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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2008


Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Budget Cuts at All Levels Threaten Medical Care

Margaret E. Parsons, MD

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EXECUTIVE DIRECTOR’S MESSAGE It’s Time for National Physician Credentialing

Bill Sandberg

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The More Things Change…

James Affleck, MD

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Medical STUDENT ESSAY WINNER Closing the Gap Between Organ Supply and Demand

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The Popularity of Early Electrotherapeutic Hokum

Kent M. Perryman, PhD

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A Posit on “Big Box” Medical Care

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Primary Care — It is a Tough Business

David J. Gibson, MD, and Jennifer Shaw Gibson

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A Blog on Indigestible Restaurant Noise

Del Meyer, MD

Gary Tsai, MSIV

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Chronophagos

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Access to Clean Syringes in the City of Sacramento

John Loofbourow, MD

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IN MEMORIAM Gerald Paul Martin, MD

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Board Briefs

Glennah Trochet, MD

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Voices of Medicine

Del Meyer, MD

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Missed Meal, Rest Periods Can Cost Employers

Kelli M. Kennaday, Esq.

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The Shifa Student Clinic

Hailey MacNear, MSI

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New Applicants

36 SSV Medicine is online at www.ssvms.org/magazine.asp

We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

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This 1980 oil painting is another in a series of covers by Dr. Robert C. Lentzner. The original is 20 by 26 inches. “Painting animals is always a welcome challenge for me,” he said. “This scene was of a quiet moment on the race track at Cal Expo.” Used by permission. All rights reserved.

July/August 2008

Volume 59/Number 4 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

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Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 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

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2006 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

Sierra Sacramento Valley Medicine


President’s Message

Budget Cuts at All Levels Threaten Medical Care By Margaret E. Parsons, MD As I write this, we face a state budget with a 10 percent cut to Medi-Cal. A Medicare cut of 10 percent faces the profession, too, and the U.S. Senate tries to find another annual fix to block the cut. Locally, our County Boards of Supervisors are dealing with the economic woes by implementing various strategies. Without question it is a challenging time for physicians and those we care for — our patients. All of these cuts are slated for implementation July 1. The Medi-Cal cuts are being protested strongly by physicians and the California Medical Association. A suit by the CMA is making its way through court systems; the CMA hopes for an injunction to stop the cuts, and we shall see in coming weeks if that effort succeeds or not. California’s rates for Medicaid (which we call Medi-Cal) are among the lowest in the nation. Physicians simply cannot afford to provide care at a loss while their practice expense increases. Much of the Medi-Cal care in Sacramento County is provided through Geographic Managed Care; our other constituent counties, Yolo and El Dorado, use a mix of payment modalities for their Medi-Cal patients. Federal Medicare cuts are being debated in the annual game of will they or won’t they “fix” it for a year. It is a game played for far too many years now. We continue to hear promises of a “formula fix” so that we will not be continually lobbying on this issue and being unsure of a payment schedule until the deadline hits us. In an election year, little major policy is enacted at the federal level, so we can only hope for a fix for this round of the game. There is talk of an 18-month fix. Lawmakers are also tired of playing this game every year. Unless the formula

is fixed and answers found, Medicare will not be financially viable in 10 years. At deadline for this issue, the U.S. Senate had not agreed on a Medicare bill. If the impasse is not broken by early July, the Medicare cuts will go into effect. The Sacramento County Board of Supervisors is making sudden and dramatic changes to the county health system. The Supervisors voted to change the current CMSIP system of providing care to the needy and jail inmates from a primarily UCD contract, which is cancelled effective June 30, to one managed by a third-party administrator and a Blue Cross Prudent Buyer product. County staff claims the move will save $13 million. SSVMS testified with concern about the vagueness and suddenness with which this change was made and how it will take effect in the community. We are concerned that those who have generously cared for patients at a lesser reimbursement will not have access to providing care to those patients they know well. We are concerned that patients will not know where to go for care. We are concerned that other hospitals and clinics are not set up to provide prisoner care, and lack the safety precautions that need to be in place. We are sympathetic to Sacramento County’s difficult budget challenges, but remain concerned about the impact of dramatic and short-notice changes. How this plays out in the coming months will be interesting and there will be bumps (or possibly large hills) in the road. Please let us know at SSVMS of your experiences as this contract change moves forward.

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Understanding how individual physicians, systems, and patients are affected is important as we participate in discussions of how to best find answers to caring for the community. Sacramento County has also had to closely look at other places to save dollars. It will markedly decrease hours at the Capital and Oak Park Clinics. Many public health programs, such as high risk perinatal care, are being cut back. Yolo County’s proportionally devastating shortfall led to a collaborative effort far in advance of any crisis between the four health systems, the county and the safety net providers, to find innovative solutions to both budget shortfalls and access issues. We have seen the wonderful kindness of our many physician volunteers in the SPIRIT Program of the SSVMS Community Service, Education and Research Fund (CSERF). Other non-profit groups and clinics are also reaching out to those in need of care. Hopefully, we can learn from other counties and communities and build a network to reach those that need care. Sacramento County’s health system changes

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are drastic and will likely lead to challenges in the coming months. I hope this will be an opportunity to collaborate and creatively find answers, so all providers, systems, and various organizations in the community can benefit from a cooperative and shared effort on behalf of those needing basic health care in our region. Our challenges as physicians are many. Organized medicine through SSVMS, CMA, AMA and our specialty societies all work to aid us in the financial, legal, and regulatory hurdles of medicine. Our personal involvement in many roles — as organization members, as community leaders, and as doctors caring for patients — plays into this as well. We are the voice for our patients and ourselves, to insure we will be able to practice medicine and care for patients. I still think being a doctor is wonderful. Every day, I enjoy the challenges of combining science, medicine, a patient’s story and training. And the “thank you” from patients or their family member makes it all worthwhile. mepmd@ix.netcom.com


Executive Director’s Message

It’s Time for National Physician Credentialing By Bill Sandberg At its web site, www.medbd.ca.gov, the Medical Board of California warns physicians applying for a California license to expect the process to take 6 to 9 months. Without a California license number a physician cannot apply for Medicare, Medi-Cal, gain hospital privileges, obtain professional liability coverage, join a state or local medical society. The application and instructions to gain a California license is 25 pages long. For a physician being recruited to California who wants to hit the road running, getting a license and all the other privileges needed would take 18 months. So much for running. All organizations that license physicians, give them privileges, grant them membership, pay for their services, allow them to prescribe, discipline them and insure them, want the same original source materials. Some of the required information: Live Scan fingerprints, 2 x 3 original head and shoulder photographs, letters in good standing, certified medical school transcripts, certified copies of medical degrees, examination scores directly from the reporting entity and a host of other forms, depending on whether you are US-trained or an IMG. Don’t forget the DEA license and valid California driver’s licenses that some require. Many national entities collect these same data — like the National Practitioners Data Bank (NPDB), The Healthcare Integrity and Protection Data Bank (HIPDB), the Federation Credentials Verification Service (FCVS) of the Federation of State Medical Board of the United States, the Veterans’ Administration, the Department of Justice (DOJ), the Drug Enforcement Agency

(DEA) and, of course, Medicare and its subcontractors. There must be others. We have all of this redundancy and original source rules because no institution wants to be caught allowing a physician to practice who has managed to hide or run from personal or professional disasters. While it is getting harder for errant physicians to cover their tracks and sneak in somewhere else, it’s still a devastating situation for an institution when a physician with a checkered past injures a patient or others. So, why not create a single agency like the one housing the NPDB and the HIPDB and have it become the single source? Probably billions of dollars would be saved. Physicians could routinely check the accuracy of their credentials and the reports filed in their online folder. When errors crop up today, it’s nearly impossible for a physician to clean up the problem across all the credentialing organizations. Perhaps liability could be removed for hospitals and others that have been duped. States could continue to license, collect fees and establish medical practice laws, but would have to accept the national file. National credentialing would allow physicians to move about the country with very little hassle and would simplify recruitment by communities and health systems. It would be convenient in times of natural disaster. If my personal health records can be digitized and trusted to be protected by my physician and health system, why not your credentials? bsandberg@ssvms.org

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The More Things Change… By James Affleck, MD “Plus ça change, plus c’est la même chose.” — Jean-Baptiste Alphonse Karr It was 1936 and I was 5 years-old. I was a bystander at a conversation where my grandfather told my father that medicine was going to hell. My grandfather had come to Sacramento in the early 20s and hung out his shingle on his home on 21st Street. It struck me that medicine must not have been worse then than the tales he told me of practice in Utah where he was paid for medical treatment with a chicken (tax free?). He died at age 72 of a stroke suffered while making a house call at midnight. My father was a pharmacist, and as a young graduate, founded Affleck’s Pharmacy in 1921. He provided “Prescriptions Exclusively” — no greeting cards or cosmetics for him. He did, however, sell CP (chemically pure) grade chemicals to students for their chemistry sets. All went well until the 40s when pharmaceutical companies started manufacturing compressed tablets and sealed capsules. There went the “art of pharmacy” and pharmacists suddenly became mere “pill counters.” Now, pharmacy was going to hell. Fortunately he did not live to witness the present era when all community pharmacies have been economically forced to close and sell their prescription lists to the Rite-Aids and Safeways. My return to Sacramento was in 1962, and everything seemed fine to me. We are now said to have practiced in the “golden era” and, indeed, within 20–30 years, governmental agencies and health insurers were imposing prior authorization and drug formularies, and I was becoming totally frustrated. But what about those fresh, young MDs entering practice? They seemed to have no problem accommodating to these intrusions.

