2009-Jan/Feb - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2009

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE 2009 — Our 155th Year

Charles H. McDonnell, III, MD

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Letters to the Editor

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Never Events

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Med Student Empowerment on the Annual Lobby Day

Daniel Stein, MS II

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Nightvoice

David F. Dozier, Jr., MD

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Corrections — the Best Kept Secret in Medicine

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The Annual Meeting

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Posit: Medical Care for Indigent Illegals?

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IN MY OPINION The Recession and its Effect on Healthcare

David J. Gibson, MD, and Jennifer Shaw Gibson

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CMA’s Legislative Wrap-up

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IN MEMORIAM Kenneth Hisao Ozawa, MD

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IN MEMORIAM Ernest J. Petrulio, MD

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New SSVMS Committees

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Board Briefs

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New Applicants

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Classified ads

Jane Grametbaur, RN, CCHP-A, CLNC

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Voices of Medicine

Del Meyer, MD

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The Escuela Latinoamerica de Medicina in Cuba

George Meyer, MD

We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below.

Authors will be able to review any edits before publication.

All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

SSV Medicine is online at www.ssvms.org/magazine.asp This is the first in a series of covers by orthopedic surgeon Greg Joy, MD, of Placerville, who thought about becoming a photographer before entering medical school. After retiring, “I wanted to pick up where I had left off, but found that 40 years had brought significant change to photography.” Nearly all his work now takes advantage of the “digital darkroom,” used “to create a picture that represents what was foremost in my mind at the time photographs were or could have been obtained.”

This cover, First Fall Rain, is a composite of three 35mm slides worked over with Photoshop. “You are looking at the plastic straps of a lounge chair through which you see leaves covering the surface of a nearby swimming pool. The concept of a lounge chair floating over a swimming pool is silly.

However, the gentle drops and the single leaf on a lounge chair, when put together with the many fallen leaves, contrast so well in color and concept, and remind me of the veracity of that first fall storm.”

January/February 2009

Volume 60/Number 1 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.

2009 Officers & Board of Directors Charles McDonnell, III, MD President Stephen Melcher, MD President-Elect Margaret Parsons, MD, Immediate Past President District 1 Alicia Abels, MD District 2 Michael Flaningam, MD Michael Lucien, 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 Marcia Gollober, MD At-Large Alicia Abels, MD Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Margaret Parsons, MD Charles McDonnell, MD Janet O’Brien, MD Kuldip Sandhu, MD Earl Washburn, MD

District 5 John Belko, MD David Herbert, MD Robert Madrigal, MD Elisabeth Mathew, MD Anthony Russell, MD District 6 J. Dale Smith, MD

Alternate-Delegates District 1 Robert Kahle, MD District 2 Margaret Parsons, MD District 3 vacant District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Karen Hopp, MD At-Large Richard Gray, MD Sanjay Jhawar, MD Robert Madrigal, MD Mubashar Mahmood, MD Connie Mitchell, MD Anthony Russell, MD Gerald Upcraft, MD

CMA Trustees 11th District Dean Hadley, MD Richard Pan, 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 William Peniston, MD David Gibson, MD, Vice Chair Robert LaPerriere, MD Gerald F. Rogan, MD F. James Rybka, MD Gordon Love, MD Gilbert Wright, MD John McCarthy, MD Lydia Wytrzes, MD Del Meyer, MD George Meyer, MD John Ostrich, 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

2009 — Our 155th Year With the country in a recession and healthcare reform on the front burner, all physicians need to step up to the plate.

By Charles H. McDonnell, III, MD This talk by Dr. McDonnell at the SSVMS Annual Meeting has been lightly edited for print.

As I look across the audience tonight I see many members and guests who I admire and who are very dear to me.

I want to thank all of you for taking the time out of your busy schedules to share this evening with us at this important time in history for our profession and organized medicine.

I joined the Medical Society’s Board of Directors in 2004. While on the Board, I observed Doctors Pan, Chatterjee, Sandhu, Jones and Parsons serve as presidents with aplomb. With the help of Executive Director Bill Sandberg and Associate Director Chris Stincelli, they emphasized community service and advocacy.

They updated the society’s policies and procedures, fine-tuned the society’s finances, bolstered membership and even replaced the windows in our building, initiating a green movement for the SSVMS. We heard Dr. Parson’s talk about the success of the Medical Society this past year. I want to take this opportunity to speak with you about our challenges today, how I think we can meet those challenges and my vision for a successful future.

Today’s global healthcare reforms and initiatives impact us directly at the local level. As your new Medical Society President, I will continue to facilitate and encourage the collective voice that we as physicians must have in this great society.

As we all know, I am not the only new President entering office this January of 2009… and it is no secret that our new American

President is pursuing health care reform.

That being said, I must stress the importance of our being a part of whatever directions are formulated for the future evolution in healthcare — to not only ensure the protection of our physicians, but to also protect and improve the healthcare provided to our patients and community.

Then there is the economic crisis; a crisis leading to increasingly desperate and drastic cuts in medical services as more and more people are losing their jobs and health insurance. In light of such powerful forces of instability, now is not the time to bow out of SSVMS and CMA. In fact, it is the time to not only step up to the plate as a member of this society, but to also be active in SSVMS and truly become part of the voice and modern evolution of organized medicine. In our profession the phrase “be global, act local” rings especially true and especially now. I firmly believe that we cannot make a difference statewide or nationally, if we cannot protect the physicians and patients today in our own backyard, and maintain and improve the reputation, prestige and standing that our pioneering colleagues built for us.

The very birth of organized medicine in California was in response to a crisis, a public health disaster — the cholera epidemic of 1850.

It was this society that established the first public health department and led to the CMA’s founding of the California State Department of Health in the 1870s.

SSVMS and the CMA continued to rise to many other challenges. BloodSource was created in 1948 in response to local blood shortages. NORCAL Mutual Insurance Company was

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founded in 1975 in response to a malpractice insurance crisis — and always, SSVMS was there leading the way, successful, resourceful, active and indispensable.

There is no doubt about it, the number one advantage to being a member of this society in 2009 is the representation that we provide for physicians to the CMA, city, county and state in legislative and legal advocacy. There is just no doubt.

Who will represent future doctors to government? Who will look after the patient-physician relationship and our role as independent patient advocates? It will be the Sierra Sacramento Valley Medical Society — and, to be effective, we physicians must work together and be active. We must not be divided.

Annually there is legislation that eventually affects all physicians, even if they practice in a closed system or are employed by the government. Whether it’s about insurance companies rescinding patients’ coverage or scope of practice, the SSVMS and CMA are there. Of course, the most powerful example of our continued legislative success is the landmark MICRA legislation, which alone saves the average physician (member or not) over $70,000 a year.

Our current legal battles include challenging the legality of the Medi-Cal cuts and balanced billing regulations. Our success thus far with Medi-Cal cuts and the recent RICO suits (which returned millions of dollars to physicians) are

examples of how membership benefits return much more than the cost of membership.

The question is not, “Can a physician afford to be a member of the Sierra Sacramento Valley Medical Society and CMA?” but, “Can one afford not to?”

Subspecialty medical societies alone can’t represent the interests of all physicians. And although the importance of specialty societies cannot be discounted, especially at the federal level, they cannot speak as one. They do not provide nearly as powerful a voice in California as CMA and the local medical societies. Again, the power of the Sierra Sacramento Valley Medical Society and CMA comes from the collective voices of many in the profession.

Early on in this organization, it was a necessity for physicians in the Sacramento area to be a member to be considered credible by peers. We are now at that time again. We set the standard then and we can set it again. One of our greatest strengths is that we are a purely volunteer physician organization not beholden to anyone else’s actions but our own.

So we must continue to trumpet and market to non-members the recent and evolving successes that make this organization prestigious and noteworthy, emphasizing our actions and influence at local, state and federal levels and our success in competing against the other many special interests.

As your president, I will work to insure that we remain dedicated to upholding the authority and autonomy of physicians in the delivery of professional and ethical medical care. It is with the sincerest honor and privilege that I look forward to serving you as president of our Sierra Sacramento Valley Medical Society, to carry on the tradition of dignity, honor and prestige of an organization that truly cares about the patients of the Sacramento region and the physicians who serve them.

Let’s get the job done and let’s continue to make a difference… mcdonnell@surewest.net

Katie Curit Interviews President Elect McDonnell

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Sierra Sacramento Valley Medicine

Letters to the Editor These letters, both edited for space reasons, refer to articles in the last issue. Dr. Krahling, a former member of the SSVMS Editorial Committee, now lives in Redding.

Ambulances Remembered, Fondly Such memories you stirred by your article [California’s Ambulance Services During the 1960s] In 1949 I bought a practice in Orland, on old 99w across from Chico. I had worked for a doctor in Grass Valley a few months just out of a general internship. The local ambulance was owned and operated by the Orland ambulance association which was a membership supported by small annual dues. Members got a good rate if they used the ambulance, and others paid a little more.

Clarence Nelson was a furniture store owner/ operator who kept the ambulance at home in his garage, near his business. The ambulance was a “stretched” 1941 Chevy former panel truck, I think. Clarence was the driver and the only person. If help was needed, he called the local volunteer fire department. The chief was a baker, and the two trucks were in part of his building. The noon whistle was blown to call the volunteer, one blast if going north of town, and two if south. This was so the designated men could man a certain intersection with a little stop paddle.

Firemen were a great group of guys whom I soon learned to know. They had no training, but the year before I came to town, Aaron Stockton’s son was struck by a baseball, rendered unconscious, and died. There was no respirator so Aaron bought an E and J for the department. So I used it myself and trained guys while using it.

At that time the local telephone operators were the communication. They seemed to know where I was all the time, and could reach me by phone or send the police. If I was gone for the weekend they would collect calls for me, and often I was busy until midnight or later.

I stayed in Orland until 1960 and little had changed except Mr. Pratt became the driver and his wife became an answering service. They had a new ambulance built, and staff remained unchanged. We had some RNs we could call on if needed.

Those were the days!!!!!!!!

— Buren Krahling, MD

Reflections on Pain As an occupational medicine physician, I enjoyed your article [on Abusing the Workers’ Comp System]. In most chronic pain management, to come in every month is excessive.

Perhaps your patient might look at it this way: Each visit is a chance to make sure it is actually his work injury that is the cause of the problem.

The docs should be checking for medication side effects and referring him for new work when that is indicated. Patients often want to blame everything on a work injury...and docs who disagree risk a patient’s anger, but may save his or her life.

My grandfather had a work related injury in his late 40s…. In attributing everything to his shoulder pain, he did not seek proper work up, so that his work injury indirectly led to his death…

It is sad that we are pressured to see patients more and more quickly and lose the chances to get to know our patients. Even though I am a “work comp” doctor, I don’t forget that my patients are people. In first doing no harm, I try to protect patients from needless disability, job loss and depression and encourage them to be active.

When I am pressured to send folks back inappropriately I have found adjusters can seek other doctors easier to bully. When patients try to bully me into putting them off work, they often leave but find their next doc says the same thing I have!

