or older, if there is no evidence of immunity to the disease. During a varicella outbreak, persons exposed to the virus who have received only one dose of the vaccine should receive a second dose if the appropriate interval between the two doses has elapsed. The appropriate vaccination interval since the first dose is 3 months for children 12 months of age to 12 years and at least 4 weeks for those 13 years of age and older. For recommendations on preventing chicken pox, please visit

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http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf Chickenpox is not ordinarily reportable. However, for the next six months, please report all Sacramento County residents with chicken pox to the Sacramento Division of Public Health. This includes children and adults with mild disease, not just cases resulting in hospitalization. You may use the Confidential Morbidity report or report on line using the Sacramento County WebvCMR: https://www.saccmr.net/crm/login.aspx If you have any questions or if we can be of help, please call the Sacramento County Communicable Disease Control Unit at (916) 875-5881 or the Sacramento County Immunization Assistance Program at (916) 875-7468. — Glennah Trochet, MD Public Health Officer, Sacramento County


Four Related Posits on Universal Health Care 1 “The U. S. electorate is neither willing to pay for universal health care, nor to accept rationing of health care.” Agree 50, Disagree 23 2 “Most politicians are neither willing to risk losing an election through truth telling, nor to do whatever is necessary to provide universal health care.” Agree 63, Disagree 5 3 “The nation is neither able to pay the economic costs of universal health care, nor to initiate change that could lead to universal health care.” Agree 36 Disagree 35 4 “Truly universal health care will never be achieved by design or by a ‘revolution in health care’. But it will evolve slowly and inevitably as a consequence of technologic change.” Agree 32, Disagree 48

We leave to the reader any inference to be drawn from the numbers above. They don’t add up because many responded to one or two posits. We think you will find the commentary below to be particularly cogent and interesting. Recall that our purpose is to encourage dialogue among members, rather than to conduct a poll. Posits do not necessarily reflect the views of Sierra Sacramento Valley Medicine, the Medical Society, or Board of Directors. “The concept of ‘rationing’ healthcare would necessarily include a reduction in available options and freedom of choice. The public would need to be educated re the ethical concept of distributive justice, and willing to accept the least expensive diagnostic and therapeutic options that are effective. Also, mandatory preventive health measures and screening measures for early signs of disease or disease risk, as well as regulatory or financial consequence for high risk behavior, might be necessary for a universal health plan to work. I believe that what the average person wants as ‘universal healthcare’ is care that is immediate, on demand, using the most expensive technology and medications, cost free, risk free, and with no negative outcomes. It would take a massive educational and public relations effort

to gain any degree of public acceptance of what is needed. I don’t think that this society is ready for it.” — Elliot Mazer, MD “I think that true universal health care will occur only if there is a mindset shift…on what we consider ’universal health care.’ We cannot afford the expensive universal health care that all of us desire with coverage of every medical condition, at any age, with any prognosis, and any… treatment. We need to decide as a nation to offer coverage of some conditions and set appropriate guidelines on treatment and then we can we afford (as a nation) some basic level of ’universal health care.’ — Sangeeta Marwaha, MD “My reply to 1) I think that the electorate is willing to pay for health care as long as they know what they are getting and what they need to do about it. A free handout should be removed. An innovative way to pay back to the system must be created. A portion of the taxes should be apportioned for this and it must be universal to the citizenry. 2) The word is ’most’ [politicians].… Some have addressed the issue no matter how unpopular this may sound. 16 years ago Hillary Clinton…attempted to do so, but was beaten down…, she did something that a majority of politicians cower away from, and [that] does indeed show some greatness of May/June 2008

“We cannot afford the expensive universal health care that all of us desire with coverage of every medical condition, at any age, with any prognosis, and any…treatment.”

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“And when it comes to paying for health care, people want to eat steak and pay for hamburger.”

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mind. Look at the history of England’s William Wilberforce; he pushed health care changes and accomplished it, he was a politician and did away with a lot of social ills way before the USA even thought of it… 3)…If we put avarice aside and see if we can accomplish some common good collectively, we can do it. 4) Technological changes do not always solve problems; they sometimes, and presently more often than not, complicate things and make situations worse…” — Elisabeth Matthew, MD “When the system crashes and burns we will be appalled to see what emerges as the next system.” — Tom Wilkes, MD “I believe we first need to decisively replace the predatory, personal injury…system with a responsible…justice system and then turn health care back into an area where the individual carries a substantial part of the responsibility for his own health care before any consideration can be given to a successful universal health care transformation.” — William Johnson, MD “I think cost control should be put in the hands of the patient.” — Richard J. Frink, MD “I never believed that healthcare was a ‘right,’ but I do believe the government has a responsibility to take care of its citizens. If Canada and Britain and other countries can do it, we should [too]. I like the idea of the 4th statement, but it sounds a lot like a plot for a science fiction novel.” — Ronald Rodgers, MD “It would be difficult to enact universal health care in this country because of all the competing interests and lobbies that want to keep the system the way it is and that make it seem as if the ONLY problem with our current system is that there is not enough money to cover more people in it.” — Teresa Flores, MD “I think we’re getting closer to being able to make the necessary changes but unfortunately not there yet. We’ll see if this election helps at all.” — Jason Flamm, MD “A recent Harris Poll (12/07) commissioned by the Mayo Clinic Health Policy Center found that 85 percent of American adults ‘are opposed to paying more taxes to achieve health care reform.’ Unfortunately,our healthcare ‘nonsystem’ may have to deteriorate even further before