Everything looked fine as they had had no other experience. And thus starts another cycle. My son is a hospital pharmacist: a scientist dealing with pharmacokinetics, pharmacodynamics and pharmacogenomics. He is in his 26th year of practice and at one point was pressured to join a union. He has gone from a clinical pharmacist, working on the floors with physicians, to sitting at a computer all day as a data inputter, to make the hospital network function. His constant complaint is of the emphasis and pressure for cost control at the expense of simple good medical judgment. And what do the new to practice pharmacists think? Everything’s fine. The more things change, the more they remain the same. jaaffleck@comcast.net

This 1935 photo shows the Affleck pharmacy and the motorcycle used to deliver drugs. It was located on 10th Street near J Street in downtown Sacramento, to the right of Levinson’s book store.

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This drawing is part of the collection of the Sierra Sacramento Valley Museum of Medical History. The original has lightly tinted red arteries and blue veins. This is one of 36 plates in a book, “Surgical Anatomy,� by Joseph Maclise, Fellow of the Royal College of Surgeons, published by Blanchard and Lea in Philadelphia, in 1851.

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Medical Student Essay Winner

Closing the Gap Between Organ Supply and Demand By Gary Tsai, MSIV, UC Davis School of Medicine lmagine lying on your deathbed knowing that someone is capable of saving your life, only you don’t know who it is or when it will be. Every year in the United States almost 100,000 men, women and children are subjected to this frightening experience; and every day, 18 of them die as they wait for lifesaving organ transplants. Since the world’s first kidney transplant in 1954, the focus of transplantation has shifted from patient survival to the shortage of available organs and how to persuade more people to become donors. Overwhelming data reveals that the current organizational and legal system regulating organ procurement is failing the needs of transplantation. According to the United Network for Organ Sharing (UNOS), for every one person removed from the waiting list, two are added. Economically speaking, supply is being dwarfed by demand. Despite millions spent on education and awareness, organ donation rates have failed to show any significant increases. Thus, health organizations are calling for more sweeping changes to improve all aspects of transplantation. At the heart of the debate is the current “opt-in” system for donation whereby prospective donors must indicate their preferences by signing a donor card, checking the box on their driver’s license, or signing up with a State Donor Registry. The problem with the opt-in policy is that many potential donors are lost because they are either unaware of the procedures or unwilling to spend the extra effort to register. The pursuit for an improved alternative to current policies resulted in the proposal of a program termed presumed consent, whereby

individuals who do not want to become organ donors must “opt-out” by entering their name on a national database. Currently employed in a number of European countries including Belgium, France, Italy and Sweden, this proposed system would essentially cast a wider net, respecting the wishes of people who choose not to donate while capitalizing on both individuals who explicitly want to be donors and those who do not care either way. In a 10-year study of 22 countries, investigators found that once other determinants of organ donation were accounted for, donation rates were on average 25–30% higher in countries with presumed consent. It has, therefore, been shown that this policy could lead to the goal of obtaining more organs. However, the far more difficult question is whether or not the end justifies the means. Respect for the fundamental ethical value of patient autonomy is the basis of informed consent. In a society where patients’ rights for fully informed consent are ingrained into medical education and the minds of litigation-fearing physicians, the notion of removing organs without explicit permission clashes with current medical philosophy. Exploring the evolution of medical culture, it is apparent that the institution of medicine has continually taken steps to better involve patients in treatment decisions. It is equally clear that adopting a system such as presumed consent would be an ethical step backward in the progression of patient autonomy. Importantly, no educational program

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This proposal would elicit and empower donor response, which is a limitation of the current opt-in system, while also enhancing our ability to respect the final wishes of deceased individuals, which is a weakness of presumed consent.

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could guarantee that every member of society is appropriately informed about the policy in place. Therefore, a population of those registered as donors would not necessarily be giving their informed consent, inevitably leading to the wrongful harvesting of organs. Given that a significant proportion of the public believes that signing a donor card would cause doctors to care more about harvesting their organs than saving their lives, presumed consent would undermine what is already a thin trust people have in the process. In turn, society may respond with a backlash of negativity toward organ donation, causing donation rates to actually decrease rather than increase. An optout program for organ procurement would also unfairly target minorities. Individuals who did not learn English as a first language would likely be lost in the process, unjustifiably skewing the demographics of willing donors. Presumed consent is exactly that — a presumption. No matter if an individual is unaware of the policy or unequivocally against donation, presumed consent is an assumption that unless specifically affirmed, one is willing to become an organ donor in the event of tragic demise. Subsequently, consent may or may not be informed, and thus may or may not be considered true consent. When factoring in the emotionally charged and life-altering events that precede organ donation, it becomes unmistakably clear that such a far-reaching medical policy cannot rest on such weak ethical foundations. There are inherent rights that one is entitled to that do not belong to the state, regardless of registry. For this reason, presumed consent is an unconstructive solution to the organ shortage today. Nevertheless, it is blaringly clear that we are in need of an alternative system of organ regulation. Required response is an approach which mandates that people declare their donation status to public authorities, for instance when applying for a driver’s license. This proposal would elicit and empower donor response, which is a limitation of the current opt-in system, while also enhancing our ability to respect the

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final wishes of deceased individuals, which is a weakness of presumed consent. Since surveys by UNOS have shown that 90% of Americans say they support organ donation, mandatory donor response would almost certainly have a positive effect on contribution rates. Moreover, safeguards to required response would be in place to ensure optimal donation rates while staying well within the boundaries of medical ethics. For example, people would be able to change their donation status at any time and the determination of donation preference for minors or those deemed mentally incompetent would be transferred to respective parents, legal guardians, or families. In the end, the ultimate gift of becoming an organ donor is a very intimate and individualized choice, and the policies designed to implement this decision should reflect this point. With this in mind, we can comfortably and confidently move forward, both medically and ethically, as we strive to improve the lives of the hundreds of thousands of people worldwide in need of transplants and better match the tragic imbalance between organ supply and demand. gtsai@ucdavis.edu Gary Tsai, 26, now in his fourth year at the UC Davis Medical School, is the winner of this year’s essay contest in the medical student category. His parents are biochemists doing cancer research. As a youth, he wanted to become a veterinarian, until an illness in the family focused his interest on treating humans. After graduating from high school in Thousand Oaks, he attended UC Santa Barbara, majoring in biopsychology. He decided to attend the UC Davis Medical School because the faculty seemed warmer toward students than at other schools, and because students seemed happier. He also wanted to experience life in Northern California. UC Davis has turned out to be “a fantastic experience” and he feels lucky to be there. Gary likes to travel and has been to several foreign countries. He recently returned from Venezuela after a year involved in medical research.


Access to Clean Syringes in the City of Sacramento A public health measure turned down by the Sacramento County Board of Supervisors appears to be working smoothly in the City of Sacramento.

By Glennah Trochet, MD, Public Health Officer, Sacramento County This is a May 6 report to the City Council of Sacramento on pharmacy sales of clean needles and two needle exchange programs. Initially, the Medical Society and others sought similar programs countywide, but that recommendation was defeated. The report below has been reformatted and some extraneous headings have been removed for space reasons, but the text is unchanged. The original can be viewed at www.SSVMS.org. Recommendation: 1) Receive and File the first annual report on Access to Clean Syringes Programs in the City of Sacramento and 2) Direct staff to work with the County Public Health Officer on a plan to deal with syringe disposal as it relates to the syringe exchange programs and the new state law that takes effect September 1, 2008 and return to Mayor and Council for approval of the plan. Description/Analysis Issue: In November 2006, the Mayor and City Council approved the over-the-counter pharmacy sales of clean syringes in the City of Sacramento. And in January 2007 the City of Sacramento Mayor and City Council authorized the operation of clean syringe exchange programs in the City of Sacramento. The ordinances required an annual report detailing the status of the programs. This report includes information on blood borne infections associated with needle sharing activities, as well as a description of the implementation of both programs and known outcomes as of February

29, 2007. In Sacramento, the use of illegal drugs and sharing of syringes is the second most common way in which HIV is transmitted and the most common in which Hepatitis C is transmitted. From the beginning of the epidemic in 1982 until December, 2007, Sacramento County has recorded 3,605 cases of AIDS. Of these 72 % (2,858) were living in the City of Sacramento at the time of the report. As of the end of 2007 there were 1,204 cases of HIV reported in the county, of these, 78% (944) lived in the City of Sacramento at the time the report was made. It is estimated that 600,000 people in California are infected with Hepatitis C. If this is so, then we project that 22,100 people in Sacramento County must also be infected. In 2007 there were 795 new cases of Hepatitis C reported in Sacramento County, compared to 982 cases reported in 2006. Of these, 554 reported cases in 2006 and 432 reported cases in 2006 lived within the City of Sacramento limits. Disease Prevention Demonstration Project (DPDP): There are currently twenty-four registered pharmacies participating in the project in the City of Sacramento including thirteen Rite Aid pharmacies, four Longs Drugs pharmacies, five Leader pharmacies, and the Center for AIDS Research and Education Services (CARES) pharmacy. Since the inception of the project, one