— Sarita Salzberg, MD, MPH January/February 2009

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Never Events Printed by permission of NORCAL Mutual Insurance Company. NORCAL is the premier provider of professional liability insurance for physicians, medical groups, community clinics, hospitals and medical facilities. To access additional articles published by NORCAL, visit www.norcalmutual. com.

The topic of Never Events is an important development within the healthcare industry, bringing changes to the hospital environment in which many physicians practice. Those changes are a result of many hospitals’ efforts to reduce these events.

Physicians should find value in being able to identify Never Events, and in understanding the impact of recent state and federal regulations on Never Event reporting and reimbursement, and preparing for coming changes in inpatient care.

The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF). There are currently 28 Never Events. They are grouped into six categories: 1. Surgical (e.g., wrong site, wrong procedure, wrong person surgery, retained objects, intraoperative or immediately post-operative death in a normal healthy patient) 2. Product or device (e.g., death or disability caused by contaminated drugs or devices, the use or function of a device or air embolism) 3. Patient protection (e.g., infants released to the wrong parents, patient elopement or patient suicide) 4. Care management (e.g., stage 3 or 4 pressure ulcers, death or serious disability caused by medication error, hemolytic reaction, hypoglycemia, kernicterus, spinal manipulative therapy or labor and delivery in a low risk pregnancy) 5. Environmental (e.g., an oxygen or gas line containing the wrong gas or contaminated

with a toxic substance, patient death or serious disability caused by fires, electrical shock, falls or restraints) 6. Criminal (e.g., care ordered or provided by someone impersonating a licensed health care provider, sexual assault of a patient, abduction of a patient, death or significant injury caused by a physical assault).1 In general, Never Events are difficult to defend in medical liability litigation, mostly due to the alarm associated with their occurrence and the tendency for them to occur as a result of failed patient-safety systems or substandard medical care. That is not to say, however, that these events cannot occur when a patient’s care has been appropriate.

Healthcare providers should also be aware of Never Event reporting laws. For example, in September of 2006, the California Legislature adopted legislation that directs hospitals to report Never Events (referred to in the legislation as “adverse events”).2 The Joint Commission considers all of the NQF Never Events to be “Sentinel Events.”

Accredited organizations are expected to identify and “respond appropriately” to all sentinel events, according to the Joint Commission.

An appropriate response includes “conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements.” Although the Joint Commission does not mandate reporting, the organization encourages it.3 More information on sentinel event policies and requirements can be accessed on the Joint Commission website, www.jointcommission.org.

In addition to professional liability concerns, Joint Commission requirements and reporting mandates, hospitals will also experience increased difficulty obtaining reimbursement

January/February 2009

In general, Never Events are difficult to defend in medical liability litigation...

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Although Never Event rules, regulations and guidelines are currently directed towards hospitals, individual healthcare providers will feel their effects.

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for treatment rendered as a result of a Never Event.

For example, in August 2007, the Centers for Medicare and Medicaid Services (CMS) announced that beginning October 1, 2008, Medicare will no longer pay at a higher weighted MS-DRG for 11 conditions (some are on the Never Events list) when acquired during a hospital stay. These conditions are referred to as “Hospital-acquired Conditions” (HACs). As anticipated, private health insurers are following CMS’s lead in refusing to reimburse for care rendered as a result of a Never Event/HAC. For example, Aetna and WellPoint have started to include reimbursement refusal provisions in some of their contracts.4,5 Although Never Event rules, regulations and guidelines are currently directed towards hospitals, individual healthcare providers will feel their effects. Hospitals, if they haven’t already, will begin developing new policies and procedures to deal with these changes, and providers will be expected to comply with them.

Furthermore, it is anticipated that Never Event legislation and reimbursement limitations will be used in malpractice claims against individual providers to support allegations of medical negligence. Finally, some commentators suggest that the Medicare and private health insurer reimbursement limitations will be extended to individual providers.6 Keeping a Never Event from occurring is an appropriate goal for any healthcare provider.

Consistently adhering to policies and procedures designed to guard against the occurrence of Never Events can protect patients, reduce liability exposure, reduce reporting burdens and preserve reimbursement rates.

NORCAL has provided risk management advice via the monthly Claims Rx and CME courses related to many of the 28 Never Events and CMS’s HACs. Providers are encouraged to review the following publications, available at www.norcalmutual.com.

• Wrong patient, wrong site, wrong surgery, surgical site infections — The July 2008 Claims Rx entitled: “Risk Management and Patient Safety Strategies for Surgeons”

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• Medication errors, contaminated devices — The June 2008 Claims Rx entitled: “Strategies for Making the Medication Delivery Process Safer” • Hypoglycemia — The November 2006 NORCAL CME course entitled: “Diabetes: Managing Comorbidities” • Hyperbilirubinemia/Kernicterus — The May 2008 Claims Rx entitled: “Focus on Newborn Patients: Strategies for Reducing the Incidence of Kernicterus as a Result of Hyperbilirubinemia and Vision Deficits as a Result of Retinopathy of Prematurity” • Surgical Fires — The December 2007 Claims Rx entitled: “Reducing the Risk of Surgical Fires” • Deep Vein Thrombosis/Pulmonary Embolism — The March 2008 Claims Rx entitled: “Deep Vein Thrombosis Prophylaxis” To learn more about new Medicare rules on reimbursement for hospital-acquired conditions (HACs), see “Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates,” in the Federal Register/Vol. 72, No. 162, August 22, 2007/Rules and Regulations.

To learn more about proposed 2009 rule changes on HACs, see “CMS Proposes Additions to List of Hospital-Acquired Conditions for Fiscal Year 2009” at the CMS website at www. cms.hhs.gov.

To learn more about California’s new rules on reporting adverse events, see the California Health and Safety Code, Sections 1279.1-1279.3 and 1280.4.

As physicians interface with hospital staff and administrators, they will hear more about Never Events. As hospitals face the lack of reimbursement for patients who experience these events, physicians will be witnessing policy and procedure changes, discussions at medical quality and peer review committees, and other measures aimed at the prevention of these events. By understanding the history and the reimbursement factors associated with Never Events, physicians will be better prepared to be involved in these activities and offer support and input.

Keeping a Never Event from happening from occurring is optimal. However, they continue to occur at a significant rate. Having appropriate policies and procedures in place to guard against the occurrence of Never Events can increase patient safety, reduce liability exposure, reduce reporting burdens and preserve reimbursement rates. When those policies and procedures do not work and a Never Event occurs, in addition to analyzing those policies and procedures to determine what has gone wrong, hospitals must follow adverse event reporting laws and be prepared for limitations in Medicare and private insurance reimbursement.

1 Patient Safety Primer: Never Events. Available on the AHRQ Patient Safety Network website.

2 California Health and Safety Code §§ 1279.1-1279.3 and 1280.4.

3 Sentinel Events. Available on the Joint Commission website.

4 CMS proposes additions to list of hospital-acquired conditions for fiscal year 2009. April 14, 2008. Available on the CMS website.

5 Report of the board of trustees. Presented by: Edward L. Langston, MD, Chair. Available on the AMA website.

6 Medicare’s no-pay conditions: not always preventable. July 14, 2008. Available on the American Medical News website.

Alternate Medical Definitions coffee (n.), a person who is coughed upon. lymph (v.), to walk with a lisp. abdicate (v.), to give up all hope of ever having a flat stomach. willy-nilly (adj.), impotent balderdash (n.), a rapidly receding hairline. testicle (n.), a humorous question on an exam. discussion (n.), a frisbee-related head injury. flabbergasted (adj.), appalled over how much weight you have gained. pokemon (n), a Jamaican proctologist. flatulence (n.) the emergency vehicle that picks you up after you are run over by a steamroller.

— from a column in the Washington Post

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Med Student Empowerment on the Annual Lobby Day

By Daniel Stein, MS II, UC Davis Medical School I don’t remember the first time I felt true empowerment. It seems an ephemeral emotion — I can’t quite decide when I feel it and when I don’t. In 2001, as an undergraduate student, I joined in protesting the University of Michigan’s contract with Nike in front of Lee C. Bollinger’s house, then president of the university. There was a sense among all 50 of us that we could tear down the walls of the university’s contracts and bring a little bit more justice to our world.

Maybe we were naïve, maybe we were hopelessly hopeful. But in those younger days, we knew that our voice would make a difference.

Two years later, before extending its contract with Nike, the University of Michigan demanded Nike change its working condition standards around the globe. Nike didn’t. The next year, the University of Michigan signed a contract with Adidas.

Medical school is a different beast in and of itself. I have a constant vision of myself as a marble rolling through a downhill maze. There is nearly no control over where I go. I simply fall into the next obstacle with no chance of slowing down or going back.

This sense of loss of control is, to me, the antithesis of empowerment. I am, in some ways, completely disempowered. I do what is expected with little time to reflect on what happens before the next obstacle is before my eyes. Many of you may have experienced this during your education. Yet in this journey of jumping through one burning hoop after the next, there is one event that has been marked on my calendar as the day where I feel empowered of not only my own life but of the future of our healthcare system.

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For the last 5 years, on a day in January, medical students from across California have gathered in Sacramento to rally support for statewide healthcare reform and universal healthcare.

On January 11 and12, the 5th annual Lobby Day had over 550 medical students come together in Sacramento to present a unified front for health care reform in California. This was the largest lobbying effort for universal healthcare ever!

With the support of the California Legislative Alliance (CaLA), the California Physician’s Alliance (CaPA), and the American Medical Student Association (AMSA), the students gathered at the UC Davis School of Medicine on Sunday, January 11 for an afternoon of education. Students learned about the legislative process, the advantages of universal healthcare, the details of SB 840 (the universal healthcare bill currently in the Senate), and instruction on how to lobby at the state capitol.1 Presenters at the training day included Senator Sheila Kuehl, original author of SB 840, Sara Rogers, former healthcare policy analyst for Senator Kuehl, and Parker Duncan, CaPA Fellow.

One breakout session facilitated discussion between students on healthcare reform and allowed for students to think about the arguments for and against universal healthcare and SB 840. A second breakout session was designed to have lobbying teams discuss their detailed strategy on how to lobby for SB 840.

Monday, January 12 began at 11 a.m. with a march from the Embassy Suites hotel to the capitol. Students, all wearing white coats, proclaimed their support for universal healthcare and SB 840 with chants, posters, and simply

their presence. Once at the steps of the capitol, multiple speakers, including Senator Mark Leno, rallied support and excited the crowd.

Members of the press were present, interviewing student leaders and rally speakers. The energy was explosive and contagious; one could feel the power of the hundreds of students in their white coats rallying for universal healthcare.

Then began the real lobbying efforts. Teams of 5–8 students visited legislators or office staff throughout the state capitol to discuss the benefits of universal healthcare and to encourage legislators to support SB 840. Students sat for a half hour with each legislator for a forthright conversation about healthcare reform. In all, over 125 offices were visited.

Legislators were asked to support SB 840 and to continue the discussion with their fellow law-makers and their constituents. Some were convinced to vote for SB 840; others were convinced to be co-authors of the bill. In the end, however, it was the conversations that the medical students brought to the state capitol that will have the most profound effect.