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we, as a nation, will be willing to make any substantial or meaningful changes.” — Ralph Koldinger, MD “I do not think universal healthcare is a worthy goal…. [It] is often delayed or substandard in quality, as demonstrated in other countries where it now exists. I have no problem with people who pay for their insurance or get it through work having access to better health care. It is a motivator to strive for success which is the basis of a free market economy in the first place. But from a business standpoint, it is ludicrous to not give universal preventive healthcare, which is far cheaper, and to then absorb the cost of much more serious acute problems…” — Kelly Sharrar, MD “I expect that the health care ‘system’ will come under more and more pressure as the ’age wave’ crashes over our society;…baby boomer politicians, and their constituents, as they face the challenges of caring for family members who are living longer than anyone expected, and who are saddled with chronic medical conditions that are equally unexpected.… I hope that this crisis is not shoved out of sight simply by shipping patients and money to nursing homes; instead I hope that more and more families learn first-hand about our broken health care system, and insist on change.” — Alfredo Czerwinski, MD “To my concern, the federal government will impose universal health care upon us, without much input or consultation.” — Norman Label, MD “In health care policy, we can trade off between quality, access, and cost. We have very high quality health care [yet] making it available to everyone would be incredibly expensive. Many people are appalled at the concept of rationing health care, little realizing that it’s that or ration by who can afford what. And when it comes to paying for health care, people want to eat steak and pay for hamburger. They want up-to-the minute health care delivered by a host of superbly trained providers, with cultural sensitivity and fluency in their language, using the very best diagnostic and treatment tools and medications available...for 49 cents. If we


took the money that we now spend on what we could call ‘administration’ — insurance plan administration, utilization review, health plan profits, multi-million-dollar salaries for health care executives — and added in the money we waste in other ways, we might be able to afford a basic plan for everyone. Paying for universal coverage would be easier if we took…prevention more seriously.” — Janet O’Brien, MD “The government is already responsible for over half of all health care costs. Extending it to the remaining population would not be a stretch.” — Sidney Scudder, MD “Universal health care is an excuse for another governmental boondoggle. One has only to look at any federally run program to see the consequence of such a decision. I can look back to my days at the VA hospital system to see how badly managed medical care will be. Our society has to change its attitude about health care as a ‘right’ not covered in the Constitution and look at it as a service provided by competition which will provide more options to the consumer through more, not less providers.” — Michael Robbins, MD “The first mistake is to assume that universal health care is desirable. I do not agree that all people should have access to ALL services. This country has some serious issues to deal with in regards to rationing scarce resources like healthcare. Technology is the number one cost driver…. Everyone assumes that it is a right to have access through the latest technology, yet we are not allowed to interfere or judge whether unqualified/ unsuited people should continue to have children…. Doctors’ pay should not suffer to make ends meet. Let the medical technology companies and drug companies shoulder the burden of rising healthcare costs.” — Eric Schwartz, MD “Universal health care is essential…. Every health care provider and employee in the US healthcare industry should be actively supporting universal…health care. There is already more than enough financial resources…. It is simply mis-distributed with…inappropriately funding over charged care for those with access while rationing access to others through lack of professional resource availability or unreason-

able charges discouraging user access. Universal ‘Insurance’ should not be considered synonymous with Universal Access. While it can be secured with universal coverage, there are prefunding options that do not require private insurance company regulation to assure universal access.” — Michelle Famula, MD “Until the public (and politicians) understand that they are already paying the cost of universal healthcare without receiving the benefits, it will be impossible to achieve universal coverage and access. There exists a significant deficit of knowledge on how health care in this country is funded and provided.” — Kathy Gaspar, MD “We clearly need universal health coverage as the system we are using at present is not working. [But] I do think that we will achieve this...” — James Martel, MD “At the present time the challenge is not universal health care, but the gross inefficiencies that now exist in the care we deliver,…making the costs unsustainable. We cannot afford UHC. Whether we could effect the necessary changes or not is unanswerable, the bottom line is we will have to. Technology is only one part of the equation.” — Gary Fields, MD “Although I agree with the first part of #4, I disagree that technologic change will cause the evolution. My sense is that the system is depleting its financing right now and as more and more of the ‘haves’ of our society discover this through injury to themselves or their loved ones, they will slowly begin to accept/demand change.” — Bette Hinton, MD “A superb review of the problem and potential solutions can be found in a recent book by Shannon Brownlee, “Overtreated”. As she clearly documents, we can afford it if we are willing to change the perverse incentives in our current compensation system.” — Stan Gambrill, MD “…I think…many politicians agree with #4 and therefore #2 would not apply. I believe the U.S. cannot afford universal health care and that rationing of care is unacceptable. We need health insurance companies competing nationwide to lower costs and evolve to low cost policies for young health people.” — Stephen R. Shapiro, MD

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“The government is already responsible for over half of all health care costs. Extending it to the remaining population would not be a stretch.”

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Living Longer — Hospice and Palliative Care There is a widely held belief in the medical profession and in the community that hospice and palliative care hasten death. Is this belief true?

By James McGregor, MD, Medical Director, Sutter Visiting Nurses Association and Hospice, Roseville and Sacramento The National Hospice and Palliative Care Organization (NHPCO) reports that, based on surveys, the majority of Americans would prefer to die at home. In contrast to this preference, only 25 – 30 percent actually do so. Why this discrepancy? Hospice is intended to help patients die at home with love and dignity. Many physicians say that they are reluctant to refer patients to hospice because they do not want the patient to lose hope or do not think the patient is “ready to die.” There is a widely held belief in the medical profession and in the community that hospice and palliative care hasten death. Is this belief true? A retrospective study in 2007 showed that enrollment in hospice extended life by 29 days compared to other more aggressive treatment.1 The study reported longer lengths of survival in four of the six disease categories studied. The largest difference in survival was observed in congestive heart failure patients, where the mean survival period jumped from 321 days to 402 days. The mean survival period was also significantly longer for hospice patients with lung cancer, 39 days, and pancreatic cancer, 21 days. More than 98 percent of Medicare decedents spend at least some time in the hospital the year before death and between 15 and 55 percent have at least one stay in the ICU in the last 6 months of life.2 Is this the most appropriate care?

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In this day of escalating health care costs, what is the best use of health care dollars at the end-of-life? Another 2007 study highlighted that the use of hospice decreased Medicare expenditures during the last year of life by $2,309 per hospice user.3 The maximum cost reduction was for cancer patients who used hospice services for the last 58–103 days of life (about $7,000). Unfortunately, NHPCO reports that the average length of stay in hospice is less than 60 days and the median length of stay is 26 days. Furthermore, approximately 30 percent of patients enrolled in hospice die in less than 7 days. Beyond traditional hospice care, inpatient palliative care consultation leads to lower costs and decreased length of hospital stay.4 At Sutter Medical Center in Sacramento, we have also shown improved patient and family satisfaction after interventions by the Palliative Care Service compared to those who do not receive the service. Physicians may not refer to hospice and palliative care because they are afraid of taking away the patient’s hope. The question arises then: what hope is offered by pursuing aggressive therapies that may in fact shorten life and increase suffering? It is false hope. Hospice and palliative care offer real hope to patients and their families by providing: • Pain and symptom management to minimize suffering at the end-of-life.