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pharmacy location has dropped out of the project. The reason given was fear that the project would attract criminal and undesirable patrons to the pharmacy. Two surveys of pharmacies have taken place, which show that all locations are selling at least 10 syringes per month, and most are averaging 100–500 syringes a month in the DPDP. All pharmacies report distributing the required brochure with each purchase of syringes, most of which are sold in packages of 10. Pharmacies reported very few adverse events: one incident of verbal abuse to the pharmacist by a patron was reported, and a few incidents where the syringes were not sold because the individual requesting to buy was under age. Syringe Exchange Programs: Two Syringe Exchange programs are in place in the City of Sacramento. Harm Reduction Services (HRS) is a community based organization that works with high risk clients providing education, prevention and HIV and Hepatitis C testing. Their clients include current drug users, men who have sex with men, sex workers and the homeless. Of their clients, 55% are male and 45% female. They range from 25 to 45 years of age, and approximately 45% are people of color. Clean syringes for exchange, and testing services, are available at their office Tuesday through Friday from 10 am to 1 pm and Saturday from 11 am to 5 pm. Also, the HRS outreach van conducts street based services three afternoons a week from 1 to 4:30 pm. and Saturday evenings from 10 pm to 1 am at various locations in the City of Sacramento. HRS staff collects used syringes during outreach contacts. Biohazard waste containers are provided to participants when possible. HRS hosts the Joan Viteri Memorial Clinic (JVMC) in partnership with the UC Davis Medical School. The clinic’s services include abscess treatment, Hepatitis vaccinations and other medical services for injection drug users. It is located at the HRS offices in Oak Park. Clean syringes are distributed, used ones are collected for disposal and clients can also receive various supplies to prevent infections. From November 2007 to February 2008

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HRS distributed 42,000 new syringes. They have vaccinated 40 individuals against Hepatitis A and Hepatitis B and more than 1,500 individuals received information about drug treatment, medical care and how to prevent the spread of blood borne diseases. The JVMC clinic saw more than 400 patients for medical services in 2007. HRS staff is trained to use the rapid HIV test. Out of 140 individuals tested for HIV, three were found to be HIV positive, and were connected to medical treatment and other services. Safer Alternatives thru Networking and Education (SANE) is the second syringe exchange program. SANE utilizes social network representatives (designated by members of the social network) to deliver the greater part of the HIV risk reduction supplies and prevention education to local injection drug users (IDU.) Social network representatives (SNR), maintain regular, direct contact with SANE staff and systematically deliver education and supplies to other IDU that do not contact SANE directly. Three staff are available on pager Monday through Saturday, 10 am – 8 pm. A return call to IDU is made within 48 hours of receiving a voice page. During the return phone call a time and place for the contact is arranged. Most frequently, program services are provided in participants’ homes and regular gathering places which allow staff to work with IDU on risk reduction strategies in the environment in which they actually use drugs. Used syringes are collected by staff during outreach (exchange) contacts (usually in biohazardous waste containers provided to participants by SANE) and disposed appropriately. Staff respond to calls from community members who have household-generated waste (e.g., diabetics) or who have seen syringes discarded in public places by traveling to the identified area and collecting the syringes in an appropriate manner (e.g., with gloves, tongs, sharps containers). SANE employees often collect publiclydiscarded syringes in their neighborhoods after receiving training in proper collection procedures. IDU are provided with the locations of pharmacies participating in the Disease


Prevention Demonstration Project (“pharmacy sales” program). From February 20, 2007 to February 29, 2008 SANE distributed 149,741 syringes during 605 exchange episodes. One percent of exchanges were conducted with IDU under the age of 30. Forty-six percent of exchanges in this time period were conducted with women and 11% were conducted with women of color. Nineteen percent of exchanges were conducted with people of color (African American 4%, Latina/o 10%, Asian, Native American and other 5%) and 39% were conducted with individuals who reported injecting primarily methamphetamines in the previous six months. Both syringe exchange programs collect used syringes that are returned either loosely or in containers. Because the containers are not opened, it is difficult to know the number of syringes that are disposed of. Both syringe exchange programs distribute information on the proper disposal of used syringes and HRS distributes labels and instructions to people on how to create their own safe containers. Recently the Health Officer met with waste management staff in the City of Sacramento to discuss the best way to dispose of used syringes. In addition to syringe disposal for the exchange program, the City will have to address syringe disposal due to a new State law that will be effective as of September 1, 2008. This new law will prohibit residents from disposing of their used syringes in their household garbage cans. Residents will be required to dispose of their syringes at the City’s hazardous waste facility or other qualified sites. Currently, residents are allowed to place their used syringes in their garbage cans as long as they are in appropriate containers. It is unknown at this time what the total impact will be for the City when this new law takes effect. However, staff expects that there will have to be a public educational component for this change in law as well as some coordination with the private sector and medical sector to maximize disposal drop off sites within the City. We would note that the City of Sacramento Police Department and the City’s Parks and

Recreation Department have had no incidents reported to them related to either the Pharmacy Sales of Syringes or the Needle Exchange programs. In addition, according to the District Attorney’s office there have been no adverse events reported to them regarding pharmacy sales of syringes or syringe exchange programs. Policy Considerations: The State of California Office of AIDS is tasked with the evaluation of the Disease Prevention Demonstration Program, prior to 2010, when the authorizing legislation sunsets. Syringe exchange programs are recognized in the Public Health literature as a valuable adjunct to other programs to decrease the spread of HIV, Hepatitis C and other blood borne diseases. Environmental Considerations: None Rationale for Recommendation: Receive and file. Financial Considerations: Due to the success of one of the syringe exchange programs to date and the ramping up of the second syringe program there is a possible cost to the City when the programs are fully implemented. Staff is recommending that we come back to Mayor and Council after a year’s worth of data to provide a better estimate on any financial impacts of the programs. In addition, staff will also have a better understanding of the cost implications of the new state law which will prohibit residents from discarding syringes in their household garbage cans. Staff recommends that Mayor and Council direct staff to work with the County Public Health Officer on a plan to deal with syringe disposal as it relates to the syringe exchange programs and the new state law that takes effect September 1, 2008 and return to Mayor and Council for approval of the plan. Emerging Small Business Development (ESBD): N/A

Submitted by: Dr. Glennah Trochet County of Sacramento Public Health Officer

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Voices of Medicine Vague health care instructions, saluting old soldiers (and MDs), advertising vs. marketing.

By Del Meyer, MD The first two articles below are excerpted from the The Bulletin of the Humboldt-Del Norte Country Medical Society of March 2008. The complete articles can be viewed at www. humboldt1.com/~medsoc/images/bulletins/ MARCH%202008%20BULLETIN_for%20web.pdf

Not Doing Everthing “Do Everything (…that makes sense!)” is a piece by Ken Meece and Scott Sattler, MD. Among the common but unhelpful phrases people use when talking about their preferences for intensity of healthcare interventions are “No heroics” and “Do everything.” “Heroics” is obviously vague, and we naturally go on to name the specifics. “Everything” doesn’t seem so vague, and can seem clear enough to be taken at face value. It’s very hard for people to specify preferences about life-prolonging measures, not only in a crisis or stressful moment but also (for different reasons) pre-need, ahead of time as in completing one’s Advance Directives. So it’s natural to use quick, global phrases to try to circumvent difficult details. Unfortunately, the actions encompassed by the phrase “Do everything” often have unintended negative consequences, sometimes unanticipated and severe… Interestingly, there is a way of hearing and dealing with a “Do everything” request that can lead to helpful, detailed communication and reasoned choices, rather than to truncated communication and frustration. This approach was shared with me years ago by Dr. Albert Jonsen, a medical ethics pioneer and current Emeritus Professor of Ethics in Medicine at the

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University of Washington. He suggested that whenever we hear “Do everything,” we always add ‘in our mind’s ear’ the phrase “…that makes sense”. Presuming that people are never asking us to do things that don’t make any sense is nearly always safe ground. Then respond: “Yes, we’ll do everything possible that makes sense. Let’s talk about what options make sense medically, that might work to help you at this point. And please, you tell me what makes sense personally to you. We’ll work out together what makes sense medically and personally. How does that sound to you?” Without adding on the phrase “…that makes sense,” the global “Do everything” leads to what is called the technological imperative: If it can be done it must be done. This is ethical nonsense, and can lead to avoidable tragedy…

The Disappearing Generation “There They Go” is the title of an article by George Ingraham, MD. On election day last month I had stopped just behind a pickup truck near the polling station. Out of the pickup stepped an old gent: ninety at least. He made his way back along the bed, supporting himself with his hands, and reached into the bed for his cane. Securing this, he walked around the back of his truck and squared up with the curb: a step up of maybe eight inches. He took several seconds to prepare himself, and then with great care and evident pain levered himself up onto the sidewalk, paused, squared his shoulders, raised his head, turned and marched (“walk” doesn’t cover it) painfully towards the poll: leftright… leftright… leftright. It took only a little effort to look back almost seventy years and imagine the soldier of


twenty; the determination and the pride were still there. Oh yeah. It may not have been much of an election, but he’d fought in the war, he was going to walk to the polls, and he was going to vote. So it hurts. Tough. Tom Brokaw called his book The Greatest Generation. And maybe they were. In and out of uniform, they took on the worst Europe and Asia had to offer, fought them on two oceans and three continents…and won. I have wondered, thinking about those years, about the physicians of that time, and the challenges which they faced. Not the least of these was the sudden disruption of their education, their careers, and their family life… We are to consider that they had, in 1941, only small, very small, quantities of a new drug called Sulfa, which could actually kill bacteria without killing the patient. Otherwise, there was not much they could do about contaminated wounds and compound fractures, let alone burns, beyond offering hope and comfort… We are losing this age group; I read somewhere, at the rate of around a thousand a day. Which reminds me of a traditional Scottish toast: “Who’s like us? Damn few, and they’re all dead!”…