The 550 students returned to medical school the next day with a unique experience and a renewed passion for healthcare reform. The stories of their experiences at the state capitol bounced around the walls of their classrooms and hallways. Today, the conversation of healthcare reform and universal healthcare remains alive in all California medical schools in part because of Lobby Day and the transformative experiences the students had there.

When I reflect on Lobby Day, on the experience of being a part of this enormous movement of medical students from all across California, I begin to remember my sense of empowerment.

Even as I return to class and tumble once again down the roller coaster path that is medical school, I know that I am capable of creating change, of engaging my legislator, and of being a part of group that believes in its ability to affect its future.

SB 840 was the universal healthcare bill passed with a majority vote in both 2007 and 2008, only to be vetoed by Governor Schwarzenegger. The political future of SB 840

remains uncertain; almost inevitably, the fate of the bill rests in the fingertips of California’s voters when the bill is placed on the ballot as a proposition.

But what is clear is that universal healthcare, in the eyes of many California medical students, is the future of our healthcare system. Lobby Day will occur, once again, in January 2010 in Sacramento, our own backyard. If you have any questions or would like more information, feel free to contact me. daniel.stein@ucdmc.ucdavis.edu 1 SB 840 passed the Legislature, but was vetoed by the Governor on September 30 because of its cost.

Nightvoice

By David F. Dozier, Jr., MD Inching out of slumber, I heard voices, No — just one voice, muffled and afar, As if in conversation on the phone, Perhaps downstairs and through closed doors.

And yet it was familiar, kind and soft, Inquiring and rhythmic, chuckles here and there, And then, I thought, I know it from somewhere, It seemed so clear — My God! My mother’s Tender tones emerged. I’ve known That voice since wombdom with my sister, And then non-verbally till one or so, Bathed in warmth and comfort, Before specific words could clarify The distant sounds that always seemed to soothe.

I found a higher ledge in my awakening, And realized there was no voice at all, But yet a sound — the “give” of give and take, Was soft and gentle, easy to confuse With ancient dreams and memories in flux.

It was, I recognized, your breathing that I heard, A trick of sound and nostrils, rate and tone.

Some thirty years gone by beyond her death, You’ve channeled me her love with your sweet breath.

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Corrections — the Best Kept Secret in Medicine

By Jane Grametbaur, RN, CCHP-A, CLNC The author works in corrections in Orange County.

The 20th century saw changes in prison architecture and the emergence of large penal institutions — hence the term “big house.”

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The concept of “don’t do the crime if you can’t do the time,” or incarceration as punishment for crime, has only recently become the accepted mode of dealing with criminal behavior. Throughout history, society incarcerated criminals only long enough to pass judgment.

The Romans became one of the earliest societies to attempt to develop a system of uniform laws to govern the populace. They plagiarized codes from the conquered Greeks, Etruscans and Byzantines and adapted them to suit the needs of the state. Many of our laws have come down to us from the Romans and other ancient and medieval societies. While the structure of our legal system came from these societies, the punishments routinely meted out to the guilty or those who confessed to guilt after torture thankfully remain in the past.

Punishment for crimes, even those we consider petty today, came swiftly. Justice meant excruciating pain and, usually, a slow and lingering death. The theory behind the brutality used in meting out justice was that witnesses present when the sentence was carried out would be deterred from committing similar crimes. The Romans found much to their dismay that the daily smorgasbord of criminals offered up to the wild animals of the Coliseum for lunch did little to slow criminal activity in their cities. Even the use of criminals as slow burning torches to light city streets failed to stem the tide of crime.

The beginnings of our current system of justice began in Europe during the 11th and 12th centuries with the institution of jury trials

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and the appointment of magistrates to deal with criminal matters. Organized police forces, jail and prison as they exist today, didn’t emerge until the late 18th and early 19th centuries. The workhouse, an innovation of the 17th century for punishment of debtors and petty criminals became the embryonic blueprint for our modern prisons.

The earliest punishments of execution and mutilation gave way to transportation and hard labor. The movement toward rehabilitation began during the Age of Enlightenment at the end of the 18th century. The name penitentiary was coined at this time. Prisoners were often isolated and forced to maintain silence so they could dwell upon and repent their sins. This did little to deter crime but did result in prisoners succumbing to insanity or committing suicide.

In the late 19th century, the penal system became more organized. Outrage at conditions led to the separation of adults from children and women from men. Early rehabilitation models were instituted. Education and counseling along with variable sentences were thought to help mold criminals into upstanding citizens.

The 20th century saw changes in prison architecture and the emergence of large penal institutions — hence the term “big house.”

Conditions remained for the most part deplorable with each state mandating the type of treatment received by its criminal population.

Prisoners were essentially “slaves of the state.”

In the 1950s and 1960s, prisoner abuse led to formation of prisoner’s rights movements, but until the 1970s the courts pretty much maintained a “hands off” attitude toward corrections or the quality of medical care for inmates.

In 1976, the United States Supreme Court ruled in the case of Estelle v. Gamble that prisoners had a right to care for serious medical needs, as well as other rights. Failure to provide care as stated was ruled a violation of the 8th Amendment to the Constitution and considered cruel and unusual punishment.

After Estelle v. Gamble, a number of other cases were heard by the courts. These cases further defined the inmate’s right to care. In 1995, after a number of frivolous lawsuits brought by inmates for issues such as providing salsa at meals, the Prison Litigation Reform Act was passed, making it more difficult for prisoners to sue.

During the 1970s, the government provided funding to the American Medical Association and other organizations to study conditions and recommend standards of care for prisons and jails nationwide. Out of these beginnings came organizations such as the National Commission on Correctional Health Care, American Correctional Health Services Association and in California, The Institute for Medical Quality which is associated with the California Medical Association. These organizations have worked together to develop national and state standards for the provision of care to inmate patients as well as to develop guidelines for the accreditation of jails and prisons.

According to Department of Justice statistics in the year 2007, local jails handled 13 million admissions. By mid-year there were an estimated 762 per 100,000 residents in American penal institutions.

The days of staffing our jails and prisons with unlicensed, apathetic medical professionals are long over. Many medical professionals have joined the movement and have dedicated their lives to provide quality care to a population that has traditionally received inadequate and substandard care.

Those not involved in correctional medicine may disagree with the need to provide quality medical care to this population but those involved in the delivery of care to incarcerated patients see the benefit to society as a whole.

Prisoners are generally poor and uninsured.

They may abuse drugs or alcohol, live a high risk

lifestyle and generally are unable or unwilling to obtain care for chronic medical problems.

Once incarcerated, prisoners receive a medical screening; diseases that put the public health at risk, such as tuberculosis, venereal diseases, and HIV, can be identified and treated, slowing their spread. Those with severe mental health conditions can receive appropriate medication and therapy. Once identified, chronic and acute medical conditions can be evaluated and stabilized.

With the closing of the mental health hospitals and a shift to community-based mental health care, the nation’s jails and prisons have become a repository for the mentally ill. Psychiatric patients diagnosed and treated while in custody suffer from fewer acute exacerbations and can be transitioned into the community when released.

Inmates with chronic medical problems who receive medication and community referrals on release are less likely to suffer deterioration of their medical condition requiring expensive hospitalization and save taxpayer dollars.

Medical professionals who accept the challenge offered by correctional medicine are rewarded with the opportunity to see and treat conditions not often seen in the middle class community today. Conditions such as tertiary syphilis, active drug resistant tuberculosis, acute tetanus and typhus, as well as orphan diseases, while rare in middle class practice, are not uncommon in corrections.

Those who choose correctional medicine as a career constantly struggle with overcrowding, lack of funds, lack of staff and antiquated facilities while still attempting to provide the standard of care found in the community. While inmate patients often present as manipulative, hostile and have the potential to be extremely volatile and dangerous, caregivers will discover that this population has a great deal to teach us about humanity.

Practicing medicine in a correctional setting is the practice of medicine in its purest form.

It is the provision of care without judgment.

Those who chose accept the challenge will find a rewarding and fascinating career.

Practicing medicine in a correctional setting is the practice of medicine in its purest form. It is the provision of care without judgment.

jgrametbaurrn@aol.com January/February 2009

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Voices of Medicine Electronic Medical Records have some advantages; and anesthetizing an orangutan.

By Del Meyer, MD

Before and After EMR

Leisurely flipping through the chart is followed by frenzied tearing through misfiled pages, different volumes, and sections devoted to Workers’ Comp.

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Lee Leer, MD, discusses “EMR From the Trenches” in the Humboldt-Del Norte County Medical Society Bulletin: Much has been written lately about Electronic Medical Records (EMR’s). Some of the authors have even spent a bit of time working with an EMR. Many authors are not particularly positive though at least recently even those who don’t like EMR’s bow to their inevitability. Most seem to feel that something is lost in the patient interaction when computers come into play.

I propose to paint another picture. I believe, and have experienced, that EMR’s not only contain the tools to improve “objective” quality (such as health screening benchmarks), but also “subjective” quality (what goes on in the exam room and its impact on patient satisfaction).

Before moving on, however, I must remind myself what pre-EMR life was like. I would get a chart (or charts, in the case of complex, longterm patients) with various bits of loose and bound paper in and on the chart. I would hopefully review all these bits of paper (x-ray reports, labs, consult reports, and the like) before going in the room with the patient. Every few days, a chart simply could not be found in time for a patient’s visit. It would often have been buried in the stack of charts on a provider’s desk…

You know the gig (pre-EMR): I get in the room, hopefully with a chart balanced on my knee, and begin to review current results with the patient. Often, they ask, “What were the results last year?” Leisurely flipping through the chart is followed by frenzied tearing through misfiled pages, different volumes, and sections devoted to Workers’ Comp. Concurrently, I’m

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attempting to jot a few notes from our encounter, or else keep it all in my head to dictate at the end of the visit. If the patient asks me about a drug or disease or procedure I’ve never heard of (an increasingly frequent occurrence, I fear), I take notes and promise to get back to them. If we are beginning a new medication, I “fire up” my memory banks and “run” a drug interaction check. If the potential drug interactions are significant, or if my memory banks are empty, I excuse myself and try to find printed material on interactions. This can consume several minutes. Finally, I fill out a visit charge and a diagnosis on a paper form. I give that paper to the patient and hope they won’t discard it before they reach the front desk. When the person working outbound acquires the paper and successfully interprets my scribbles about follow up, we’re done!

Currently (post-paper records), I turn my computer on each morning, look through my list of patients, and review potential problems with my medical assistant. We make sure that all studies to be reviewed are available and in the chart (i.e., on the computer). When the patient is ready, I walk into the exam room carrying my small laptop. I sit, make eye contact, and have a several minute conversation with the patient, during which time my computer does nothing but warm my knee. Eventually during the discussion, I will look down to the computer and type in a few words. Typically, by the time the visit is complete I’ll have finished at least the rough outline of the “subjective” portion of my note. All labs, current and old, are retrieved, reviewed, and compared with a couple of clicks. Medications are renewed by a few more clicks. Drug/drug interactions, drug/ allergy and drug/diagnosis contrain-

dications are automatically checked. Usually, the prescription is electronically transmitted to their local pharmacy as we speak…

To read all of Dr. Leer’s article, go to www.humboldt1.com/~medsoc/images/bulletins/NOVEMBER%202008%20BULLETIN_ for%20web.pdf

Otis, One Ornery Orangutan Dr. Stanley Perkins details his encounter with an orangutan named Otis, in “Animal Rites: Some Patients are Wilder than Others,” in the Summer 2008 Bulletin of the California Society of Anesthesiologists. Dr. Perkins is an anesthesiologist at Sharp Memorial Hospital in San Diego, where he cares for a variety of humans.