• Emotional support to help patients and families address their fears and worries so that life can be meaningful up to the end. • Family and caregiver education and resources. • Assistance with activities of daily living. • Spiritual care to help patients and families explore the meaning and purpose of life and death. Some physicians may be reluctant to refer because they are concerned about losing control of their patient, sometimes after very long relationships. When a patient elects to receive hospice, he or she designates an “attending” physician. If this physician is not the hospice medical director, the attending physician’s services continue to be covered by Medicare Part B, which pays for outpatient care. Thus, the attending physician (unless a hospice employee) bills for professional services in the usual manner, independent of the hospice benefit and the local hospice program. In addition, the attending

physician, in consultation with the hospice medical director, continues to provide services to the patient. Rather than being reluctant to refer patients to hospice and palliative care programs, physicians should partner with these services to provide the best care possible to patients facing a life limiting illness. I challenge you to look at your own practice, your own beliefs, your own comfort with death, and your commitment to your patients. How would you answer the question: Am I providing the most appropriate care? McGregJ@sutterhealth.org 1 Connor SR et al. Comparing hospice and non-hospice patient survival among patients who die within a three-year window. J. Pain Symptom Manage 2007; 33: 238-246. 2 Dartmouth Atlas of Healthcare, 1999. 3 Taylor DH Jr. et al. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science and Medicine, 65 (2007) 1466-1478. 4 Ciemins EL et al. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med 2007; 10: 1347-1355

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Shall We Tango? By John Loofbourow, MD Tango, like most art forms is not static; it is alive. There are modern and professional iterations. Yet these differ from the original classical Argentine tango. Perhaps, in some ways the new is “better”; where art is concerned, who is to say? Nonetheless, the tango in its classic form holds an enduring appeal that is again being resurrected as a unique combination of poetry, music, and dance. Today, even in our little threecounty area, one can dance every evening of the week away somewhere to the sound and sentiment of Argentine tango. There are from two to five milongas (dances) and/or classes nightly.1 Why has the tango lasted so well over time? And why has it reappeared here and now? Every art form springs from the loins of a people. It begins, and develops, in the womb of a time and place. It is nourished by the placental blood of a culture. It is born, and grows to maturity within a generation or two. It can be preserved, or reborn, but is never recreated. From time to time the world reinvents an art form, yet later generations inevitably fail to reproduce that original unique expression of the inexpressible. No one faithfully recreates, for example, the feel, the power, the essence of Pericles, Michelangelo, Beethoven, Puccini, or even Hank Williams; each was, and is, unique. As I write this today, new and never to be recreated art is developing everywhere, even though the public and the creators themselves are unaware. But why resurrect the Argentine tango here; and why now? First, dancing tango unites people rather than isolates them. The old expression “It takes

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two to tango” is apt. In classic Argentine tango there is no long distance dancing. No solos. It is a dance for and by two people who attempt to communicate physically and emotionally, to dance as one. It requires an invisible and intimate connection between the dancers, a sensibility and sensitivity, each for the other, while they dance. Dancers often put on what I call a ”tango face” — a focused, intense or concentrated look; idle chatter and joking is not common, except between sets. Second, tango is egalitarian. It is perfectly attuned and accessible to all ages and conditions, not confined to the young, the beautiful, the lean, limber, athletic, or even the trained dancer. Nuevo Tango or professional tango ballet skills are inappropriate for classic milonga or tango dancing venue where the dance floor is too limiting or crowded. No. Classic tango is for the ordinary, and allows us to express the extraordinary. A middle-aged couple, a college student and a widow, a pair of McDonald’s clerks, all find themselves dancing together and trading partners as is traditional at a lesson, or a pracitca or a milonga. The short leather-skinned pair under a streetlight on the nighttime streets of Bariloche are one with the wealthy couple at a Luis El Suave Sacramento Waldorf School practica on a Wednesday evening. Third, tango can be sensual but not usually particularly sexual. It has the aura of sexuality but, like Flamenco, in the flesh it is usually too serious, and too focused, to be very sexually arousing. Fourth, dancing tango is not about Self. The lyric is not about the dancer or even the dance, but about universals: life, loss, love, revenge, privation, resentments, age, death, and yearn-


ing. The poetry embedded in classic tango is particularly powerful, though the message, if it should be called that, can be perceived readily without language. Fifth, it invites ordinary people to share music, movement, emotion, and lyrical poetry, in a cooperative physical interaction; each dance is a little creation by two people. The dancers don’t focus or generally follow a beat or an insistent pulsating rhythm. They dance to the underlying, often contrasting song and feel of the music itself. Each dance is therefore open to infinite interpretations of the moment. Each couple creates a different dance that forms and dissolves like a summer cloud, and then is forever gone. Tango is here in Northern California today because so many people find

in it something that tells of the numinous of existence on this little earth in this little time. And it is uncritical; unthreatening; and escape; just plain fun. The 1977 British film, Tango Lesson, by Sally Potter is an introduction to tango. I recommend it. Yet, in the movie the dancing itself is often so beautifully and professionally done that it doesn’t convey the broad appeal to the non professionals who just dance. To understand why we do so, one must simply do it; you will be in good company. john@loofbourow.com 1 A continually updated listing of tango venues and events in this area, including all of Northern California, can be found online at www.lists.sonic.net/mailman/listinfo/sacramentotango

“The CEO of the HMO is on Gurney 5. I want you to call him ‘customer’ as many times as you can…” By William Nakashima, MD