Why Advertising Fails David Zahaluk, MD, discusses the “Top Ten Reasons Why Medical Advertising Doesn’t Work” in the San Mateo County Medical Association Bulletin of January 2008. “My advertising doesn’t work!” I hear those words of lament frequently…. The incorrect use of marketing and advertising is the key reason why many practices fall far short of their potential. Marketing is not advertising. According to Webster’s online dictionary, advertising is the “the action of calling something to the attention of the public, especially by paid announcements.” It is the broadcast of specific messages through specified media, like newspaper, Valpak and Yellow Pages. Marketing, on the other hand, is “an aggregate of functions involved in moving goods (services) from producer to consumer,” also

according to Webster’s online dictionary. Marketing is an overall process of deciding who is in your target market, what their needs are, how your service fulfills those needs and how to best orchestrate the process. Ads send a specific message. Marketing calibrates the message to market to media match-up and delivers the right message to the intended target. Said differently, the way your receptionist answers the phone is not necessarily part of your advertising, but it is part of your marketing. However, advertising is not bad, if it is done strategically and in the context of a larger marketing plan. So why does advertising frequently fail? Reason #1: People Don’t Want to be Sold Patients (and the referring doctors that send them to you) are ever-inundated with advertising messages…. The typical patient weeds out the sales messages and instantly discounts them as being “just advertising.” Reason #2: Being Boring Perceptual studies have been done on the behavior of reading the newspaper. The reader scans the page quickly and separates news stories from advertising content. Then, headlines are scanned, with about four seconds devoted to each headline. After that, articles of interest are read and boring articles are skipped. Finally, ads are scanned and interesting ones are read, while most are not… Reason #3: Lacking Credibility I have always maintained that the best advertising for a physician is a full waiting room. The public tends to ignore claims that we make about ourselves and looks to the opinion of other people like themselves as validation of their opinion… Testimonials, third party and celebrity endorsements and guarantees all greatly increase credibility. An enormous amount of credibility is implied if you are the official physician for a local team… To see the entire article, go to www.smcma. org/Bulletin/BulletinIssues/Jan08issue/BULLETIN0801-Zahaluk.pdf

...the way your receptionist answers the phone is not necessarily part of your advertising, but it is part of your marketing.

DelMeyer@MedicalTuesday.net

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Missed Meal, Rest Periods Can Cost Employers By Kelli M. Kennaday, Esq. The author is a partner in the law firm of Wilke, Fleury, Hoffelt, Gould & Birney, LLP , and provides representation and advice to employers on issues such as discrimination, harassment and retaliation claims, as well as wage and hour laws. Several high-profile class action lawsuits have been settled recently, with employers agreeing to pay millions to employees for missed meal and rest breaks. Generally, these types of class action lawsuits seek compensation for all affected employees for a four year period preceding the date the lawsuit is filed. To avoid a similar fate, it is important to understand and consistently apply the rules regarding meal and rest breaks.

Rest Periods In California, non-exempt employees (i.e., not management) must be given a 10 minute rest period for every four hours of work. The rest period is to be taken in the middle of each four hour work period as far as is practical. A rest period need not be provided for employees whose total daily hours of work are less than 3.5 hours. The 10 minute rest periods are considered time worked and must be paid. The employee may not be required to perform any work during a rest period. The rest periods may not be waived. If the employer fails to provide the rest period, the employer must pay the employee one additional hour of pay at the employee’s regular rate for each work day where a rest

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Sierra Sacramento Valley Medicine

period is not provided. Although an employee is not required to take his or her rest period, the employer must “authorize and permit” the rest period. Failing to take into the account the need for rest periods when scheduling and assigning tasks may be deemed a failure to permit the rest period.

Meal Periods Non-exempt employees who work more than five hours per day must be provided with a meal period of not less than 30 minutes. The meal period must begin before the end of the fifth hour of work. If the employee works more than five hours per day, but less than six hours per day, the meal period can be waived by mutual consent. If the employee works more than 10 hours in a given day, a second meal period of not less than 30 minutes must be given. If the hours worked are more than 10 hours per day, but less than 12 hours, the second meal period can be waived by mutual consent only if the first meal period was not waived. If the employer fails to provide the meal period, the employer must pay the employee an additional hour of pay at the employee’s regular rate. However, in contrast to rest breaks, employers have an affirmative obligation to ensure that meal periods are taken as required and to keep proper records with respect to each employee. Accordingly, it is important that you require your employees to sign in and out for their meal breaks. The meal period may be unpaid unless the employee is not relieved of all duties. An on-duty (paid) meal period may be permitted


only when the nature of the work prevents the employee from being relieved of all duty and when there is a written agreement between the employer and the employee for an on-duty meal period. If the employer requires the employee to remain at the work site or facility during the meal period, the meal period must also be paid.

Protecting Yourself Given the risk associated with claims for missed meal and rest periods, many employers are now proactively addressing this issue. There are several things you might want to consider to protect against claims for missed meal and rest periods. First, you should include provisions in your Employee Handbook regarding meal and rest periods, informing your employees in writing

that such breaks must be taken. Second, you may want to include a standalone acknowledgement form, similar to your at-will acknowledgement form, in which employees certify that they have read and understand the company’s meal and rest period policies and that they agree to abide by those policies and take all required meal and rest periods. Finally, you may wish to include a statement on your employees’ time sheets, which the employee signs, certifying that they have worked all hours indicated and that they have taken all required meal and rest breaks for each day worked. While none of these methods guarantees you will not face a missed meal or rest period claim, they will provide you with the best defense possible should such a claim arise. kkennaday@wilkefleury.com.

“ So, I told my patient, ‘You don’t have to call me sir.’ So she says, ‘O.K. dude’.” By William Nakashima, MD

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The Popularity of Early By Kent M. Perryman, PhD The author is a member of the SSVMS Historical Committee. All the images in this article are of items in the Sierra Sacramento Valley Museum of Medical History. Between 1880 and 1930 the United States witnessed a flurry of electric energy-enhancement and transfer strategies to promote health care. America was transitioning to electric power for lighting, heating, and industry. Electricity became viewed as an agent of health as well as a source of energy. Regular licensed physicians and quacks were using electric energy cures during the late 19th and early 20th centuries to treat a variety of maladies. The public was mesmerized by the variety of electrical devices being promoted to treat ailments from consumption to rheumatism, melancholia and dementia. However, with the help of the American Medical Association and the passage of legislation by congress in 1938 regulating the sale of quack electrical devices employed in bogus electrotherapy treatments, the electric energy absorption health care theories were finally laid to rest.

Rationale for Electrotherapeutics Energy absorption theories in health care sprang from a Victorian mindset that the human body possesses limited quantities of energy made available to perform daily tasks and bodily functions. With the advent of the industrial revolution in America, individuals in many urban regions were coping with time constraints, increased transportation stresses and more technical labor demands. White-collar fatigue among clerical and administrative staff

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was also reported to reach epidemic proportions during this period. A prevalent diagnosis by 1900 in more urban regions of the US was “nervous exhaustion.” The demands from life during this industrial growth were purported to exhaust the human energy supply. The body had to move faster and the mind had to process increased amounts of information. An American born physician, George M. Beard (1839-1883), coined the term “neurasthenia.” According to Beard, it was characterized by sleeplessness, anxiety, weariness and despondency. The onset of these maladies was signaled by a general weakness and lethargy. Neurasthenia could also be expressed as headaches, back pain, and muscular and joint discomfort. Beard attributed this condition to depletion in “nerve force” which the body (including the mind) possessed in limited quantities. This deficiency was brought on by excessive thought and physical activity associated with the demands being placed on individuals’ life styles by the industrial expansion in America’s urban areas. Beard’s approach to reversing this condition was to restore the body and mind’s energy forces; the body and mind needed time to recover from this physical breakdown. Beard modeled the neurasthenia condition to the physics concept of entropy, where there is a disorder of available energy in a system. His cure was to prescribe treatments with faradic currents (current supplied from intermittent, pulsating induction coils and a battery power source). The patient’s depleted energy reserves could also be replenished by inducing energy from static generators (rubbing objects together), and galvanic, direct current sources (Leyden jars and primitive batteries). Prior to the advent of Beard’s neurasthenia, physicians had introduced electrical cures for a


Electrotherapeutic Hokum variety of illnesses. Charles Poyen popularized mesmerism in the 1830s. Many therapists of mesmerism employed both magnetic and electric analogies to describe the body’s physiology to their patents. A. Paige, a practicing physician in Boston in the 1840s, employed electrical currents from a Leyden jar to treat “brain fever,” a form of dementia. A positive lead was attached to the patient’s head and the negative lead to another region of the body in the belief that an affliction would be carried away by restoring the brain’s electrical balance. E. J. Fraser, another medical school graduate, also promotied the theory in 1863 that there were vital electrical forces in the body, which could be altered for the benefit of health care by an infusion of electrical energy. The main reason so many individuals bought into these early theories of energy absorption and Beard’s neurasthenia was the electrification of America. The industrial revolution was fueled in part by the distribution of electrical energy and its effect on life styles. America was fascinated with electricity beyond the boundaries of lighting, or heating. Beard’s theory of neurasthenia played into the public’s preconceptions. Numerous devices were marketed and sold to the medical profession and to the public with the implied promise that they could infuse the body with energy and drive out disease. The Sierra Sacramento Valley Medical Society’s Museum of Medical History has a variety of these devices in its collection.