When not putting people — or animals — to sleep, he flies his Turbo Commander with his dog, Amy, in the co-pilot’s seat: It had all the elements of a horror flick: a gurney, two unsuspecting doctors, and a violent yet sedated patient. In dim light the gurney glides onto a freight elevator, a dull clang reverberating as the wheels bump across the threshold. Slack-faced, with gazes riveted upward, the men watch the lighted arrow make its slow arc.

Suddenly, a huge hairy hand springs up, seizing one of the men by the wrist. His eyes wide with panic, the doctor struggles to free himself while the elevator lumbers on, slowly carrying the men and their charge out of sight.

As every fan of horror knows, such a scene never bodes well for the doctor. This time, though, the scene was real; I was the doctor and my patient was one ornery orangutan. In the two decades I’ve volunteered at the San Diego Zoo and Wild Animal Park as a veterinary anesthesiologist, that tussle with Otis was the closest I’ve come to being the guy who, when the elevator door opens, is sprawled lifeless on the floor.

Otis was one of two male orangutans at the zoo. The other, Ken Allen, had earned acclaim as an escape artist. Whenever he grew bored, he would set about loosening the bolts of his cage.

A quick slip through the door, a scamper up an incline, and a swing over a wall, and Ken Allen would be out, strolling amid a crowd of people, as if he were just another zoo patron. Each time his keepers discovered one of his escape routes,

they closed it off, but he would devise a new one. He never seemed to mind being led back into his enclosure, though; he simply relished the challenge of finding new flight paths.

Otis had none of Ken Allen’s geniality.

He was a bundle of hirsute hostility, and he detested veterinarians — and anyone associated with them — most of all. With the highest strength-to-weight ratio of any primate, orangutans are not to be trifled with, especially when they have Otis’s disposition. Whenever I received a call from the zoo about an animal in distress, I would jump into my car and head right over. If that call was about Otis, though, I had to fight the urge to jump into my car and head home instead. On the day he grabbed me, Otis was scheduled for cosmetic surgery: He needed a wart removed from his nose. But at the zoo even the simplest examinations require sedation. Jeff Zuba, the veterinary intern, tranquilized Otis with a dart so we could transport him to the veterinary hospital. I administered the anesthetic while the veterinarians removed the wart, conducted a physical exam, and untangled his long locks.

During the return trip, I administered the last of the anesthetic. Since we were only minutes from Otis’s enclosure, I figured we’d be fine. Unfortunately, I had forgotten the sluggishness of the freight elevator that led down to his cage. Jeff and I were cramped into the tiny elevator with our bodies pressed against the gurney. I was holding the oxygen mask over Otis’s face when suddenly I felt his prehensile grip. Now gasping for breath myself, I peeled his leathery digits one by one from my wrist and struggled to reinstate his oxygen mask. When the elevator door finally banged open, Jeff and I sprinted, with the gurney in tow, back to Otis’s cage. By the time we had settled the orangutan in his bedroom, he was fully awake and spitting mad. Jeff later confessed the escape plan he had formulated as soon as Otis grabbed my wrist: He would dive under the gurney — and leave me to my own devices.

For more on anesthesiology and animals, go to www.csahq.org/pdf/bulletin/animal_57_3.pdf

It had all the elements of a horror flick: a gurney, two unsuspecting doctors, and a violent yet sedated patient.

DelMeyer@MedicalTuesday.net January/February 2009

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The Escuela Latinoamerica de Medicina in Cuba

By George Meyer, MD I was interested in the small insert in the Medical Board of California newsletter for November 2008: MBC granted recognition to three international medical schools; one is Escuela Latinoamericana de Medicina (ELAM) in Cuba, or the Latin American School of Medicine.

I presume this means graduates of this school do not have the usual requirements of other international medical graduates and may apply for residency training just as any other graduate of an LCME-approved medical school in the U.S. or Canada can.

ELAM, founded in 1999, may be the largest of all medical schools. It has approximately 10,000–12,000 medical students from around the world, including about 100 from the United States (at least one was from Sacramento). The first class of 1,498 ELAM doctors graduated on August 20, 2005. Tuition, room, and board are provided for free with a small stipend.

ELAM’s goal is to educate doctors who agree to practice medicine in underserved areas after graduation (I could not find a length of commitment statement). Admission preference is given to applicants who are financially needy and/or “people of color.”

According to Wikipedia, U.S. applicants must have U.S. passports, be under age 30, and commit to practicing in underserved areas in the U.S. The first US pre-med students, 10 in all, enrolled in the Spring of 2001.

Classes are taught in Spanish, and the first year includes 12 weeks of intensive Spanish.

After the first two years, students perform clinical activities in one of Cuba’s 21 medical schools.

Emphasis is on primary care, community medicine, and hands on medicine. U.S. students are

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expected to pass USMLE exams at the appropriate stages of their education.

According to Wikipedia, in June 2000, a US Congressional Black Caucus (CBC) delegation visited Cuba to meet with Fidel Castro.

Representative Bennie Thompson (D-Miss.) mentioned that his district had a shortage of doctors. Castro responded by offering full scholarships for U.S. nationals from Mississippi at ELAM. Later that same June, the Cuban Minister of Public Health expanded the offer to all districts represented by the Black Caucus.

At a September 2000 speech, at Riverside Church, New York City, Castro expanded the offer to medical students from low-income communities from any part of the USA with, perhaps, half reserved for African-Americans and half for Hispanics and Native Americans.

The ELAM offer to US students was classified as a “cultural exchange” program by the U.S. State Department to avoid restrictions of the U.S. embargo against Cuba. In 2004, the legality of the presence of US students at ELAM was threatened by tightened restrictions against travel to Cuba by U.S. nationals. A CBC campaign led by Representatives Barbara Lee (D-Calif.) and Charles Rangel (D-NY) persuaded Secretary of State Colin Powell to exempt ELAM from the tightened restrictions.

Applications from US citizens are administered through the New York City-based Interreligious Foundation for Community Organization (IFCO), headed by the noted human rights activist and critic of the U.S. embargo of Cuba, the Rev. Lucius Walker, Jr. geowmeyer1@earthlink.net

Annual Meeting It resembled Las Vegas, but the main event was the inauguration of Charles H. McDonnell, III, MD, as the 2009 President of SSVMS. And the location was actually Sacramento’s Hyatt Regency, where nearly 200 persons attended the SSVMS Annual Awards, Installation and Dinner on January 16.

Dr. McDonnell, a radiologist, succeeds Dr. Margaret Parsons, a dermatologist.

The Las Vegas theme was carried out complete with impersonators of the famous “rat pack” — Frank Sinatra, Dean Martin, Sammy Davis Jr., Joey Bishop and, in this case, Marilyn Monroe (rather than Peter Lawford).

Winners of awards (see page 20 for photos) included: Dr. James A. Margolis, who received the Society’s highest award, the Golden Stethoscope.

Dr. Margolis, a child psychiatrist, has practiced in Sacramento County for 38 years. He has volunteered his time with SSVMS’s SPIRIT and Adopt-a-School projects.

Dr. Margolis has taught medical students and residents as a clinical professor at the UC Davis Medical School, and has been honored by the National Ski Patrol for his work as an instructor in outdoor emergency care.

Dr. Ruth Haskins, who won the Medical

Honor Award for a contribution of great significance to community health. She has practiced obstetrics and gynecology in Sacramento since 1993, and has her own solo practice in Folsom. Dr. Haskins serves on the county Maternal, Child and Adolescent Health Advisory Committee; the Western Career College’s Medical Assisting Program Advisory Board; the Medical Board of California Midwifery Advisory Council; and on CMA’s Council on Legislation, Michael Fuller, the chief executive officer of BloodSource, who was presented the Medical Community Service Award, for a non-physician who has made a significant contribution to a medical or public health problem. Mr. Fuller has been in leadership positions at BloodSource for more than 20 years, including 12 years as chief operating officer. BloodSource has grown to approximately 600 employees, serving 40 hospitals in 25 counties. In addition to two office and laboratory buildings at the former Mather Air Force Base, it operates 4 regional centers, 11 fixed satellite centers, and mobile units.

Sylvia Enoch, who received the Dedicated County Alliance Member Award; and Marla Bommer, who was presented the Dorothy Dozier Helping Hands Award.

2008 President Dr. Margaret Parsons and 2009 President Dr. Charles McDonnell, MD.

On the next two pages: scenes from the Annual Meeting.

Photography by Katherine Boroski.

President Charles McDonnell, MD, with his wife, Kristie Bobolis, MD, and daughters Diana and Mary.

January/February 2009

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Annual Meeting

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Annual Meeting

January/February 2009

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Annual Meeting

The “Rat Pack” (top left) is actually singing, not looking for an award.

At the top right, Michael Fuller, CEO of BloodSource, is presented the Medical Community Service Award by Dr. McDonnell.

At the middle left are Silvia Enoch, recipient of the Dedicated County Alliance Member Award, and Marla Bommer, recipient of the Dorothy Dozier Helping Hands Award. With them are their spouses, Dr. Douglas M. Enoch (left) and Dr. William Bommer.

To their right is Alliance president Gabriella Neubuerger, who presided over the Alliance’s awards ceremony.

At the bottom left are Dr. James Margolis, winner of the Golden Stethoscope Award, and Dr. Ruth Haskins, recipient of the Medical Honor Award.

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Posit: Medical Care for Indigent Illegals?

“Indigents seeking medical care from the County of Sacramento should be required to show proof of citizenship.”

Background: On February 10, the Sacramento County Board of Supervisors held a hearing on the elimination or reduction of medical care services to indigents provided by the County. The Supervisors voted 3 to 2 to eliminate the services.

The $4,060,000 in cuts includes the closure of two more clinics. It calls for determining citizenship before providing services and eliminating care for those who are not U.S. citizens.

The county estimates it will save $2.4 million by denying services to the estimated 4,000 nonU.S. citizens who use the clinics. SSVMS has long spoken out against such cuts in service.

Results: Of 149 replies, 45 agreed while 104 disagreed.

Those who commented were largely in disagreement. Under present circumstances, this is a difficult issue confronting the Supervisors, and all legislators.

The posit is politically charged, of course.

Therefore, it seems likely that some members, while agreeing, did not wish to say so.

While disagreeing with the first posit, others might have a harder time with this sequel posit: “A license to practice medicine in the USA, should require that all physicians treat all indigents, including ‘illegal’ aliens, without pay.” That is consistent with our oath, and ethic, and with the position of most religions. But who pays for ideal action?