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A Disingenuous Debate on Health Care Policy By David J. Gibson, MD and Jennifer Shaw Gibson The politicians’ approach to the health care policy debate during this presidential primary season has devolved into little more than pandering and demagoguery. In a previously article, we cited the now defunct candidate John Edwards using the death of 17-year-old Nataline Sarkisyan to further his political agenda.1 Sarkisyan died on December 20, 2007, after Cigna initially denied her coverage for a liver transplant, citing insufficient evidence that the procedure would be safe or effective. Jeffrey Kang, Cigna’s chief medical officer, observed that, “it is highly unlikely that any health-care insurance system, nationally or internationally, would have covered this procedure.” At the time of her death, Edwards advocated a government-run health plan open to all Americans, rather than the current private financing system. Implicit in Edwards’ posturing, a government system would have paid for this and all other experimental procedures. The public was presented a false promise. No government-based plan anywhere in the world lives up to such a grandiose promise. In a more recent example, Senator Hillary Rodham Clinton of New York frequently featured in her campaign stump speeches the story of a health care horror.2 At multiple rallies, she told the story of Trina Bachtel, a 35-year-old who managed a Pizza Hut. This woman was presented as a young, uninsured minimum-wage worker.

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Clinton would repeatedly say, “The story haunted me. It hurts me that in our country, as rich and good of a country as we are, this young woman and her baby died because she couldn’t come up with $100 to see the doctor.” Trina Bachtel did die last August, two weeks after her baby boy was stillborn at the O’Bleness Memorial Hospital in Athens, Ohio. However, Ms. Bachtel was under the care of an obstetrics practice affiliated with the hospital. She was asked to pay the clinic $100 in previously owed billings but was not refused service. Furthermore, she was insured when she sought service from O’Bleness Memorial Hospital.2 Since Ms. Bachtel’s baby died at O’Bleness Memorial Hospital, the story implicitly accuses that hospital of turning Ms. Bachtel away, However, the O’Bleness health care system did treat her, both at the hospital and at the affiliated River Rose Obstetrics and Gynecology practice. O’Bleness Memorial Hospital has now gone on the record. “We reviewed the medical and patient account records of this patient,” said Rick Castrop, the health system’s chief executive, and any implication that the system was “involved in denying care is definitely not true.” Her campaign acknowledged that Clinton frequently retells stories relayed to her by third parties. However, vetting them was not always possible. In this case, a spokeswoman for the O’Bleness Memorial Hospital said the Clinton campaign had never contacted the hospital to check the accuracy of the story. The Clinton campaign subsequently withdrew this story from future campaign speeches but did not apologize for


prior inaccuracies. Neither of the above would pass muster with the most junior reporter in a credible news organization. Why is this deliberate use of unverified information so dangerous? It produces an inaccurately informed voting public that becomes biased against the current private based system. Comparing an imperfect present system with a “perfect� future system is counterproductive. This disinformation influences the full spectrum of the voting public. For example, in a 2004 survey in Archives of Internal Medicine, more than half of U.S. doctors indicated that they favor switching to a national health care plan and less than a third oppose the idea.3 Of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program, while 32 percent were opposed. These data represent a dynamic change from past findings. For example, in a 2002 survey by the same authors at the Indiana University School of Medicine, 49 percent of physicians supported national health insurance and 40 percent opposed it. How well does a single payer system perform when compared to our current system? Furthermore, how happy will American physicians be if such a single payer system is adopted? The answer to these difficult questions depends upon the data used to reach an opinion. Generally positive outcomes data for the Canadian system relates to overall system costs not outcomes. Furthermore, how would doctors feel about working within a national health care plan if they understood that most of the cost and, therefore, the savings differentiating the Canadian and the American systems relates to differentials in labor costs? Canadian health care workers (including doctors) earn approximately half the amount their counterparts earn within the American system. The following data, relating to performance and outcomes, are taken from a 1991 National Bureau of Economic Research study.4

The percent of middle-aged Canadian women who have never had a mammogram is double the U.S. rate. The percent of Canadian women who have never had a pap smear is triple the U.S. rate. More than 8 in 10 Canadian men have never had a PSA test, compared with less than half of U.S. men. More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the United States. These differences in screening may explain why U.S. cancer patients do significantly better than their Canadian counterparts. The mortality rate for breast cancer is 25 percent higher in Canada. The mortality rate for prostate cancer is 18 percent higher in Canada. The mortality rate for colorectal cancer among Canadian men and women is about 13 percent higher than in the United States. Furthermore, among senior citizens, the percentage of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the United States. The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the U.S. rate. The advantage that any underperforming single payer system has over the private competitive model is the ability to dictate the fee providers can charge for health care. Furthermore, such a system can influence utilization by limiting the supply of high cost services. Canada limits the availability of diagnostic and therapeutic modalities along with the availability of hospital beds. In the future, we may well discover that a single payer approach to financing health care will prove to be superior to our present competitive system. Likewise, we may find that expanding Medicare to all individuals reduces administrative overhead and better serves the needs of the American people. However, should we elect to move away from the current model for health care financing and adopt a new system, we will discover that reforming the way we pay for health care is infinitely easier than actually reforming the health care delivery system itself. The health care policy debate is one of the

May/June 2008

Why is this deliberate use of unverified information so dangerous? It produces an inaccurately informed voting public that becomes biased against the current private based system.

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most important discussions we are now having within the public forum. Health care represents one-seventh of our economy. The infusion of deliberately misleading information by the presidential candidates ill serves the debate. Setting an unattainable level of performance by an alternative financing system against the emphasized shortcomings of our imperfect present system is intentionally misleading. Furthermore, the public’s cynicism towards government will only grow when the new system does not meet the unrealistic expectations put forward by politicians today. 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. 1 ”The Case Against Health Care Reform,” Sierra Sacramento Valley Medicine, March/April 2008. 2 “Ohio Hospital Contests a Story Clinton Tells,” New York Times, April 5, 2008. 3 “Single-Payer National Health Insurance,” Archives of Internal Medicine, Vol. 164 No. 3, February 9, 2004. 4 “The Evolving Canadian Landscape,” International Journal Of Canadian Studies, Fall, 1991.

Visit the Updated Web Site of the Museum of Medical History If you haven’t done so recently, you may want to visit the web site of the Sierra Sacramento Valley Museum of Medical History. A “Virtual Museum Explorer” has been added by the SSVMS Historical Committee, which displays various artifacts and exhibit cases in the museum. Go to http://www.ssvms.org/museum.asp to take something of a virtual tour.