Electrotherapeutic Devices The majority of people purchased these devices through the mail from circulars, magazines and newspapers, or from door-to-door sales people and medicine shows. Catalogue sales firms such as Sears and Roebuck and

Galvanic Battery

Montgomery Ward advertised these devices. Dr. Jerome H. Kidder manufactured some of the first mass marketed devices for physicians in the 1880s. These were usually portable enough for the doctor to carry on house calls. Kidder’s devices were housed in beautiful hardwood cases with brass contact switches.

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Violet Ray Kit

Wilshire Electric Belt

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Sierra Sacramento Valley Medicine

Galvanic energy (direct current from battery storage device) was employed to elicit muscle contractions, much like frog legs in high school biology classes. The early electrotherapeutic devices were proclaimed to stimulate digestion and evacuation as well as to reduce ulcers and tumors. The choice of polarity for the area of treatment depended on the physician’s desired effect. A positive current promoted desirable outcome while negative currents reduced undesirable symptoms at the affected area. Faradic or irregular alternating currents (AC) produced through the secondary winding of an induction coil or a magneto. Physicians soon discovered AC devices provided more powerful voltages and could be used as a “nerve tonic” or general stimulant. Beyond the placebo effect, electrotherapy at this time did have some beneficial medical merits in temporarily relieving pain and partial paralysis. The major persisting contribution that electrical therapy made to medicine was stopping blood flow during surgery by cautery. In 1888, Professor W. R. Wells made electrotherapeutic devices that had been formerly in the hands of physicians available to the general public. His device was basically a sulfuric acid battery with specialized electrodes for treating eyes, throat, ears and rectum. The battery manufacturer provided all the instructions for health use. D. C. Moorland had made an earlier version of this health battery available in limited quantities in 1847. Moorland’s Graduated Magnetic Machine came with two metal handles that were either grasped or applied to the body for 10-minute intervals to replenish diminished energies associated with physical and mental illness. Moorland possessed neither a medical degree nor knowledge of electricity, yet his device continued to sell for 20 more years. Some of these electrotherapeutic devices were marketed towards gender-specific treatments. J. L. Pulvermacher first targeted electric belts in 1875 to increase male virility. Pulvermacher’s belts had to be first soaked in vinegar for 10 minutes in order to conduct electricity from a battery source.


Later, at the turn of the century, Thomas Edison’s son, Tom, sold belts constructed of wires covered in cloth and connected to charged discs. The belts created a tingling sensation where they came into contact with the skin. The most successfully marketed version of electric belts appeared later in 1925. Coined the “horse collar” because it was worn over the shoulders; Henry Gaylord Wilshire’s I-ON-A-CO belt consisted of an insulated wire 18 inches in diameter covered in leather. The device was plugged into a lamp socket for 10 minutes of treatment. Three thousand of these belts sold the first year they were on the market for $60 a piece. Wilshire not only sold his belts but set up storefront treatment centers in Pasadena, Seattle and Portland. He also arranged easy payment options and gave public lectures. Thanks to AMA prosecutor Author Cramp and the U. S. Postal Service, electric belts eventually disappeared. The Violet Ray device was also introduced for women to delay the aging processes. The Violet Ray was also proclaimed to treat insomnia, headaches, nervousness, sallow complexion, weak lungs, hoarse voices, dandruff, gray hair and premature baldness. Needless to say, it was very popular with hair salons. The Violet Ray was essentially a handheld Tesla coil (a high voltage, low current device) that would ionize inert gases sealed in a variety of glass wand shapes. There were wands shaped like combs and probes to treat various regions of the female body. A simple spark-gap effect, ozone odor, and buzzing sound was elicited as the wand came within an inch of the body. The only effect these devices ever had on an individual was a slight shock and tingling sensation. There were never any medical benefits demonstrated from the use of the Violet Ray or electric belts. Eventually, the 1938 Federal

Food, Drug and Cosmetic Act was instrumental in diminishing the sale of these and other electrotherapeutic nostrums as well as laying to rest the health benefits of energy absorption. There were many more electric devices and electric procedures employed for health benefits, such as electric baths, electric brushes, electric combs, electrostatic generators and electropoise, which can be viewed in a medical museum. However, there is still a market today for electrotherapeutic treatments as witnessed on the Internet for “The Brain Tuner”. kperryman@suddenlink.net Major Sources: De La Pena, Carolyn T. The Body Electric. New York University Press, 2003. McCoy, Bob. Tales of Medical Fraud. Santa Monica Press, 2000.

Magneto Electric Machine

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A Posit on “Big Box” Medical Care “The provision of primary medical care by business like Wal-Mart will prove to be efficient, effective and commercially viable.”

Where access and cost are bigger issues than continuity and loyalty for a patient, this model of care will serve a need.

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The topic of commercial or corporate medical care is one that clearly concerns many practicing physicians. A two to one majority disagreed with the posit. The majority of commentary was also in disagreement, although as medical people we tend to qualify our statements; perhaps this is an example of the “not infrequently syndrome.” On the other hand, our lengthy commentary reflects the fact that medical care is evolving rapidly, and the form it will take in the future is unclear. Posits are one sided statements intended to introduce a topic for discussion. They do not reflect the opinions of the Medical Society, its Board of Directors or Editorial Committee. Edited comments follow: “I agree, for some patients in some communities. The role of retail clinics in the future of medicine is unknown. They are, and will continue to be, a controversial way for patients to access care. There are several models; some seek to integrate the care they provide with an established PCP (Sutter Express Care), and some are commercial ventures that seek to maximize revenue for their retail host (Minute Clinic), and some work with community health care providers while maintaining significant interest in the service offering (Wal-Mart). Each model and retail relationship has unique objectives. “It is clear that patients like these clinics and they provide safe effective care for the limited scope of services that are offered. (99% of patients who experience this care setting say they would return). Retail clinics are one way Sierra Sacramento Valley Medicine

of providing services more cost effectively in a lower overhead setting, assuming that volume is robust enough to pay those costs. “…Wal-Mart or others don’t “provide” care. They…lease space [to a provider] or acquire (purchase) a vendor to provide the service. The real question is whether the vendor is integrated and coordinated with the system of care in the community to most effectively manage the patient. “In some ways the quality is more consistent, the protocols are evidence-based; for example, there is demonstrated high compliance with guidelines for diagnosis and treatment of strep throat in this setting. “Where access and cost are bigger issues than continuity and loyalty for a patient, this model of care will serve a need. Whether there are enough patients to support this service is dependent on the economics and care capacity in a given community. Where care is unavailable or out of reach (the ED for minor acute illness or injury), the model helps to provide care to those who might not get it otherwise, and that’s a good thing. It’s even better when that care is integrated with a care system that manages the more complex and serious issues that many of these patients contend with.” — Thomas N. Atkins, MD “Though some patients who presently are not receiving any or minimal care may benefit, it will likely fragment further medical care and make it more difficult for PCPs to coordinate care. Even worse, if the services provided are basically screening or emergent care, patients may suffer the false impression they have


received comprehensive care and neglect their regular evaluations with the PCP, which could lead to an unnecessary increase in morbidity and mortality.” — Ronald E. Foltz, MD “I agree, but only for episodic needs like one-time sore throat, allergies, abrasions, etc. It will not be a medical home, but is better than an ER for minor issues.” — John C. Lewin, MD “Based on…unsuccessful programs in developing countries that seek only to serve and attract the poor, the Wal-Mart model seems headed for the drawing board. Healthcare is a different landscape than selling housewares to the lowest bidder. When we buy a product, we don’t have to undress in front of someone or tell them about our last menstrual period or headache or allow them to look in our ears, nose and throat. We want to know that the individual in front of us is highly trained and that our confidentiality is maintained.… “For the 250 million Americans that can afford some type of health insurance or have medical coverage, the Wal-Mart medical clinic model has a long way to go…to convince people to buy its products. “HOWEVER, it is a healthcare development [respecting the] needs of the 47 million other people in the country who don’t have health insurance or health coverage. It gives them access to healthcare professionals at affordable prices. It addresses the gap of the supply and demand in terms of quantity as well as the price. It makes a difference in a situation where there is a…need but neither the government nor healthcare providers and organizations [provide]… Therefore, the market [does]. In effect, the Wal-Martization of healthcare helps alleviate… some of the uncertainties [of] illness. It [offers] the best of management and economic models to aid the efficient delivery of service. “There will be tradeoffs between efficiency and quality, between piecemeal procedures/ treatments and comprehensive care, between low tech and high tech diagnostics, etc. There will be widened gaps between the have and have-nots of healthcare and health insurance. And what of the sacred patient-doctor relationship in these new developments? The poor