Addressing this posit, as sent to members, most of us say to the taxpayer: “You must pay to treat all indigents; but pay me.” Hippocrates, Osler, Maimonides: Help!

Edited comments follow. Seven comments arrived too late to be included, but the full text of all comments can be read online at ssvms. org. ...Although the ”county” may lower its cost, the overall costs of care will increase. Not providing healthcare does not dissuade individuals from coming to the land of opportunity. Given the legal obligation to treat anyone requiring emergency treatment in an emergency department, I believe the costs of denying preventive care through the county will only mean higher overall costs for the region in general. It only shifts the cost rather than provides an actual solution to the problem....

[T]he county should seek to form innovative partnerships that focus on this issue and strive to avoid expensive care rather than fostering...medical catastrophes that don’t serve... the community or the individual. Furthermore, the county’s income is based on sales taxes and property taxes among other sources. Citizenship is not relevant with that kind of funding stream and discouraging immigrants...diminishes tax revenues.

A more novel approach would be to partner with the federal government in establishing a work-permit “visa” that includes “taxes” for county of residence to cover healthcare needs.

Another alternative is to seek to partner with businesses that benefit from illegal immigrants — they do work (and work hard) and do many jobs in support of our community. — Mike Hogarth, MD

January/February 2009

I believe the costs of denying preventive care through the county will only mean higher overall costs for the region in general.

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If we have maxed out revenue, then American citizens need to be first in line for services.

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California is nearing bankruptcy. In good times we may be able to afford this service, but for now we have to cut back. — Gregory Joy, MD Physicians and other clinic employees …cannot be agents of the Department of Homeland Security. Their moral duty [is] to provide health care, not to enforce immigration laws. “Safety net” health care is a public service, not a private good that can be withheld on the basis of immigration status.

Should we also tell firefighters not to put out fires involving houses owned or occupied by non-citizens? Should we tell police not to investigate crimes affecting non-citizens? Should we tell paramedics not to bring patients to the hospital without proof of citizenship? Should we put fences and gates around our parks and libraries so that only citizens can use them?

If public health can be sacrificed ...to save a few dollars, then surely we should sacrifice public safety and recreation for the same reason.

— Patrick S. Romano, MD, MPH I disagree with denying services to those with no voice in our society, the most vulnerable. — Andrew D. Kincaid, MD Passage of this restriction on indigent care will have a devastating effect of increased chronic morbidities and fatal outcomes, resulting in increase acute care visits to the already overburdened ERs and area hospitals, and raising healthcare costs to the Sacramento community. — Colin P. Spears, MD Reluctantly I disagree. In general, illegal aliens will avoid seeking medical care unless there is no other choice. As a result, most present to emergency rooms for care when a disease process is fairly far advanced. Many could have been taken care of easily if medical care had been available.

The subsequent cost of caring for illegal aliens when they are very sick puts a significant burden on all health care systems, and the cost is proportionally higher than if a clinic had been available for them to go to for routine care.

— Sidney A. Scudder, MD [Agreeing,] I also suggest this as a future posit: A prepaid health insurance policy [should] be required for foreign travelers in the USA. — J.

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Dale Smith, MD I believe that our mission should be to serve our entire community and not just a select few.

If this step is allowed, where does it end? — David R. Bradbury, MD If saving money is the main concern, where will this indigent population go for medical care? Emergency rooms are a lot more costly than clinics.

By trying to solve one problem, you only create another. Instead of trying to cut off medical care to an already medically under-served population let’s search for a more humane solution. — Deepika Bindal, MD This is a difficult issue. It comes down to balancing taxpayer liability with setting priorities. The taxpayers in CA and Sacramento County are at the top of the scale for local and state taxes. If we have maxed out revenue, then American citizens need to be first in line for services. — David J. Gibson, MD The financial burden of [the] illegal immigrant must be federal responsibility; that includes care and disposition, including deportation if violating U.S. immigration law. Sorry, there’s a depression on! — Cleve Baker, MD As a SPIRIT (county volunteer) pediatrician who has seen many of the children and infants, I can testify that this is a foolish idea. I have seen many children and infants who if not treated in our clinics will end up in the emergency rooms and admitted because of severe complications of untreated infections like orbital cellulitis, pneumonia, severe asthma, uncontrolled diabetes or uncontrolled seizures.

While the economics of this neglect are clear, this great county should never forget that a child is a child is a child and sending a young mother home with a very sick child because she cannot document her citizenship is the greatest sin. — Diamond Kassam, MD It is professionally, morally and ethically wrong to withhold needed medical care.

Requiring proof of citizenship is cumbersome and a costly administrative burden which would deter care of citizens. This is a really bad idea. — Richard K. Park, MD The green card people working and paying

tax as citizens, they should have the right for medical care as the indigent citizens. — Bihai Peng, MD If excluded from primary care, many will seek care in the ER at much greater cost. Due to EMTALA, they will all be seen and treated.

It is not only the right thing to provide basic medical care, but the cheaper option. — Eric G. Tepper, MD What will be the cost if these patients end up in EDs getting care later? What about children who are here because of their parents?

Should they get care? It’s not their fault that they live here. — Michael Haight, MD All indigents should receive medical care, no matter their citizenship. — Molly R. Kirkconnell, MD As an emergency physician, I fear the added patient load in the local emergency departments. Many of these undocumented patients will have minor medical conditions, requiring an investment of time by medical and nursing personnel who should be concentrating on true emergent and urgent conditions.

The County of Sacramento is dumping their problem onto the private sector. The federal government also is shirking its responsibility.

Norman Label, MD Denial of care will increase charity care at ER. — Sunil P. Perera, MD First this is a civil rights issue and poor is poor. Not treating diseases in the early states can mean that they [poor people] may get sicker and require more services. Anyone can go to an ER [without proof of citizenship] and get care usually much more expensive than the clinic level. — Tom Wilkes, MD [I agree,] Assuming these are all non urgent/ emergent encounters. — Robert J. Forster, MD No one should be denied medical care when they need it. Let’s fix the problem, not punish people when they are in need. — Qasem M. Noori, MD I assume this refers to persons seeking services at a county facility other than a hospital emergency room unless that ER is a designated county facility. My answer is based on health statutes which state that the ”county” is ulti-

mately responsible for the health of its citizens.

If the address of documents show citizenship in another county, they should be sent to that county. However, should a report of a communicable disease accompany the patient, then the patient should be treated for sanctity of public health. — Stephen Mandaro, MD A very difficult problem that would very adversely affect emergency rooms and hospitals. Some cutbacks in the county budget may require this as a last resort as the county has limited resources. I am very ambivalent on this.

— Peter S. Carruth, MD Obviously, if care is not offered in clinics, the same patient will seek care at emergency facilities and increase the overall cost of care.

Why not require that before ER care, if presenting with a non emergent complaint, that the patient needs to be directed to a public healthcare facility instead. After all, we should seek to place the patient at the point of the lowest cost, and most appropriate setting for care and not eliminate the opportunity for low cost, efficient care. — Richard A. Gould, MD Sick people must receive care. To allow them to die on the street because they lack proper papers would be inhumane. — Norman R. Eade, MD I disagree: proof of citizenship should not be a criterion for indigent care in Sacramento.

— Monte E. Ikemire, MD Legal resident not citizenship should be required to obtain service...this has been in vogue in Canada for 40 years and, of course, there are cheats all the time because in Canada a picture ID is not permitted. — Michael H. Burman, MD A realistic compromise would be to require payment which covers the cost of service, permitting the provision of care without further burdening taxpayers. — Lee O. Welter, MD I DISAGREE b/c I don’t think funding should be cut for any sort of healthcare to our patient population. Those are the people we serve at the student run clinics and this could lead to a closure of the facilities we use on the weekends! — Lawrence Ei S. Lipana, MS I It is important to bring medical care even to

January/February 2009

The County of Sacramento is dumping their problem onto the private sector. The federal government also is shirking its responsibility.

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Diseases such as TB are not restricted to citizens, and will increase the risk to the health of the public if not diagnosed and treated in legal non-citizen immigrants as well as illegal immigrants.

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undocumented aliens for a number of reasons including many that can be considered public health emergencies, such as tuberculosis, chronic salmonella carriage, STDs, etc.... Further, this is the population that is most susceptible to severe ailments that if not caught early will end up costing the state and the country a lot of money to treat when they finally do show up for medical care. — John Belko, MD I do not agree that proof of citizenship should be required to obtain medical care. — Janet Keremitsis, MD If the Federal Government wishes to encourage and provide care for the non-citizens, then it must provide funds for payment of services.

— James O. Farley, MD Creates a layer of law enforcement not consistent with medical care. All indigents deserve medical care as determined by medical personnel. — Charles H. Halsted, MD Marvelous thinking. About time!!!! — M. Eugene Speicher, MD This population is an asset to Sacramento economy. Not providing them with healthcare will simply inundate our ERs, wasting more of the healthcare dollars. In the long run it does not save Sac County to deny healthcare to its inhabitants regarding US Citizenship status. — Annahita K. Sarcon, MS I Unless the patient has a communicable disease such as tuberculosis. — Charlie Espy, IV, MD Until there is a State/Fed plan to deal with the large numbers of indigent workers in this county and state, this does not sound like a good idea. Eliminating clinics will impact the ERs [and] the health care system at a far greater cost then 2.4 million. The limited preventive care offered in these clinics is better then nothing. — Jose J. Cueto, MD Diseases such as TB are not restricted to citizens, and will increase the risk to the health of the public if not diagnosed and treated in legal non-citizen immigrants as well as illegal immigrants. — David A. Herbert, MD If we do not treat them at County Clinic, they will show up at ER, and we end up treating them any way. Can we turn them down if they

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show up at ER ? — Dennis A. Chu, MD The county needs to find another way to balance its budget other than on the backs of the poor. — Donna M. DeFreitas, MD There should be more attempts to get volunteers to keep clinics open, and we should be more helpful to non-English speakers — not eliminate care. I heard there are more volunteers in these hard times than can be given jobs. I have offered to work in the county clinics since I’m a retired MD and have yet to be taken up on the offer. — Elaine P. Silver, MD [I disagree.] Please also address the County’s proposed cuts of mental health services, including geriatric mental health services — these are also of importance to physicians. — Esther E. Novak, MD As compassionate providers of medicine, [we] should see all patients regardless of country of origin. — Dineen J. Greer, MD I strongly disagree. In matters of public health and obstetrics, it endangers others who are either in our country or unborn. In emergencies, it is against our oath to reject patients.

In routine but necessary medical care, it is just sad that we cannot be humanitarian enough to provide services. We all have Red Cross available to us, why do we shun provision of care to other indigents? I feel the immigration authorities and border guards should be the ones to do rejection, not healthcare workers. If I were in another country and destitute for whatever circumstances...it would seem barbaric to me if I could not get needed medical care. — Evalyn Horowitz, MD Neglecting the indigent with the highest risk of having infectious diseases like Tuberculosis, Measles, etc...will lead to a resurgence of diseases in American citizens. Unfortunately, this will increase health care costs by pushing these patients into the already overburdened Emergency Rooms. Although a resurgence may encourage some of those parents who refuse vaccinations to reconsider. — Anthony W. Russell, MD, MPH If there is not enough funds to cover current residents...then we can’t also cover non-citizens.