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Care Behind Bars: We Care By Chia-Chen Lee, FNP Little girls often say, “When I grow up, I want to be a nurse.” But very seldom do you hear them say they want to work in a jail when they became a nurse. Correctional nursing is somewhat of a mystery in the world of medicine. However, regardless of where we practice, we in the health care profession all share a common goal, which is to provide the best care for our patients. Behind the bars in Juvenile Hall is an ideal place to promote preventive medicine. We see kids without a stable home life, minors with asthma sniffing cocaine or methamphetamine, others with diabetes getting high on PCP without eating for days, heroin IV abusers, heroin addicted children, and homeless teens without any knowledge of contraceptives. All are “nursing opportunities.” Can a nurse find a better place to provide health education than Juvenile Hall? How about the girl whose boyfriend “promised” he would not get her pregnant, but had two abortions; the asthmatic wondering why he or she could not run for a mile, the diabetic girl who eats a whole chocolate cake during “outtime,” or the girl whose Sexually Transmitted Disease tests are always positive at each booking? The medical clinic in Santa Clara County’s Juvenile Hall organized 10 educational committees three years ago. Nurses selected an area of interest and educated themselves to become resource persons in that area. The American Lung Association helped us, and three nurses were certified as smoking cessation trainers. Two other nurses shadowed a Valley Medical Center pediatric diabetic educator to learn more about teaching diabetic children. A nurse practitioner from a pediatric asthma clinic trained us to use an office-based lung

function laptop test, the “Ko Ko spirometer.” We use it to demonstrate improved lung function after smoking cessation. Nurses spent days in the OB/GYN clinic, learning about teen pregnancy. Planned Parenthood helped establish and coordinate follow up care. Our nurses attended childhood obesity conferences in San Francisco, a diabetic conference at the San Jose Convention Center, and fetal alcohol syndrome classes. On the day a minor arrives, we initiate a procedure for assessing and addressing their health education needs. For example, anyone with a family history of diabetes is referred to the diabetic committee. Kids who are overweight or have high BMI are signed up for childhood obesity prevention and nutrition classes. Asthmatics are tested for lung function via the Ko Ko spirometer. Smokers are offered smoking cessation classes. Girls with positive pregnancy tests are evaluated and counseled. San Francisco State University and San Jose State University nursing students contribute by conducting a section of health education as part of their curriculum requirements. In the clinic’s waiting area we play short DVDs about STD prevention, dating safety, HIV prevention and safer sex. The once boring waiting room became an educational corner. Models displaying the visible signs of STDs attract curious eyes, and that curiosity opens up opportunities for health education. The kids in turn open up, revealing their needs to the nurses. Why a girl stays in an abusive relationship, how she struggled with low self-esteem on the one hand and the craving for love and attention on the other hand. Why

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How do we teach a gang affiliated boy not to use dirty needles when all his male relatives have multiple tattoos and share needles for IV heroin? How can a 15 year-old pregnant girl understand the risk of teen pregnancy when her mother and grandmothers all had children during their teens?

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the girl usually doesn’t have any support system, or a place to verbalize her concerns. What’s wrong when a boyfriend punches you, or when you grow up where your father hits your mother almost daily, where your aunt has bruises every other week. How can such a girl understand dating violence? How do we teach a gang affiliated boy not to use dirty needles when all his male relatives have multiple tattoos and share needles for IV heroin? How can a 15 year-old pregnant girl understand the risk of teen pregnancy when her mother and grandmothers all had children during their teens? How can a diabetic girl go home, bake a chocolate cake and finish off the whole cake by herself? Why does she feel that when her single mother goes out for housekeeping work, eating is the only way she is in control? It is an amazing experience to listen and share knowledge with the kids. When a diabetic child learns to self inject insulin correctly, an asthmatic is able to demonstrate a correct method of using an inhaler, a pregnant girl shows you the various foods which are rich in folic acid, a teenager tells of the importance of eating high calcium food, a boy with tattoos advises his peers how to avoid IV drugs in preventing HIV/hepatitis C, when a diabetic boy loses 32 pounds — we jump up and down with joy. A nurse could not dream of any better reward than the success of the kids. We reach them with various games that are not only educational, but also fun. We throw a condom on the desk with wax for lubrication and ask them what is wrong when they laugh. Girls enjoy a game we devised called “choices for life.” They exchange their own stories about making choices. We play “cup sex” with the kids in demonstrating how STDs spread without obvious signs. A touching moment occurred when a girl told how she got into prostitution because of drug addiction. What is the definition of home for one who never experienced a home in her life? A girl told of bouncing between 23 foster homes in five years. Her beautiful innocent eyes were seeking

Sierra Sacramento Valley Medicine

approval as she claimed she would come back to Juvenile Hall next year to assist with decorating the clinic for the holidays! “I know how to come back to Juvenile Hall; it is so easy.” It is sad when kids ask if they can stay in the Juvenile Hall even though they have served their time, because they feel a sense of belonging. Kids growing up in the world of TV commercials have a false sense that any medical problem can be resolved with a pill. Compounding that with their low self esteem, they can easily get hooked on medication. Juvenile Hall’s pill call carts even have a poster which reads, “Do you have a dream? Ask your nurse.” The nurse tries to help them set up short and long-term goals. A ”Bear to Dream” project was born with the assistance of Valley Medical Center foundation grant. Juveniles who set up their goal for life are given a “build a bear” kit; they keep their life goal message inside the stuffed animal. The bear is given to them upon release. They can open the bear at home or open it later in life. Some of the messages simply read, “What lesson did I learn when I was a troubled teen?” A simple message like this can refocus them, and put their life in perspective. Life is never without problems in Juvenile Hall, but the nurses always make it a priority that each child who goes through the clinic leaves with a better understanding of how to care for themselves and their health. Whether it is a high protein diet, a correct way of wearing a condom, a needle exchange program, safe sex education, relaxation techniques, safe dating tips, changing diapers for a new born, a smoke cessation class, the proper way to control blood sugar, or the correct way of using inhalers, we are committed to making a difference. They are our future and our hope. Nurses are not here to judge what is right or what is wrong. We believe everyone has the potential to learn and change. Our mission is clear. We are here to provide our patients with the best health care and training possible, and we do it because we care. Chia-Chen.Lee@hhs.co.santa-clara.org


Sampling Cancer Cases in Local Racial Subgroups “Ethnic misclassification” distorts cancer incidence in subgroups of the Sacramento Region — and the problem is worst with the largest subgroup, non-Hispanic whites.