can…opt for a living, breathing healthcare provider [and] a prescription for a four dollar generic drugs just a few steps away at the Wal-mart pharmacy…. Healthcare professionals in these clinics will become retail service representatives, customer service, as well as assembly line personnel. And don’t think this effect will be limited to Wal-Mart; it is a wake up call to healthcare professionals, medical societies, organizations and associations.… Respect the needs of 47 million people without healthcare or health insurance and stop [avoiding] healthcare reform. Can [anyone] actually say that the medical profession is concerned about people’s health and well-being [in the face of] these kinds of disparities?” — Stephanie R. Yan, MSII “[I agree] as long as the care is limited to acute care issues like sore throats and ear aches, not blood pressure monitoring or routine diabetic care. It is a convenience to the patients who don’t want to wait to be seen in their PCPs offices.” — Monique B. Hanible, MD “Medicine and healing are not widgets, or equivalent to cheap t-shirts that can be made by child labor in China.” — Francisco Prieto, MD “Good quality primary care requires a trained physician with a three-year residency. The hourly income for a viable practice is at least $500 per hour, which means each visit requires a payment of $125 plus tests. The reason health care costs 150% of what it should is because primary care is not valued by our society. Primary care is rapidly becoming a triage service. The RUC supported by the AMA and specialty societies have killed quality primary care.” — Gerald N. Rogan, MD “The services are too limited to constitute a viable business. The practice of medicine is not like serving up burgers at a fast food outlet. People want a more personal [provider] relation, whether…an FNP or a physician.” — Joanne Berkowitz, MD “There have been few instances in which medical care provided by corporations have been ideal, or quality care.” — Dawn Sung, MSIII “I agree, but ONLY if (1) the patient brings a synopsis of all the medications (and doses) they

July/August 2008

It will not be a medical home, but is better than an ER for minor issues.

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To imply medical care can be delivered like a retail business product further erodes the concept of medical care as a professional service provided in a personal relationship between patient and physician.

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are taking, and a list of their chronic medical conditions, allergies, etc. [otherwise] Wal-Mart [care] can…be dangerous [medicine] and (2) the patient’s medical doctor receives a copy of the note produced during the Wal Mart visit (otherwise the patient’s medical care is only complicated and not bettered).” — Sheryl A. Haggerty, MD “Medical care is a profession, NOT a business. Such a provision will be one more step in the ongoing ruination of our profession.” — William A. Peniston, MD “For-profit will not work and will not work for sick patients and those with chronic illness, [or] co-morbidities.” — Robert P. Diamond, MD “It may be commercially viable(?) The biggest issue I see is follow-up care and obtaining subspecialty care when needed. Will obviously be used by the uninsured unless a patient’s co-pays are greater than the cost for the visit. Follow-up and labs and x-rays, etc. will still be a problem, however.” — Maynard Johnston, MD “To imply medical care can be delivered like a retail business product further erodes the concept of medical care as a professional service provided in a personal relationship between patient and physician.” — Ronald J. Cole, MD “I believe that the Kaiser Steel company proved many years ago that a large corporation could provide medical care. There is no reason to believe that another company would not be able to produce a similar result if they started their own health care organization.” — Sidney A. Scudder, MD “What we need is more primary care and better access...[with] a system of urgent care as part of their on-call/backup. I don’t see a ”doc in a box” approach as valid or useful.” — James A. Margolis, MD “It may very well be commercially viable and competitive with hospital emergency room care; However, I don’t believe the [big box clinics] will see patients who cannot pay, [and] thereby further burden those who do, [like hospital EDs do]. — Allan H. Galbreath, MD “Any Tom, Dick, Harry, Molly, Sue or Jane

Sierra Sacramento Valley Medicine

can set up a Shack and choose a corner in any location, put up a shingle and practice medicine. What a wonderful way to get rid of malpractice costs, deliver health care to all, with no need for all that expensive education and costs and debts. And I can retire from medicine and take up electrical and plumbing?” Elisabeth Mathew, MD “It is a business model issue. The revenue in primary care is inadequate given the overhead. Primary care has devolved either into a loss leader for hospitals and large medical groups or it is analogous to a ’Chinese restaurant’ — family members working in the business for little or no pay with no benefits. To attract investors and meet their expectations for returns is not feasible in this business model.” — David J. Gibson, MD “Though medicine as a mechanical intervention may be better at large scale vendors in terms of reaching the masses, medicine as an art-form may well be worse [off]. The truth is we need large scale high quality care; but at this point I will settle for large scale care period.” — Donna M. DeFreitas, MD “I think this will lead to further fragmentation of our health care system which is already poorly integrated, as a whole. Kaiser does a better job of integration than most.” — Thomas J. Curran, MD “We already have the ‘Docs-in-a-Box’ facilities that seem to be working for minor emergencies but it won’t fit the needs of those who desire a relationship with their physician.” — Michael D. Maddox, MD “Cheap care, cheap outcomes; [I] would be interested in seeing a study. Even Kaiser allows follow-up after ’phone advice.’” — Evalyn Horowitz, MD “I think these drive-through medical care facilities further fracture an already fragmented medical system, minimize the importance of establishing a medical home and suggest to the public that all skill levels are equal in the quality of care and level of knowledge. However, I am sure someone will profit from establishing these ’clinics.’ I just don’t think it will be patients.” — Vivian E. Worn, MD


Primary Care — It is a Tough Business By David J. Gibson, MD and Jennifer Shaw Gibson Here is a news flash that will come as no surprise to the SSV Med readership. Primary care is a tough business. From the investor perspective less than a year ago, the idea of putting walk-in clinics into pharmacies, supermarkets and big-box retailers seemed like a slam-dunk profit opportunity. Hailed as an inexpensive option for treating minor health ailments like sore throats and rashes, the retail clinics had grown in number to 963 as of May 1 — from just 125 three years ago. These clinics typically feature nurse practitioners who can prescribe basic drugs, and the price for a visit ranges from $50 to $75. But reality has dawned on investor groups as they observe the financial performance of their investment. Health clinic operators are closing their doors, shuttering 69 clinics in 15 states. Now, according to the Wall Street Journal,1 the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back expansion plans for its MinuteClinic brand. It is becoming evident that the venture capitalists and private-equity firms that backed many of the retail clinic operators failed to appreciate how complicated and expensive these clinics

The largest clinic operators* Operator MinuteClinic TakeCare The Little Clinic RediClinic Target Clinic

Retail partners CVS,  QVC,  Cub  Foods Walgreen Kroger,  Publix,  Fry’s Wal-Mart, HEB Target

• as of 05-01-08 • Source: Merchant Medicine LLC

Clinics 513 162 57 34 24

are to establish and operate. Each new clinics costs about $500,000 to open. Furthermore, these operations need to spend a lot of money on marketing to build public awareness during their start-up and ongoing operational periods. Thus, these clinics become very expensive very quickly. Not everyone is trimming sails. Walgreen Co has announced that it still plans to more than double the number of the company’s Take Care health clinics this year by adding about 240 locations between now and the end of the year. This development activity will bring Walgreen clinics closer to the number operated by rival CVS (see accompanying graph). The expansion will cause a drag on earnings in fiscal 2008 of five cents a share, the company says. Wal-Mart plans to partner with established community hospital systems to open as many as 400 co-branded store clinics by the end of 2010, up from about 50 sites in operation now. These hospital partnerships leverage the established hospital brand, thus decreasing the marketing costs. This approach is a departure from an earlier strategy under which Wal-Mart leased space to operators like CheckUps that weren’t associated with hospital systems. The problems confronting investor backed primary care has been recognized for some time. The cost structure for diagnosing and managing clinical conditions is becoming progressively untenable. The primary culprit

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Median Compensation for Selected Medical Specialties* Radiology (diagnostic)

$450,000

Orthopedic surgery

$400,000

Gastroenterology Anesthesiology

$350,000

Dermatology

$300,000

Ototorhinolaryngology

$250,000

General surgery Obstetrics-gynecology

$200,000

Emergency medicine

$150,000

Primary care internal medicine Pediatrics

$100,000 1997

2000

2001

2002

2003

2004

Family practice (without obstetricsgynecology

*Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005.

is the current reimbursement system that favors invasive procedures over cognitive skills (see following graph2). This disparity in reimbursement is skewing the choice medical students are making when they select a residency (see following graph). Thus, the de facto public policy

Percent Change Between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties* Percent Change Anesthesiology Pathology Diagnostic Radiology Emergency Medicine Dermatology General Surgery Pediatrics Obstetrics-Gynecology Internal Medicine (includes primary ) Family Practice

150% 122% 34% 18% 7% -4% -8% -16% -18% -51%

-100% -50%

0%

50%

100% 150% 200%

* Data are from the National Resident Matching Program

effect of the current reimbursement system will influence health care over the next generation and will continue to do so unless it is changed. The warning signals that have been evident within health care are now coming from the investment sector. The current reimbursement system is not only a barrier to innovation in health care delivery; it is also a major obstacle to reforming the health care system itself.