— David G. Telander, MD

In My Opinion

The Recession and its Effect on Healthcare

By David J. Gibson, MD, and Jenifer Shaw Gibson This article has been heavily edited for publication. The complete article appears online at ssvms. org.

America is in a severe recession. Last November, the U.S. lost over half a million jobs, the largest one month drop in employment in 34 years. That brought the total jobs lost in 2008 to 1.9 million. A job loss usually means a family will lose its health insurance.

Magnitude of the problem.

We are close to the line that separates a recession from a deflation. America’s household balance sheets shed almost $3 trillion in the third quarter of 2008, thanks in large part to declining stock prices. That loss, the largest 3-month drop on record, brings the total loss

by U.S. households in 2008 to $10 trillion, or about 10 years worth of equity earnings.

Beyond stocks and bonds, most family wealth is based on real estate. Household real estate assets fell for a 10th quarter out of the past 11 and the net worth of real estate is now down 32 percent since 2005. This is an unprecedented loss of family wealth — almost $6 trillion in real housing wealth in 2008, or on average of $85,000 per homeowner.1 In addition, retirement accounts have been devastated. Since October 2007, 401(k)s have lost $1 trillion in value — fully a third of the value of all 401(k)s. Another $1 trillion has been stripped from people who lost or changed jobs and rolled their 401(k)s into individual retirement accounts. Millions of others have been forced to make early, so-called hardship withdrawals for unanticipated expenses.

Spending by consumers, which has sustained the economy over the past decade, is in free fall.

Most consumer spending has been based on mortgage debt. Mortgage-based debt declined in the third quarter of 2008 by 1.7 percent, the first decline in 25 years, resulting from an end of mortgage equity withdrawals.

The economic damage from prior consumer debt-based spending is becoming apparent. A recent report by New York University Professor Nouriel Roubini indicates credit debt could peak at $3.6 trillion for U.S. institutions.2 If this prediction proves accurate, the U.S. banking system is effectively insolvent because it starts with a capital of $1.4 trillion. Thus, the new Obama Administration will have to use as much as $1 trillion in yet uncommitted public funds to shore up capitalization of the banking sector.

America’s true wealth is based on productivity, not paper derivatives. Here again, the news is not good. After averaging 2.7 percent productivity growth from 1995 through 2002,3 annual growth of productivity in the non-farming business sector has slowed dramatically — to just 1.7 percent in 2005, 1.0 percent in 2006 and 1.4 percent in 2007. At this last rate, it would take nearly 52 years for average living standards to double — versus just 26 years at the earlier rate.

This decline in productivity is reflected in the Labor Department’s employment report for December. Employers shed more jobs in 2008 than in any year since 1945. Worse, the pace of job loss is accelerating. In the third quarter of 2008, the economy shed an average of 199,000 jobs a month; in the fourth quarter, 510,000 jobs were lost on average each month. Moody’s Capital Markets Group in New York predicts

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As the new Administration greatly expands its funding footprint in health care, permanent entitlement costs will be in place without realistic sources for long term funding.

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about 2.1 million U.S. jobs will be lost in 2009 with 80 percent of the layoffs by the 4th of July.

What is the long-term significance of these figures? Are we facing a recession bordering on deflation or are we redefining the country’s wealth? If a severe recession, the economy over the next few years will begin to recover and show increasing rates of growth.

It is an entirely different issue if we are redefining actual wealth — and that appears the most likely result. An early indicator is a recent announcement by Standard & Poor’s. The rating firm reported the U.S. Treasury bond would lose its AAA rating by 2012 because Washington has been reporting the government’s financial statements with a cash accounting rather than an accrual accounting methodology. America will then have the same credit rating as Estonia, Greece, Poland, Brazil, and Mexico. The borrowing spree funding the US spending will come to an end when foreign investors, particularly the Chinese Government4, no longer buy America’s bonds.

For the short term, the recession will affect every segment of the economy. For the long term, if we “right size” the country’s wealth, we will need to right size all segments of the economy — with serious implications for the health care industry.

Government services.

Even before any new health care entitlement programs and expansions, federal health entitlement programs are an economic disaster.

Medicare Trustees note that the program has an unfunded liability of some $36 trillion over the next 75 years. As a percentage of GDP, expenditures are projected to increase from 3.2 percent in 2007 to 10.8 percent by 2082.

The lesson of 2008 may well be that we must ensure that federal, state and local governments renew their focus on cost-effectively achieving their fundamental missions of protecting citizens’ safety and security. Government will no longer be able to perform numerous philanthropic and social functions that individuals and private associations can do for themselves.

Unfortunately, old ways of thinking die

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hard. For generations, and in both parties, American politicians have gained power by delivering new programs and services paid for with borrowed funds. Initially, these were raided from the Medicare and Social Security Trust Funds. More recently, funding has come from the sale of bonds to foreign investors.

The new Administration has embarked on a long, highly dubious attempt to return to prosperity by throwing hundreds of billions of newly printed dollars at myriad systemic problems in the health care industry, the housing industry, the financial services industry, the auto industry, the Congressional pork barrel industry, and many other enterprises.

But government has no ability to create demand; only the market can. Government does not create wealth, it can only redistribute it. Government does not create jobs; it can only delay the inevitable creative destruction in any free market. Furthermore, government “stimulus spending” inevitably leads to inflation.

The new Administration is signaling it will exacerbate the recession and its attendant problems by trying to hold labor markets of yesterday in manufacturing, health care and government along with their rich benefit structures.

Make-work jobs in infrastructure will not meet tomorrow’s needs. In recent years, government statistics show that about 25,000 jobs are destroyed and created every hour that America is open for business. Rapidly evolving markets create dynamic labor markets.

American government at all levels from the local school systems to the federal are bankrupt.5 Politicians are good at giving things away.

They have no experience in restricting spending and eliminating programs.

Changes for health care.

As the new Administration greatly expands its funding footprint in health care, permanent entitlement costs will be in place without realistic sources for long term funding.6 These new entitlement programs would be created using temporary “stimulus funding” based on borrowed money. Private health plans will be driven from the market; and we will be left with

a hopelessly underfunded health care system with no options.

So far, we have few details of how health care policy will evolve under the new Administration. However, there are clear indications of Congressional thinking. The Senate Finance Committee is calling for massive increases in both Medicare and Medicaid. This “Baucus Plan”7 will add between $200 billion and $300 billion to the $2.3 trillion we spend each year on government paid health care.

Medicare sets standards for 8,000 medical procedures and services at a 2007 cost of some $425 billion for people 65 or older, or about $10,000 per person. Under the Baucus bill, the age for joining Medicare would drop from 65 to 55. A healthcare system serving 44 million people would make 32 million more (4 million of whom are now without health insurance) eligible.

Medicaid will expand to cover every American living in poverty, rather than just the 61 million people it serves today. This could push 7 million people into the government program and add billions of dollars to its cost.

Finally, the State Children’s Health Insurance Program, or SCHIP, will expand to cover all children with family incomes less than 250 percent of the poverty level — up to $53,000 for a family of four. That would add millions more people to SCHIP, which today costs $5 billion a year to cover 6.5 million children.

Put all this together and existing health care programs — Medicare, Medicaid and SCHIP — will be expanded, new healthcare regulation for business and individual policies will be established, and America will have a vast new healthcare program run for and largely paid for by the government. With little input from patients or physicians, government will run it, regulate it, supervise its performance, mandate how company participation in it, and somehow come up with more than several hundred billion dollars each year to pay for it all.

All these program expansions represent fixed future spending obligations. Given the revenue claims by existing social entitlements, there is no long term funding for these spending increases. It

is difficult to find the pony in all of these data.

With expanding government health care financing, we can expect a decline in payment to providers compared to their rising cost for delivering services. Competing interest groups will clash for a piece of the spending pie. Highly politicized Medicare-like price controls on providers and services will spread to every health funding decision. The result will be rationing and declines in the quality of services.

Meanwhile, outsourcing of high end health care to international markets8 is accelerating.

There is a clear and present risk that high tech diagnostic and invasive therapy will migrate to international markets.

Formerly this competition came from distant markets in SE Asia and beyond. Now American hospital chains are starting to buy into Mexico. International Hospital Corp. in Dallas has 5 Mexican locations. Dallas-based CHRISTUS Health has built 6 hospitals in Mexico through its partnership with a Mexican chain. Procedures performed cost a third to two-thirds less than they would in America.

People are coming from as far away as Alaska for bariatric, plastic and cardiovascular procedures, as well as knee and hip replacements. Many health insurers are adding cross-border facilities to their networks.

The future will unfold in one of two ways.

Either we will deliver an affordable health care financing system in the private sector, or we will find health care thrust onto the political appropriating arena.

The former will require a series of dislocating changes. Innovation will become essential.

Increased productivity will be the basis for the reward system. Health care labor costs, which are out of control,9 will be reduced. Return to an intermediary free market will be unavoidable.

The latter is more likely. Industry inertia and the primacy of parochial interests will oppose dislocating free market changes. Costs will be controlled through shortages. Provider incomes will be dictated. Innovation will be suppressed.

Organized criminal activity will increase as more limited funding is diverted into fraud.

Americans with resources will seek care in the

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international markets and our best talent will go offshore.

As government power and resource move further into health care funding, we will find our ability to make our own choices about our lives, our families and the world around us progressively limited. These policies will ensure that more health care decisions are made — and more of our and our children’s money is spent — by a progressively smaller group of policy makers who live far from our communities. They will care little about our personal preferences, religious convictions or personal aspirations. None of this could have happened without the failure we have witnessed in the private sector.

It is not a pretty picture.

DJGibson@winfirst.com Jennifer Gibson traded energy commodity

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futures on the Chicago Mercantile Exchange. She is also an economist who trained at the London School of Economics and now specializes in evolving health care markets. David Gibson is the C.E.O. of Reflective Medical Information Systems, a software development and consulting firm.

1 Projections by the Center for Economic and Policy Research are based on the numbers in the 12/16/08 Case-Shiller home price index, which showed accelerating price declines in most big cities.

2 http://www.bloomberg.com/apps/news?pid=20601087&sid=aS0y BnMR3USk&refer=home 3 Primarily driven by the introduction of information technology into the workplace.

4 China has bought more than $1 trillion in American debt. Now the key drivers of China’s Treasury purchases are disappearing.

5 For more on unfunded GASBY-45 benefits, see http://www. ssvms.org/articles/0809gibson.asp 6 PAYGO, the pay-as-you-go rule of fiscal responsibility mechanism self-imposed by Congress, is being ignored in the “stimulus” package.

7 Named for U.S. Senator Max Baucus (D-Mont.), Chairman of the Senate Finance Committee; http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf 8 http://www.ssvms.org/articles/0711gibson.asp 9 Labor costs for professional services in health care are twice those of any other industrialized country.

CMA’s Legislative Wrap-up “It was the best of times; it was the worst of times.” The 2007-08 session evokes the famous quote from Charles Dickens.