By Monica Brown, MPH, PhD, Dawn Nozicka-Ferris, MHSE, CHES We have long known that cancer incidence varies by race and ethnicity. We also know that race and ethnic categories define large heterogeneous populations who may vary as much within their own group as between race or ethnic groups. Differences in subgroups stem from their diverse nationalities, genetics and culture. Culture drives lifestyle, which is considered the strongest determinant of cancer risk in our society. Lifestyle influences health-related behavior such as diet, exercise, tobacco and alcohol use as well as cancer screening utilization. An excellent example of cancer incidence variation by ethnic subgroup is cancer among Asians and Pacific Islanders (API). Cancer is the number one cause of death for API in the Sacramento region, and they are the only race/ethnic group with that distinction. APIs in the Sacramento region have a higher incidence of liver cancer than any other race or ethnic group with an annual average age-adjusted incidence rate (AAIR) of 12.3 per 100,000 cases. When we compared liver cancer incidence among API subgroups to that of non-Hispanic whites (AAIR 4.6 per 100,000 cases), we learned that the Hmong, Korean and Vietnamese have the highest proportional incidence while Filipino, Asian Indian and Japanese have the lowest (see chart on the next page). Analysis of cancer incidence by race and ethnic subgroups could be important for targeted cancer control activities. Unfortunately, we cannot conduct subgroup analyses on every

race and ethnic group. The worst example is cancer among nonHispanic whites (NHW). They are the largest proportion of our population and therefore have the greatest number of cancers. The category of NHW includes many subgroups: those of European descent and those from the MiddleEast and northern Africa. As with other race and ethnic groups, both native and foreign-born are included. The California Cancer Registry (CCR), as well as most healthcare data systems and organizations, can only provide sparse and thus unreliable data on NHW subgroups. The reason is a phenomenon known as “ethnic misclassification.” Ethnic misclassification is the incorrect classification or absence of documentation of an individual’s race, ethnicity and/or birthplace. In a state as ethnically diverse as California, the impact of ethnic misclassification is immense and leads to an underestimation of the cancer burden for immigrants and ethnic minorities. How ethnic misclassification affects the state’s cancer statistics is simple. Usually, upon admittance into a healthcare institution, the patient is not asked to identify his or her race, ethnicity or birthplace, even though this information is required by a

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number of hospital and healthcare agencies. We believe that often the admissions personnel will “guess” the patient’s group based on surname or physical appearance. Missing race, ethnicity and/or birthplace data is recorded as “unknown” in the patient’s medical record. The CCR, a population-based registry, includes all cases of cancer diagnosed in the state since 1988. Details of the patient’s diagnosis, treatment and demographics are abstracted from the medical record. Therefore, cancerspecific information of individuals is recorded in the CCR, but appropriate race, ethnicity and place of birth information is not. When the Sacramento regional office of the CCR was asked for information on breast cancer incidence and stage at diagnosis among Russian immigrant women by a Slavic communitybased organization, we were unable to provide the requested statistics. The Sacramento region has the largest population of Slavs (which includes immigrants from the former Soviet Union, Ukraine, and Romania among others) in the nation. Therefore, statistics on breast cancer could potentially affect a significant and important portion of the population and could provide the basis for targeted

education, screening and health care outreach. What can physicians do about ethnic misclassification? You can document and encourage your staff and healthcare institutions to document your patient’s race, ethnicity and birthplace. Will patients be offended or suspicious of your questions about their birthplace, national origins, race and ethnic backgrounds? Maybe. But research by the American Hospital Association tells us that the majority of the patients don’t mind being asked as long as they understand how the information will be used. Our newest annual report of cancer incidence in the region will be available in this month at www.ccrcal.org, under regional reports. MBrown@ccr.ca.gov Monica Brown is Cancer Epidemiologist for the Sacramento Region of the California Cancer Registry. Dawn Nozicka-Ferris is Program Manager, Asian American Network for Cancer Awareness, Research and Training, (AANCART); Asian and Pacific Islander Cancer Education Materials (APICEM); and Coordinator, National Cancer Institutes’ Cancer Information Service, California.

Proportional Incidence of Liver Cancer Among Selected Asian-Pacific Islander Subgroups Compared to Non-Hispanic Whites, Sacramento Region, 2000-2004 25.00 20.00 15.00 10.00

Non-Hispanic Whites = 4.6

5.00 0.00 Asian Indian

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Chinese

Filipino

Hmong

Sierra Sacramento Valley Medicine

Japanese

Korean

Vietnamese


Board Briefs March 9, 2008 The Board: Approved that Society Bylaws, Article VII, Section 1 (d) be added to state, “No district or medical group shall obtain more than a majority of district director positions.” If a membership district continued a steady growth pattern, it could under current bylaws achieve a majority of seats on the Board of Directors. This amendment would prevent that and give the Society the ability to have a representation of Directors reflecting our region’s diversity in practice modes and geography. A ballot will mailed to all active members on this proposed bylaws amendment some time in late spring. Approved the 2007 Year-End Finance Statements and the 2007 Year-End Investment Performance Reports. Approved establishing an interest-bearing Financial Management Account with Smith Barney for the UC Davis Medical Student Outreach Funds and that the signers on the account be the Executive Committee, the Executive Director and the Associate Director. Supported potential removal of AMA dues from the SSVMS dues invoice. The CMA and medical societies throughout the state have been concerned by a lack of coordination by the AMA over its dues collection process. Although a decision has not been reached, medical society executives in California have been discussing for some time the cessation of AMA dues billing and collection. Also, the Board believes that billing for AMA dues with a separate invoice would help membership retention. Approved the Membership Report: For Active Membership — Dale J. Gorski, DO; A. Macduff Sheehy, MD; Tracy M. Skolnick, DO; Bhuvaneswari Thirunavukkarasu, MD; Hartej S. Uppal, MD. For Reinstatement to Active Membership — Ranjit Bajwa, MD.