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Sierra Sacramento Valley Medicine

DJGibson@winfirst.com David Gibson is the president of Reflective Medical, a health care software development 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 http://online.wsj.com/article/SB121011939298572 319.html?mod=2_1566_leftbox 2 http://content.nejm.org/cgi/reprint/355/9/864.pdf


A Blog on Indigestible Restaurant Noise By Del Meyer, MD; hearing score: 80 percent; discrimination score: 40 percent It is estimated that 90 percent of people with vision loss generally obtain glasses to correct their loss, while only 25 percent of people with hearing loss obtain hearing aids. Hearing aids are very good at amplifying the sound to bring volume back to normal. However, all hearing loss is not conductive. Much of it is perceptive — where the hearing impaired person is unable to distinguish between many words. An audiogram describes the decibel hearing loss with the familiar curve. However, the perception or discrimination score is far more important. In this part of an audiogram the audiologist turns up background noise and asks that words be repeated back. Discrimination scores are commonly in the 80s and 90s which means that you are able to correctly identify 8 or 9 of words out of 10. People with hearing impairment often don’t hear the first word or two and work backwards to guess from content the first word of a sentence. Therefore it is important when talking to a person with hearing aids to speak in sentences: To say “yes” or “no” is seldom understood, so say, “Yes, you can” or “No, you can’t” for better understanding by the person with hearing loss. If a discrimination score drops to 40 percent, that means you hear 4 words out of 10 and you no longer can reconstruct a sentence. People with hearing aids watch your lips very carefully since lip reading helps understanding. So try to never talk to a person wearing hearing aids from the back or side. Speak directly from in front. People with perceptive hearing problems and poor discrimination scores have huge prob-

lems when dining in a noisy environment, as is found in many restaurants. Background noise makes communicating across the table almost impossible, and the hearing impaired generally fail to communicate. In a noisy restaurant you may notice the hearing impaired, silently nodding as if they could hear, yet isolated, often attempting to hide behind a fake bright fixed smile. Our blog is dedicated to noise-rating restaurants. We hope this blog will provide a list of hearing-friendly venues. After all, with luck many who now hear well will live long enough to become impaired. We would like your help. When you dine we ask that you rate the restaurant relative to background or ambient noise on a scale from one to ten — One being an intolerable din making it impossible to hold decent conversations, and Ten being a quiet dining environment where conversation is easily carried out among several people. In addition to the one to ten rating, please provide the name and address of the restaurant, the day of the week and time you were there, and a comment: If you made a reservation and asked for a quiet table, was it quiet? How were the service and the food? Are you aware of certain days when the ambient noise is different, as, for example, when there is entertainment? We are particularly interested in the Sacramento, Yolo and El Dorado Counties area, but if you find a particularly noise friendly place elsewhere in California it will be appreciated. Results will be collected and displayed at our blogsite http://medicaltuesday.blogs.com DelMeyer@MedicalTuesday.net

July/August 2008

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Chronophagos By John Loofbourow

It was a universal carnage that I knew not; He had agreed from before time began to attack by day and by night; To infiltrate, subvert, steal, or poison all and every thing that made me human, free, and whole; I was his enemy, unaware, and unwary. At first, along the shrinking years, I laughed at his pretensions; Flaunted my innate strength, Ignored his puerile rant and cant. But he used holy weapons unknown to me, yet known to all. They served him in covert and overt ways, As lately have my rebellious fickle powers, Silent deserters; old and querulous.

I wash his tortured feet, warm his rheumy joints, Attend his phlegm clogged airways. Suffer his remembrance of a past which was, and was not, Go with him to bury and mourn those who loved us, or not, Watch over his shrinking form and sallow face, Past rheumy, crusting eyelids; Remain silent as he takes even my own name to himself. Shaking, I feed and dress him; Stumbling, I walk in his pain filled shoes; Mumbling, I curse my dedication to his welfare; Terrified, I fear we shall live forever While he seems to fear that we shall not.

#

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They enslave me; proclaim him my heavenappointed master. And I? I give mute consent; Am his bond servant, working vainly for my own chimeric freedom. He grows more demanding; I grow weary of caring for his aging flesh. He gives cynical praise to my efforts; But denies my release from servitude. We dispute and redefine the term and the terms of my sentence. He is relentless; my illusion is his strength. He relies on my lies to myself. “The fine print reads,” he says, “that before your release, You will serve as my nursemaid.”

Yet sometimes he seems wise, and not altogether evil. I fear to mistake him for myself. He is sleeping now in fits and starts. I could break free. But no; I pity his infirmities as my own. A failing resentment, a tired knowing, Prevents me from tearing out his heart, Or wringing his turkey neck. When he imagines himself alive, I charitably confirm his illusion. “This, and this alone,” he claims, “is the timeless text of God’s eternal law.” I see. I shall not prevail. God is love, and so must abandon all of His creation, except for my enemy. Meekly now, and reconciled, we wait, While the immortal infant Chronos, Grown huge, devours the universe.

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July/August 2008

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In Memoriam

Gerald Paul Martin, MD 1940–2008

In February, the Roseville and Sacramento medical community lost a superb radiologist, a leader at many levels and a true friend. Gerald Paul Martin was born on July 11, 1940. He did his undergraduate work at UCLA from 1958–1962 and then attended Vanderbilt University School of Medicine. After graduating in 1966, he completed a surgical internship at the University of Pittsburgh’s Presbyterian University Hospital. From 1967–1969 he served in the U. S. Air Force as a general medical officer at Langley AFB Hospital. He then entered a Diagnostic Radiology residency at David Grant USAF Hospital. After finishing his residency and becoming board certified, he spent a year as Chief of Radiology at Mather AFB Hospital. In 1973 he moved to Roseville California and in 1976 helped found Roseville X-Ray Medical Group. He continued to practice in Roseville and the surrounding area as a member of Radiological Associates of Sacramento until illness forced his retirement in early 2007. Jerry was active in the medical community of Roseville and Placer County. He was President and Member of the Board of Directors of the Placer-Nevada County Medical Society. He served in the California Medical Associations’ House of Delegates and on the CALS Hospital Survey Team. At the local level he was President of the Placer Health Planning Council and an active member of the Sierra Sacramento Valley Medical Society. He was an important member of the Planning Committee for the new Sutter Roseville Medical Center. This impressive chronology does not begin to describe the person that was Jerry. He entered

radiology as the new technologies of ultrasound, computed tomography and, later, MRI revolutionized the field of diagnostic imaging. Jerry enthusiastically learned each of these new modalities. He worked industriously and always did more than his share of the cases. His quick humor, insights and pithy comments lightened many days. Jerry often acted as an examiner at the mock boards put on for the Northern California radiology residents. He returned with tales of how profoundly impressed he was with the quality of our younger colleagues and how much he looked forward to working with them. He was a man of broad interests Gerald Martin, MD and could converse easily on such diverse subjects as literature, history, philosophy and enology. In January of 2007, Jerry was diagnosed with metastatic pancreatic cancer. Despite his grim prognosis, Jerry’s humor and upbeat personality never left him. He survived his diagnosis by more than a year. During that time he never complained or felt sorry for himself. Only a few weeks before his death, Jerry and his wife of 43 years, Suella, took their three children along with their spouses and six grandchildren on a cruise in the Caribbean. When he returned, he spoke glowingly of the trip and how it had exceeded everyone’s expectations. Jerry’s wit, humor, insights and friendship will be greatly missed by the Roseville and Sacramento medical communities and by his many friends outside of medicine. — Richard Gross, MD

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MICRA: Protecting Patients’ Rights. Preserving Healthcare Access and Affordability California’s Medical Injury Compensation Reform Act (MICRA) is a critical component of California’s healthcare infrastructure. It ensures injured patients receive fair compensation, while preserving patients’ access to healthcare by keeping doctors, nurses and healthcare providers in practice and hospitals and clinics open. Enacted by an overwhelming bi-partisan vote, MICRA has saved healthcare consumers tens of billions of dollars. Though MICRA has helped contain runaway liability costs, many specialty services like OB-GYNs, nurse midwives, emergency providers and rural health providers are particularly vulnerable to any liability increases or weakening of MICRA’s reforms. • DID YOU KNOW…that because of MICRA reforms, liability premiums for California doctors have increased at one-third the rate of the rest of the nation -- and medical providers of all types have been less likely to close their doors because of skyrocketing liability costs? • DID YOU KNOW…that half of all medical students decide where to begin their careers based significantly

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Sierra Sacramento Valley Medicine

on the cost of malpractice coverage? • DID YOU KNOW…that weakening MICRA reforms will also reduce access to routine preventive healthcare, including regular screenings for high blood pressure and cholesterol, diabetes, sexually transmitted diseases and other serious health risks? • DID YOU KNOW…that in states with soaring medical liability insurance premiums, there is reduced access to obstetrics and emergency surgery services, particularly in rural areas, because certain doctors in high-risk specialties are no longer serving on-call to hospital emergency departments? Californians Allied for Patient Protection (CAPP) works with the county medical societies and the California Medical Association to identify local clinics to join in the fight to protect MICRA. If you practice in a clinic, or if you are a doctor with a compelling story about how your practice might be changed if MICRA were altered, please also contact CAPP’s Executive Director Lisa Maas at (916) 448-7992 or LMaas@micra.org.