By Dustin Corcoran Vice President of Government Relations Following is the introduction to major 2008 legislative activities by CMA. The complete, 5,000word report, which includes information on significant bills, is viewable at SSVMS.org.publications.

There are moments in political life that should be preserved in a time capsule to warn future generations from repeating the mistakes of their predecessors. This legislative session could certainly qualify as one of those moments.

At the beginning of 2007, the Governor embarked on a massive media blitz to pass universal health reform. But by the end of 2008, the state passed a budget that eliminates health care coverage for 250,000 Californians. What happened?

Sacramento was buzzing in January of 2007 with the possibility that universal health care would finally be achieved. Governor Schwarzenegger had proposed a comprehensive proposal that garnered national attention. Both Democratic leaders also had proposed their own plans and the state seemingly was set for a banner year.

That year-long effort famously flamed out when the State Senate defeated the Governor’s proposal on January 28, 2008, largely due to concerns over the growing budgetary problems facing the state.

As much as 2007 was dominated by hope, 2008 was dominated by anger, animosity, and a broken state budget. The Governor invested mightily in his health care reform effort and its defeat left a bad taste in everyone’s mouth.

There was enough finger-pointing to satisfy even the most cynical of political observers.

The Governor and Assembly Speaker Fabian Nunez blamed Senate President Pro Tem Don

Perata. Don Perata blamed the Governor and Fabian Nunez. And while the blame game was in full force everyone suddenly realized we had a massive budget problem with no real way out of it.

By February of 2008, the Governor was forced to exercise his mid-year cut authority to close a $15 billion budget deficit. The Legislature became immediately embroiled in a fight over whether to adopt or reject the proposed cuts. All of the Legislature’s energy was lost to the reality that the state was, and remains, broke.

As part of the mid-year cuts, the Governor and Legislature slashed Medi-Cal reimbursement rates by 10 percent, forcing CMA to go to court to block the state from implementing the cuts. It is a sad commentary on political reality when politicians are cutting already dismally low reimbursements and judges are the only ones standing in their way. At least our justice system works on occasion.

The structural deficit remained pegged at over $15 billion dollars even after $7 billion in mid-year cuts. That massive deficit, combined with a partisan stand-off, led to a historic budget delay. The new budget was not enacted until September 23, 2008. The Governor now holds a dubious record: signing the latest budget in the history of California.

And what did Californians get as a result of the historic delay? A gimmicky budget that is already out of balance. Legislators are likely to be called back into special session to consider mid-year budget cuts even before the New Year begins. Such is life in Sacramento.

The next two years are likely to be dominated by a perfect financial storm: a Legislature

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The next two years are likely to be dominated by a perfect financial storm…

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unable or unwilling to make difficult decisions to increase revenue or massively cut services, a Governor who has become completely isolated from both Republicans and Democrats in the Legislature, and a weakening economy that will lead to diminishing tax revenues for the state.

Is there a chance that the animosity that has defined the last two years will disappear or at least diminish in the Governor’s final two years? Perhaps. Both the Assembly and Senate have elected leaders, Karen Bass and Darrell Steinberg respectively, who are known to be driven primarily by policy and a desire to do what is best for the state.

Whether they can contain the hostility and bitterness of past battles and find some way to coax Republicans to the negotiating table remains a very open question. Governor Schwarzenegger vetoed a record number and percentage of bills in 2008, making even more difficult legislative leadership’s efforts to overcome their colleagues’ animosity and frustration and move forward with a positive agenda.

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Their success or failure will probably be the best barometer for the state’s ability to dig itself out of a massive structural budget deficit. If they fail, the Governor’s final two years will likely be incredibly disappointing.

Given all of that uplifting news, there were still many legislative proposals significant to patients and physicians, and considering the insanity of the 2007–08 legislative session, CMA was incredibly successful.

Among the bills signed into law was legislation to provide physicians whistleblower protections and a prohibition on insurance companies from rescinding treatment authorizations after the service has been provided in good faith.

Perhaps most importantly, an egregious HMO loophole was closed. HMO fines will no longer be used to offset the fees they pay to the Department of Managed Health Care. Instead, that money will be used to finance the Steve Thompson Loan Repayment Program (STLRP) and the Major Risk Medical Insurance Program (MRMIP). The STLRP provides loan forgiveness to medical school graduates who agree to practice in underserved areas.

MRMIP provides insurance to those with pre-existing medical conditions that cannot obtain coverage in the open market.

CMA also defeated a bevy of scope bills and an attempt to obliterate the corporate bar on the practice of medicine. Additionally, CMA defeated an incredibly onerous bill that would have created a commission of political hacks to rank physicians. This legislation also would have allowed the commission to demand any and all records from physicians and medical groups and levy any tax they saw fit on physicians and medical groups.

All in all, it was a successful legislative session for CMA despite the major disappointment of not achieving universal health care.

Go to the SSVMS website for details on individual bills.

In Memoriam

Kenneth Hisao Ozawa, MD 1931–2008

It is with deep sadness that we share the news that Kenneth Ozawa, MD, passed away on November 29, 2008.

For many years, Dr. Ozawa chaired this Medical Society’s Emergency Care Committee made up of the emergency department medical directors from our region. This is one of the few medical societies in California to have such a committee. It was under his direction, and his gentle but persuasive leadership, that we performed the first regional audit of ED deaths; that trauma audit survey laid the groundwork and built community and physician support for establishing the UCD Trauma Center.

Ken also organized the now retired Hospital Emergency Alert Radio system, consisting of dedicated radios in each ED. This HEAR system allowed communication between disaster preparedness facilities and a series of portable radios installed in key vehicles.

In cooperation with the Hospital Council of Northern California, Ken led our committee through the process of drafting and implementing our region’s first diversion policy in the early 1980s. He was among the first to call for a new, stronger policy that has proven to be so effective.

Ken led our committee in developing two position papers: “The Need for a Second Trauma Center and Physician Specialty Coverage of Hospital Emergency Departments,” February 1988 and “Rescuing Emergency Care,” September 1989. The papers represent the need for additional trauma facilities (in the south and in the north) and established dialogue regarding the problem of specialty coverage of the ED in our region.

Ken was a key, if not the founding member, of the Sheriff’s Sacramento County Medical Reserve Corp. He was the recipient of the

Medical Society’s highest honor, the Golden Stethoscope Award in 1990, for his devotion to patient care and the medical needs of the community.

Ken was a family practice physician with a keen interest in public safety. His leadership in these fields was always a part of his participation as a Delegate to the California Medical Association House of Delegates where his resolutions impacted public policy and legislation in California.

One of his close friends and fellow Golden Stethoscope Honoree, Henry Go, MD, had this to say about Dr. Ozawa: “In the big pond of Human Experience we will forever see the Kenneth Hisao Ozawa, MD ripples from a life well lived. His good works place him in the pantheon of fine physicians who did good works in this valley.

“Kenneth Ozawa shared with me the same orbits as general practitioners here in Sacramento; we were of the same cut of cloth, same ideals and beliefs, commitments, but I was never the moral compass of the community. He had a sense of duty: to patients, community, family, organized medicine, to his country: to wit his years of service in the reserves. He was loyal. In reflecting on his years of internment in the camps during the second world war, he never spoke with bitterness. There was a spiritual side to him; once when we were working on a quality issue over a doctor’s performance, I was thinking of preponderance of fact: he smiled at me and said, ’He was weighed and found wanting.’ Simple as that.

“Like a shaman, ambiguities did not confuse him. He could see Truth. And he had that continued on next page

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In Memoriam

Ernest J. Petrulio, MD 1928–2008

On October 20, 2008 Ernest J. Petrulio, MD, passed away. He was born in New Jersey December 27, 1928. He graduated from Columbia College in 1951 and New York Medical College in 1955.

After his pediatric residency he entered the Air Force and was assigned to Mather Air Force Base.

I first met Ernie at pediatric clinical meetings. His devotion to learning and keeping up with the latest medical advances were very obvious. Early on, I asked him if he would consider becoming my partner. He said, “No, we are going back East.” I urged him to remember that I asked him first.

When he and Helen decided to stay here, he joined me in practice for the next 30 years. There was never a Ernest J. Petrulio, MD stressful moment in the relationship.

Helen, Ernie’s wife of 50 years and a fellow pediatrician, preceded him in death. He leaves their two children, Karen Dudley and Richard Petrulio, and four grandchildren. He also leaves many others whose lives he touched.

His son, Richard, expressed these feelings: “His life’s work was pediatrics, where he cared for the many children he saw as well as helping their parents raise them properly. He had a wonderful ability to listen attentively and think carefully before speaking. For many years he taught at the UC Davis School of Medicine where he received the Departmental Excellence in Teaching Award in 1982 and 1984. His extraordinary humbleness never allowed him to speak of this recognition.

“He leaves behind a legacy of caring and kindness that not only greatly impacted our lives, but also the lives of everyone he met. After he retired, he continued to touch the lives of those who needed help from the community by volunteering at Loaves and Fishes. We miss him very much and pray that he is smiling down upon us, alongside our Mom, knowing what a wonderful gift he was to the world he left behind.”

I echo Richard’s sentiments. I could not have asked for a better friend and partner, and I will miss him always.

— Dennis Marks, MD

continued from previous page smile. At one meeting he looked across to his colleague, smiled and simply said, ‘I think you are wrong.’ The doctor reflected later he did not sleep well that night.

“He never lost his link with the common man: ‘We all being God’s children; we all have our place under the sun.’

“And for those of us left on that pond, what does he leave us? His close colleagues say, ‘the mentoring, the passage of knowledge.’ I say also his legacy of Truth, service above self, a life lived well, with redeeming consequence.”

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Dr. Ozawa, was born in St. Helena on July 21, 1931, earned his medical degree from Loma Linda in 1957 and completed his rotating internship at the U.S. Naval Hospital in Oakland, in 1958. He was a battalion surgeon and captain with the United States Marine Corp Reserves. He is survived by his wife, Leatrice, his daughters, Dede Fernandez, Emi Johnston and Carole Opsahl, and six grandchildren.

— Bill Sandberg and Henry Go, MD

New SSVMS Committees These are the 2009 Committee appointments approved by the SSVMS Board of Directors.