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For a Change in Membership Status from Resident to Active — Fariborz David Fakhri, DO. For a Change in Membership Status from Active to Active 65/20 — Alton L. Curtis, MD. For Retired Membership — Stamatiki Coss, MD; Linda Lee Huston, MD; Namin Kuachusri, MD; Jay C. Owens, MD. For Resignation — Heather R. Awaya, MD (moved to Hawaii); Un Hui Har, MD (moved to Santa Clara); Phaniraj Iyengar, MD (moved to Connecticut); Amanpreet Kaur, MD (moved to Contra Costa); Sung J. Kim, MD (moved to Anaheim); Robert M. Licoln, MD; Leslie D. McDaniel, MD; L. J. Michael Mott, MD; Neville Pimstone, MD (moved to Los Angeles); Arjun D. Sharma, MD (moved to Minnesota); Camillus O. Udoffia, MD.

April 14, 2008 The Board: Approved that the Executive Committee, the Executive Director and the Associate Director be the signers on the Society’s accounts with Smith Barney for the General Fund, Building Fund, Scholarship Fund and the Community Service, Education & Research Fund. Also approved adoption of the Corporate Resolutions for these funds. When new officers are installed, Smith Barney requires a Board action updating the signers on the SSVMS accounts. Approved guidelines for SSVMS administration of the UC Davis Medical Student Outreach Fund. The AMA provides outreach funds to medical students as in incentive for medical student recruitment. The CMA previously administered these funds for UC Davis medical students; however, the funds have been transferred to SSVMS in an effort to streamline the administrative process, and because of the Society’s close working relationship with medical student leadership. Reviewed the follow-up notes from the 2008 Retreat and directed staff to create a work


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 AGARWAL, Manoj, Hematology/Oncology, Christian Med Col, India 1997, Sutter Medical Group, 1020 – 29th St #680, Sacramento 95816 (916) 453-3300 BABBITZ, Jesse D., Neurosurgery, Univ of Louisville 1996, UCDMC, 4860 Y St #3740, Sacramento 95817 (916) 734-3658 BOULE, Jennifer N., Pediatrics, Tufts Univ 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 BRODDRICK, Frances A., Family Medicine, UC Davis 1988, Sutter Medical Group, 1014-w North Market Blvd., #20, Sacramento 95834 (916) 565-8600 DAKKAK, I. George, Anesthesiology, Tanta Faculty of Med, Egypt 1980, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

DRAZNIN, Michelle, Dermatology, Univ Colorado 2001, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 6312142 GUPTA, Deepa, Internal Medicine, Patna Med Col, India 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6097 HEIR, Jagdey S., Oral & Maxillofacial Surgery, New Jersey Med School 2000, 4170 Truxel Rd #C, Sacramento 95834 (916) 419-4588 HONGKHAM, Alex S., Radiology, Virginia Commonwealth Univ 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4371 KLINEBERG, Eric O., Orthopedic/Spine Surgery, Univ Maryland 2001, UCDMC, 4860 Y St #3800, Sacramento 95817 (916) 734-5476

LAKSHIMINARAYANAN, Renuka, Pathology, Univ Madras, India 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7277 MORGAN, Parham V., Ophthalmology, Univ Arizona 2001, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015 MORROW, Joelle, OB-GYN, UC Irvine 2002, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055 RANASINGHE, Leonard E., Emergency Medicine, Loma Linda Univ 1981, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 TRAN, Mai B., DO, Family Medicine, WUHS 2004, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6579

Board Briefs, continued from page 32 plan to improve Society communications and membership recruitment and retention. Approved the Membership Report: For Active Membership — Frances A. Broddrick, MD; I. George Dakkak, MD; Eric O. Klineberg, MD. For Reinstatement to Active Membership — Leonard E. Ranasinghe, MD For a Change in Membership Status from Resident to Active — Tammi R. James, MD For a Change in Membership Status from Active to Illness Leave of Absence — Peter J. Koch, MD For Retired Membership — William R. Dugdale, MD; Andrew M. Hazen, MD; Donald C. Oliver, MD; Craig N. Pfeiffer, MD; J. Garland Stroup, MD. For Resignation — Athea M. Alrawi, MD (moved to Michigan); Abdo Faddoul, MD (moved to Placer County); Van K. Huynh, MD (moved to Washington). Approved terminating the membership of the following members for non-payment of 2008 dues —

Elliott Adams, MD; Usman Afzal, MD; Thomas Amott, MD; Daniel Anderson, MD; Russ Braun, MD; Laura Bultman, MD; Jessica Chabot, MD; Stanley Chew, MD; Franklin Chinn, Jr., MD; Gregory Cox, MD; David Estep, MD; David Fakhri, DO; Barbara Gardner, MD; Bonnie Gieschen, MD; Richard Grutzmacher, MD; Kent Hart, MD; Ron James, MD; Robert Karsh, MD; Rodger Kobes, MD; Arnoldas Kungys, MD; Luko Laptalo, MD; Marcela Lau, MD; Reena Lewis, MD; Richard Lewis, MD; Walter Malhoski, MD; Stephen Mann, MD, Bernard McGinity, MD; Joseph Morales, MD; Tammy Morin, MD; Randall Ow, MD; Leon Owens, MD; Robert Peabody, Jr., MD; Andres Pena, MD; Shaista Rauf, MD; Eric Schwartz, MD; Michael Shea, MD; Spencer Silverbach, MD; Mark Smedley, MD; David Steinberg, MD; Dennis Sullivan, MD; Cecille Taylor, MD; Jo Taylor, MD; Robert Treat, MD; Stephen Tseng, MD; Judith Vaughan, MD; Geoffrey Wiedeman MD; David Woodruff, MD; King-Wah Yeung, MD.