Board Briefs May 12, 2008 The Board: Approved the Audit Report for the Year Ending December 31, 2007 and Auditor Recommendations. Approved the Auditor’s recommendation to revise Policy 100-06, Maintenance of Reserves in the General Fund, to state that SSVMS shall strive to maintain sufficient reserves to assure uninterrupted operation for a minimum of 12 months and for other unexpected contingencies. Approved the recommendation to sunset Policy 100-05, Building Fund, since it is no longer necessary. Approved the follow-up work items from the 2008 Board of Directors Retreat. Unanimously approved that proposed bylaws amendments be submitted to the Active membership for approval. Referred to the Executive Committee for final approval the establishment of the 2008 Nominating Committee. Approved the Membership Report: For Active Membership — Jennifer N. Boule, MD; Michelle Draznin, MD; Deepa Gupta, MD; Sheryl A. Haggerty, MD; Jagdey S. Heir, MD; Alex S. Hongkham, MD; Renuka Lakshminarayanan, MD; Parham V. Morgan, MD; Joelle Morrow, MD; Erik V. Soloff, MD; Edna D. Taniegra, MD; Mai B. Tran, DO. For Annual Renewal of a Special Leave of Absence — Derek J. Wong, MD. For Retired Membership — Sajad Janmohamed, MD. For Resignation — Michael S. Edwards, MD (moved to Santa Clara).

June 9, 2008 The Board: Approved the annual report of the Community Service, Education and Research Fund (CSERF) and the Operations Manual for the Sacramento Physicians’ Initiative to Reach Out Innovate and Teach (SPIRIT).

Received a report concerning proposed cuts in the Sacramento County Budget to health and safety net programs, and the effect these actions will have on the physicians, hospitals, emergency rooms and citizens in Sacramento County if approved. A letter will be sent to the Board of Supervisors expressing the Society’s profound disappointment and concern. Representatives of the Society will attend and provide testimony at hearings on this matter. Also, received a report concerning the future of Yolo County’s safety net activities. Approved the First Quarter Financial Statements and Smith Barney Investment Report. Approved not renewing the Society’s peer review contracts with the Sacramento Juvenile Detention Facility and the Yolo County Corrections due to reimbursement and liability concerns. Approved the following appointments to the 2008 Nominating Committee: Richard Jones, MD, Chair; Ruth Haskins, MD, District 1; Michael Burman, MD, District 2; Barbara Arnold, MD, District 3; Earl Washburn, MD, District 4; John Ostrich, MD, District 5; Marcia Gollober, MD, District 6; Jon Finkler, MD, At-Large; Richard Pan, MD, At-Large.

Wisdom… • A day without sunshine is like night. • On the other hand, you have different fingers. • 42.7 percent of all statistics are made up on the spot. • 99 percent of lawyers give the rest a bad name. • Remember, half the people you know are below average. • He who laughs last, thinks slowest. • Depression is merely anger without enthusiasm. These selections appear on a number of websites as “The Wisdom of Larry the Cable Guy.” The cable guy is actually comedian Daniel Whitney.

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The Shifa Student Clinic By Hailey MacNear, MSI, UC Davis School of Medicine When I started medical school at UC Davis, I already knew that I wanted to be involved with the student-run clinics. It is a rare opportunity that first-year medical students get to see patients, practice procedures, and learn under the attention of seasoned practitioners so early in their careers, and I jumped at the offer. What I found, though, was much more than I could ever have asked for — a chance to be involved in a deep and committed community effort to provide care to the underserved. Shifa Community Clinic is one of the student-run clinics affiliated with the UC Davis School of Medicine. It is open every Sunday and generally sees between 12 and 20 uninsured patients each Sunday. Many of Shifa’s patients are immigrants with limited English proficiency, and most patients belong to Middle Eastern or East Asian communities. Shifa works to provide culturally sensitive care in many ways. Translation services are available for Punjabi, Hindi, Farsi, Arabic, Urdu, and other languages. Health education is tailored to the population. For example, diabetics get special information to assist them during fasting for Ramadan, and dedicated undergraduate volunteers create language-specific health education materials on a variety of topics. Special chronic care clinics on the first Saturday of each month allow extra time for patients with more complicated chronic diseases. The second Sunday of each month is women’s clinic — female preceptors and medical students ensure women get the culturally sensitive care they need. Shifa continually strives to meet the needs of its community through outreach, research,

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Sierra Sacramento Valley Medicine

and commitment to patient care, none of which would be possible without the generosity of local physicians. For example, Shifa has held bi-annual retinopathy screening clinics in which our diabetic patients have the opportunity to be seen by local ophthalmologists. This summer, patients will have the chance to be screened for colon cancer with a free flexible sigmoidoscopy clinic at Kaiser in Sacramento. All of the seven UCD SOM student-run clinics rely on the selfless support of volunteer physician preceptors, who assist medical students in directing patient care, writing prescriptions, collecting lab specimens, and doing procedures. They are valuable teachers and role models who demonstrate their caring for both patients and students by donating their time and knowledge — on weekends, no less! As I look back on my first year of medical school, I feel infinitely blessed to have such incredible clinical experiences so early in my career. The opportunity to be a part of such a dedicated community health team is invigorating. They are teaching me not only how to be a physician, but what kind of physician I want to be. The Shifa Clinic hours are Sundays from 8:30 a.m. to 2:00 p.m. at 419 V Street, Suite A, Sacramento, CA 95818. For more information, contact the clinic at 916/441-6008 or www.shifaclinic.org. Physician volunteers are needed and are very greatly appreciated. hmacnear@gmail.com The author grew up and went to high school in Davis, and received a B.A. in psychology and anthropology from Oberlin College in Oberlin, OH.


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 DOMINGUEZ-JONES, Julieta, Family Medicine, Loyola Stritch School of Med 2000, Sutter Medical Group, 8170 Laguna Blvd., #215, Elk Grove 95758 (916) 691-5900

SOLOFF, Erik V., Radiology/Abdominal Imaging, Med Col Ohio 2000, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

HAGGERTY, Sheryl A., Internal Medicine, Univ Nebraska 2000, 5290 Elvas Ave, Sacramento 95819 (916) 739-1507

TANIEGRA, Edna D., Family Medicine, Far Eastern Univ, Philippines 1983, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-2166

LIOU, Alex J-C, Internal Medicine/Pediatrics, National Defense Med Ctr, Taiwan 1984, California Department of Corrections & Rehabilitation, 1600 California Dr, Vacaville 95695 (707) 448-6841

YOUNG, Jeffrey L., Physical Medicine & Rehabilitation, St. Louis Univ 1995, 5525 Assembly Ct, Sacramento 95823 (916) 428-2330

…More Wisdom… • Support bacteria. They’re the only culture some people have. • A clear conscience is usually the sign of a bad memory. • Change is inevitable, except from vending machines. • If you think nobody cares, try missing a couple of payments. • How many of you believe in psycho-kinesis? Raise my hand. • OK, so what’s the speed of dark? • When everything is coming your way, you’re in the wrong lane. • Hard work pays off in the future. Laziness pays off now. • How much deeper would the ocean be without sponges? • Eagles may soar, but weasels don’t get sucked into jet engines. • What happens if you get scared half to death, twice? • Light travels faster than sound. That’s why some people appear bright until you hear them speak. • Life isn’t like a box of chocolates, it’s more like a jar of jalapenos. What you do today, might burn your butt tomorrow.

July/August 2008

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Classified Advertising

Positions Available PART-TIME PHYSICIANS for urgent care center. Hours flexible. BC/BE in FP, IM, EM preferred. Competitive compensation and malpractice paid. Kim Marta, MD. The Doctors Center, 4948 San Juan Ave., Fair Oaks, CA 95628. (916) 966-6287.

Membership Has Its Benefits!

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

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

Billing & Collections

Athenahealth 1-888-401-5911

Car Rental

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

Clinical Reference Guides-PDA

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

Collection Services

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

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

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

Office Supplies

Corporate Express /Brandon Kavrell (916) 419-7813 / brandon.kavrell@cexp.com

Practice Management Supplies

Histacount 1-888-987-9338 Member Code:11831 www.histacount.com

Medical office space for lease! 2 options available. 1,783 sf shell space with generous TI allowance OR share existing office with another practice. Sue (916) 367-6352.

Electronic Claims

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

St. George Medical Center has been transformed! Imaging center, clinical labs, cafe and pharmacy on ground floor. Great medical office space available on upper floors. Sue (916) 367-6352.

Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...

Marsh Affinity Group Services 1-800-842-3761 CMACounty.Insurance@marsh.com

HIPAA Compliance Toolkit

PrivaPlan 1-877-218-7707 / www.privaplan.com

Investment Services

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

Magazine Subscriptions

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

Notary Service/Free to Members

Medical Society (916) 452-2671

Security Prescription Pads

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

Professional Publications

UCG Decision Health 1-877-602-3835 / www.decisionhealth.com

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

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.

Office Accreditation We’ll prepare your office for licensure, general anesthesia or conscious sedation with any accrediting agency. Contact Outpatient Settings at (530) 758-3324 www. outpatientsettings.com

Office Space

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

Doctor’s Placement Agency

Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911

All medical personnel (916) 457-4014

… Wisdom’s End • • • • • • •

Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning

Since 1973 • Max Uden, Owner • (916) 455-5880

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• Inside every older person is a younger person wondering, ‘What the heck happened?’ • Just remember -- if the world didn’t suck, we would all fall off.

Sierra Sacramento Valley Medicine

• Why do psychics have to ask you your name? • The early bird may get the worm, but the second mouse gets the cheese in the trap.


partnership

whatdrivesyou? A commitment to excellence. A passion for the art of medicine. A basic desire to heal. Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL.

(800) 652-1051 www.norcalmutual.com

NORCAL is proud to be endorsed by the Sierra Sacramento Valley Medical Society as the preferred professional liability insurer for its members.

July/August 2008  

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

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