Child and Adolescent Health Services Drs. Mary Jess Wilson, Chair, Charles Maas, Vice Chair, Fawzia Ashar, Marcia Britton-Gray, Lindalee Huston, Maynard Johnston, Robert Meagher, Richard Pan, Patricia Samuelson, Rachel Weinreb Continuing Medical Education Drs. Denise Satterfield, Chair, Arlene Burton, Satya Chatterjee, Alfredo Czerwinski, Barbara Hays, Maynard Johnston, Richard Jones, Charles Maas, Travis Miller, Lee Snook, Jr., Lee Welter Editorial Drs. John Loofbourow, Editor/Chair, David Gibson, Vice Chair, Robert LaPerriere, Gordon Love, John McCarthy, Delbert Meyer, George Meyer, John Ostrich, William Peniston, Gerald Rogan, F. James Rybka, Gilbert Wright, Lydia Wytrzes. Ted Fourkas, Managing Editor Emergency Care Drs. John Tucker, Chair, David Berman, Michael Carl, Troy Falck, Hernando Garzon, Peter Hull, J. Douglas Kirk, Robert Kozel, Norman Label, James Martel, Karen Murrell, Kelly Nations, Pankaj Patel, Harold Renollet, Steven Schorer, Steve Tharratt, Lee Welter, David Wisner, John Wood Historical Drs. Robert LaPerriere, Chair, Francine Gallawa, Nancy Gilbert, Julian Holt, Joseph Masters, Margaret Masters, Otto Neubuerger, Kent Perryman, F. James Rybka, Irma West Judicial Drs. Joanne Berkowitz, Jose Cueto, Ralph Koldinger, Richard Pan, Paul Phinney, Boone Seto Membership Drs. James Sehr, Chair, James Farley, Vice Chair, Christine Fernando, James Hamill, Barbara Hays, Daksha Shah

Medical Review and Advisory Drs. Howard Slyter, Chair, Joanne Berkowitz, Vice Chair, Denny Anspach, Jose Arevalo, Richard Axelrod, Peter Carruth, Mark Chang, Satya Chatterjee, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Richard Gray, Kern Guppy, Okyanus Gurel, Ruth Haskins, David Haugen, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Michael Luszczak, Charles McDonnell, Gail Pirie, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto, Gerald Simon Professional Conduct and Ethics Drs. Joanne Berkowitz, Chair, Frank Apgar, Satya Chatterjee, Jon Finkler, Richard Gray, James Hamill, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Robert Lentzner, Ivan Rarick, Ronald Rogers, Linda Schaffer, Daksha Shah, Robert Treat, Glennah Trochet Public and Environmental Health Drs. Donald Lyman, Chair, Richard Sun, Vice Chair, Janet Abshire, Regan Asher, Donald Brown, Clinton Collins, Anthony DeRiggi, Jason Eberhart-Phillips, Jody Gordon, Sandra Hand, Alexander Kelter, Robert LaPerriere, Charles Maas, Stephen McCurdy, Robert Meagher, Connie Mitchell, David Root, Glennah Trochet Scholarship and Awards Drs. Byron Demorest, Chair, Margaret Parsons, Vice Chair, Ruenell Adams, Frank Boutin, Sr, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kaplan, Paul Kelly, Mark Levy, Travis Miller, Caroline Peck, Anthony Russell, Patricia Samuelson Wellness Committee Drs. Michael Parr, Chair, Lee Snook, Captane Thomson, Robert Treat

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Board Briefs November 10, 2008 The Board: Approved the 2009 Budgets for the General Fund, Building Fund and the Community Service, Education and Research Fund.

Approved the 2008 Third Quarter Investment Reports and Recommendations.

Approved the Membership Report For Active Membership — Bernadette V. Del Rosario, MD; Lisa Marie Guirguis, MD; John S. Lee, MD; Sangeeta S. Parulekar, DO; Julie L. Steiner, MD. For Return to Active Membership from Retired Status — Jay C. Owens, MD. For Return to Active Membership from a Special Leave of Absence — Stephen K. Parkinson, MD. For Retired Membership — Alton L. Curtis, MD; Peter J. Koch, MD; Patricia D. Will, MD. For Resignation — Richard E. Brunader, MD (moved to Oregon); Debra L. Callahan, MD (moved out of the area); Ravinder Khaira, MD; Mark A. Winchester, MD (moved to North Carolina).

Membership Terminated for Nonpayment of Dues — Ron E. James, MD; Aaryan K. Koura, MD. Serving as the Administrative Board to the Community Service, Education and Research Fund (CSERF), the Board approved support in general of the recommendation to purchase a Non-Mydriatric Digital Fundus Camera to be donated to the Sacramento County Clinics, but to refer the matter to the Executive Committee for further review.

December 8, 2008 The Board: Approved five governance policies to comply with the IRS Form 990 Annual Tax Return/Report Form. The policies are the IRS’s reaction to concerns expressed by key committees in Congress for greater disclosure and improved governance in nonprofit tax-exempt organizations. The policies also enhance compliance with federal income tax exemption requirements. The policies approved are: Conflict of Interest; Compensation and Review of Executive Director; Document retention and Destruction; Joint Venture Policy; and Whistleblower Policy.

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Approved the 2009 Committee Appointments.

Approved upgrading the parking lot to become ADA compliant and proceed with the preliminary design of the Board room.

Approved the Membership Report For Active Membership — Anthony F. Bellomo, MD; Henry H. Chang, MD; Janeline T. Daubert, MD; Jason M. Guardino, DO; Brian H. Kim, MD; Cheri W-P Leng, MD; Daniel Lopez-Uribe, MD; Laura C. Miller, MD; Vinay Penmetcha, MD; Rick N. Phan, MD; Jennifer L. Schwarz, MD; Ardeep K. Sekhon, MD; Zi-Jian Xu, MD; Stepahnie A. Yee-Guardino, DO; Eduardo O. Zapata, DO. For Retired Membership — Bette Hinton, MD For Resignation — Samuel V. Bartholomew, MD (moved to Oregon); Marc K. Chinn, MD (transferred to Santa Clara); Karyn D’Addio, DO; Louis Pagnone, DO. Serving as the Administrative Board to the Community Service, Education and Research Fund (CSERF), the Board approved (Dr. Trochet abstained) four policies from the SPIRIT Project Management Committee addressing governance issues. Also, the Board approved purchase of a Non-Mydriatric Digital Fundus Camera to be donated to the Sacramento County Clinics.

January 12, 2009 The Board: Elected Glennah Trochet, MD, 2009 Secretary and Katherine Gillogley, MD, 2009 Treasurer. Also, welcomed new directors, Drs. John Belko, Michael Flaningam, J. Dale Smith.

Approved supporting the Alliance’s participation in the AMA Alliance project “Screen Out,” a campaign aimed at eliminating smoking from youth-rated films.

Approved the Membership Report For Active Membership — Amy R. Benson, MD; Steven T. Chan, MD; Hui-Li Chiou, MD; Aaron B. Cullen, MD; David P. Foos, DO; Kayvan D. Haddadan, MD; Holly J. Haight, MD; Dominic J. Herda, MD; Sonya M. Jackson, MD; Sylvia R. Jones, MD; Uma A. Kunda, MD; Edward J. Lee, MD; George C-C Lin, DO. For Reinstatement to Active Membership — Bradley W. Barnhill, MD.

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 GREENFIELD, John H, III., Orthopedic Surgery, UT Southwestern 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5852

LENG, Cheri W-P., Ophthalmology, University of Washington 2004, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 746-4356

BENSON, Amy R., Pediatrics, UC Davis 2004, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060

GUARDINO, Jason M., Gastroenterology, WUHS College of Osteopathic Medicine 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6675

LIN, George C-C., Physical Medicine & Rehabilitation, WUHS, College of Osteopathic Medicine 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2036

CHAN, Henry H., Anesthesiology/Pain Medicine, UC Los Angeles 1989, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6893

HADDADAN, Kayvan D., Physical Medicine & Rehabilitation, Shahid Beheshti Univ, Iran 1995, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2600

CHAN, Steven T., Physical Medicine & Rehabilitation, Brown University 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6729

HAIGHT, Holly J., Orthopedic Surgery, Mayo Medical School 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7768

AXELROD, Yekaterina V., Neurology/Critical Care, Russian State Medical University 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6932

CHIOU, Hui-Li, Pediatrics/Neonatology, Taipei Medical College, Taiwan 1984, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7725 CULLEN, Aaron B., Orthopedic Surgery, Temple University 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6303 CORPUZ, Virginia T., Psychiatry/Geriatric Psychiatry, St. Louis University, Philippines 1989, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 DAUBERT, Janeline T., Nephrology, St. George University 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6988 FINLEY, Randall J., Radiology/Neuroradiology, Albert Einstein 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 FLORES-MERRITT, Isabella, General Surgery, Temple University 2004, Acute Care Surgery Medical Group, 2800 L St #200, Sacramento 95816 (916) 423-3255 FOOS, David P., Family Medicine, Touro University 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4652

HERDA, Dominic J., Psychiatry, University of North Dakota 1992, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 HOFER, Mark A., Orthopedic Surgery, University of Chicago 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6096 JACKSON, Sonya M., Psychiatry, UC Davis 2000, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 JONES, Sylvia R., Internal Medicine, University of Rochester 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4657 KIM, Brian, Cardiology, Medical College of Pennsylvania 1995, Sutter Medical Group, 5301 F St #117, Sacramento 95819 (916) 733-1788 KIM, NaYoung, Allergy/Immunology, Northwestern University 2002, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6500

MILLER, Laura C., Neurology, SUNY Buffalo 2003, Sutter Neuroscience Medical Group, 2800 L St #500, Sacramento 95816 (916) 454-6850 MORTENSON, Melinda M., General Surgery/ Surgical Oncology, UC Davis 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5649 PENMETCHA, Vinay, Internal Medicine, M.R. Medical College, India 1997, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 PHAN, Rick N., Internal Medicine, St. George’s University 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 RHODES, Robert J., Family Medicine, University of Colorado 2005, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-7070 SEKHON, Ardeep K., Neurology/Neurophysiology, Univ of Debrecen, Hungary 2002, Sutter Neuroscience Medical Group, 2800 L St #500, Sacramento 95816 (916) 454-6850

KUNDA, Uma A., Internal Medicine, Andhra Medical College, India 1992, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661

THAKUR, Nicklesh, Neurology, Arizona College of Osteopathic Medicine 2001, Sutter Neuroscience Medical Group, 2800 L St #500, Sacramento 95816 (916) 454-6850

LEE, Edward J., Otolaryngology, Albert Einstein 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322

XU, Zi-Jian, Cardiology, Shanghai Medical University, China 1983, Sutter Medical Group, 5301 F St #117, Sacramento 95819 (916) 733-1788

GASCON, Diana Z.L., Family Medicine, Univ of the East Ramon Magsaysay, Philippines 1984, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-2169

Board Briefs, continued from previous page For Retired Membership — Monte Ikemire, MD. For Resignation — Michael P. Giovan, MD (moved to New Hampshire); Yoav Hahn, MD (moved to Michigan); Hasina Nasir, MD (moved to Hayward, CA).

LOPEZ-URIBE, Daniel, Family Medicine, Case Western Reserve 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

YEE-GUARDINO, Stephanie A., Pediatric Infectious Diseases, WUHS College of Osteopathic Medicine 2000, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5206 YU, Haifeng, Psychiatry, Shanghai Second Medical College, China 1982, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100 ZAPATA, Eduardo O., Internal Medicine, Nova Southeastern University 1996, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2600

January/February 2009

35

Classified Advertising

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36

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

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

Electronic Claims

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

Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911 Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...

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

HIPAA Compliance Toolkit

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

Investment Services

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

Magazine Subscriptions

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

Notary Service/Free to Members

Medical Society (916) 452-2671

Security Prescription Pads

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

Professional Publications

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

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

Sierra Sacramento Valley Medicine