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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 or Family Practitioner needed to share management of start-up medical obesity clinic in Sacramento. Must be familiar with management of diabetes, hypertension, dyslipidemia and medical conditions associated with serious obesity. Must have some familiarity with business aspects of an incorporated medical practice and must have professional liability insurance. Please respond with CV to: Julie@ weightmanagement.net

West Sacramento Medical Office Space to Rent. Conveniently located. 1-4 exam rooms, 600-1000 sf. Full services available. Contact Liz: (916) 275-3747.

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Investment Services

Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com

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Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma

Notary Service/Free to Members

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Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php

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Sierra Sacramento Valley Medicine


The Death of a Young Pathologist in 1890 By Gordon Love, MD and F. James Rybka, MD See the inside back cover for accompanying color photos. Dr. Love is a practicing pathologist. He and Dr. Rybka are members of the SSVMS Editorial Committee. In addition to collecting artifacts, another mission of the Sierra Sacramento Valley Medical History Museum is to preserve oral histories of how early doctors battled diseases. Last summer, curator Dr. Robert LaPerriere received a phone call from Mrs. Jean Di Cristoforo, RN (Stanford, ’45) of Sacramento concerning a microscope and some pathology slides passed down to her from her paternal grandfather, Dr. Frederick Osborn Lloyd. He had graduated from Columbia College of Physicians and Surgeons around 1880, and then practiced as a pathologist in upstate New York. In this capacity, he apparently lectured to students around autopsy cadavers in a manner said to have been similar to Rembrandt’s famous painting of the anatomy lesson of Dr. Tulp. One day in 1889, as he was dissecting a victim of miliary tuberculosis, a crowd bumped against him and Dr. Lloyd was accidentally cut “rather deeply.” He carefully made, labeled and dated a pathology slide of tissue taken from this cadaver. Not very long thereafter, he was stricken with tuberculosis, reportedly also of a miliary type, and he died about a year later at age 32. He had maintained the hematogenous inoculation he received was the causal agent of his illness. After he died, his widow and young son (Mrs. Di Cristoforo’s father) were diagnosed with tuberculosis apparently contacted from him. They were treated at the Trudeau Sanatorium at

Saranac Lake, New York, for about a year before being released, much improved. The slide, which has been in the family’s hands for 118 years, has never been examined by another pathologist, nor has there been any modern-day evaluation of Dr. Lloyd’s story of the accident leading to his death. It is eerie to look at a slide labeled “February 25, ’89” probably as the first pathologist to review this case since Dr. F.O. Lloyd over a century ago. The borax-carmine stain is still vibrant after all these years. Somehow fittingly for an 19th century stain, the primary ingredient, cochineal extract, is derived from Dactylopius coccus, a parasite of cacti in tropical and subtropical areas of South America. A variation of the borax-carmine stain known as Grenacher’s stain still is used to stain parasite cyst forms. Caseating granulomas — typical for tuberculosis — are seen at low magnification and represent a typical histologic pattern of miliary tuberculosis. Tubercule bacilli cannot be seen with Grenacher’s stain. The tissue is thick, probably about 20-30 micrometers. Normal lung alveoli and few pigmented pulmonary macrophages can be appreciated between the tubercules. A pulmonary vessel, probably an artery, is unremarkable. The presence of normal lung parenchyma with minimally pigmented pulmonary macrophages suggests that the autopsy subject was a non-smoker and also likely a young

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person. Thickness of the specimen and fading of cellular detail impedes further evaluation. Tuberculosis was a scourge of the United States during the 1800s (see Dr. Irma West’s article in the previous issue), which were momentous times for infectious disease pathology. Robert Koch established in 1882 that a bacillus was the cause of tuberculosis, and he eventually received the Nobel Prize for his tuberculosis research. Owing to high lipid and wax content, staining of acidfast bacilli requires heating or prolonged application of powerful dyes. Koch used an extended incubation of alkaline mixtures of aniline dyes to label the tubercule bacillus in tissue. Ziehl in 1882 demonstrated an improved acid-fast stain in which an acidic dye produced improved staining with limited incubation. A modification of this stain is still in use today. Miliary tuberculosis — socalled in that the lungs appear seeded with millet seeds — comprises about 1 percent of cases of tuberculosis.1 The disease

results from hematologic seeding of acid-fast bacilli (AFB), often as a result of an infected lymph node draining into a vein. Infected blood, after circulating through the heart, may lead to multiple seeding of the lungs as well as other organs. Could an infected cut during an autopsy transmit tuberculosis? Certainly, but the development of miliary tuberculosis in the recipient seems unlikely. It is doubtful that sufficient AFB could gain access to circulation during a cut to result in miliary dissemination; it would instead produce granulomatous disease at the site of the cut. More likely, tuberculosis could have been transmitted during an autopsy through inhalation of AFB. The delicate manipulation of tissue required for this slide preparation could have facilitated infection. The Johns Hopkins Hospital performed frozen sections with autopsies in 1900 and probably earlier (Archives of Pathology 2008 vol 132:261-2264). Dr. F.O. Lloyd may have used this technique to prepare his post-mortem slides. Propelling frozen tissue containing AFB into the air is a most efficient means to spread tuberculosis among pathologists. For this reason, frozen section cryostats must be disinfected frequently. Dr. Lloyd died of tuberculosis, but probably not of the miliary type. Chances are he was infected because of his work as a pathologist and teacher, unaware of a danger in the air he breathed. Gordon.L.Love@questdiagnostics.com jimrybka@hotmail.com 1 Miliary tuberculosis evokes an image of the radiologic appearance of lung studded with radio-dense nodules. But this term was likely developed earlier to describe the autopsy appearance of the affected lung, as was noted by Dr. F.O. Lloyd. The first medical x-ray was performed in 1895, six years after this event.

At the left is a photo of Dr. Lloyd holding his son — the father of Mrs. Di Cristoforo. At the top left is the slide that Dr. Lloyd prepared in 1889.

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Sierra Sacramento Valley Medicine


Miliary Tuberculosis — A close-up of a slide prepared nearly 120 years ago clearly shows granulomas (the two red areas in the center) typical of miliary tuberculoses. To the right is a blood vessel. See the story on page 35. At the right is a photo of the Rembrandt painting mentioned in the text, the 1632 “Anatomy Lesson of Dr. Nicolaes Tulp.”


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2008-May/Jun - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...

2008-May/Jun - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...