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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2009


Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE The Mystery of the OMSS Revealed

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The Case Against the Electronic Medical Record

Charles H. McDonnell, III, MD

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LETTER TO THE EDITOR The Stimulus Package and Electronic Health Records

David J. Gibson, MD, and Jennifer Shaw Gibson

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Voices of Medicine

Del Meyer, MD

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O Asilo Novo: Caconde, Brazil, February 2009

John Loofbourow, MD

Joseph L. Dunn

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EDITOR’S MESSAGE To Families, Associates, and Should-Be-Members

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.

John Loofbourow, MD

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When a Physician is Married to a Physician

BOOK REVIEW How Doctors Approach Patients — and Vice Versa

George Meyer, MD, FACP, MACG

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Proving One’s Citizenzhip

Michael Stevens, MD

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Improving Peer Review

Gerald Rogan, MD

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IN MEMORIAM Sami Haddad, MD

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After 30 Years, Blood Banking Gets Personal

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IN MEMORIAM Pierce A. Rooney, Jr., MD

Michael J. Fuller

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Posits on EMR

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Board Briefs

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2009 History Museum Lecture Series

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New Applicants

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Classified ads

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 “Costa Rica” is the second magazine cover by retired orthopedic surgeon Greg Joy, MD, of Placerville. It was taken with a digital SLR camera, using a tripod and a 200mm lens. Dr. Joy often uses a “digital darkroom” to alter or mix images; however, this photo, other than having been cropped, is in its original state. “Costa Rica has much to offer, but the number, color and variety of birds and the unimaginable opportunities to photograph them is high on the list of reasons to go there,” he says. “This is one of the six varieties of Toucans present in Costa Rica, which boasts being host to 10 percent of all the species of birds in the world.”

Volume 60/Number 2 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

Some of Dr. Joy’s images can be seen at his website, www.alegriastudio.com.

March/April 2009

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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 2009 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 Stephen Melcher, MD John Ostrich, 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 David Gibson, MD, Vice Chair Robert LaPerriere, MD William Peniston, MD Gordon Love, MD Gerald F. Rogan, MD John McCarthy, MD F. James Rybka, MD Del Meyer, MD Gilbert Wright, MD George Meyer, MD Lydia Wytrzes, 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

The Mystery of the OMSS Revealed By Charles H. McDonnell, III, MD Warning for those of you who have attended a California Medical Association (CMA) annual House of Delegates meeting: you should probably stop reading and go to the next article, as you are most likely already familiar with the OMSS. For the rest of you seekers of truth, OMSS does not refer to the Organization of Medical Students in Sacramento, or the Occupational Medical Society of Sacramento. And it certainly is not a naval ship or charter boat (while that would be nice on occasion). Rather, it stands for the Organized Medical Staff Section of the CMA. Since 2007, I have had the great pleasure of serving on the Sutter Roseville Medical Center’s (SRMC) Medical Executive Committee as its representative to the OMSS. In this capacity, I am frequently asked what the OMSS is and does, prompting me to write this article. Any medical staff in California is eligible for membership in the OMSS. Dues are based on the number of hospital beds and range from $300 to $1,500. In our area, the medical staffs that were members in 2008 included Mercy Folsom, Mercy General, UC Davis and SRMC. There are many valuable benefits of membership in the OMSS. Members are provided access to the CMA’s sundry resources and personnel. For instance, with membership comes free access to the CMA’s Model Medical Staff Bylaws and Model Code of Conduct required by the Joint Commission. To keep up with relevant issues, members also receive the OMSS Advocate Newsletter, published quarterly. Membership also provides free access to the CMA On-Call

documents, which cover topics such as medical staff governance, economic credentialing, fair hearing requirements, peer review immunity and adverse events. Probably of greatest value, though, is representation of the member medical staff to the OMSS and CMA. Each member medical staff designates or elects a representative (and an alternate if desired) who must be a member of the CMA. Representatives are admitted for free as voting members to the annual OMSS assembly and are encouraged to participate in developing CMA medical staff policy and advocacy. OMSS representatives are typically included on their member medical staff’s medical executive committees. Thus, serving as a representative provides many opportunities for development of leadership skills that can positively impact the OMSS, CMA and their respective medical staffs. The OMSS Board consists of OMSS representatives (physicians and CMA members) who are elected to two year terms at the Annual OMSS Assembly. Included on the board are two delegates and two alternate delegates to the CMA’s House of Delegates. Also serving on the OMSS Board is an elected representative to the CMA Board of Trustees. The board also designates an OMSS representative to the CMA Council on Legislation. The board meets face-to-face three times throughout the year in addition to several teleconferences and is supported by CMA staff. (At the end of this article is a roster of current OMSS officers and staff.) The OMSS Annual Assembly currently meets the day before the House of Delegates. In addi-

March/April 2009

...OMSS does not refer to the Organization of Medical Students in Sacramento, or the Occupational Medical Society of Sacramento. And it certainly is not a naval ship…

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At the most recent annual assembly there was a presentation on the results of the medical board’s study on peer review (the Lumetra Report). The report concluded that peer review in California was “broken.”

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tion to OMSS representatives, there are nonvoting attendees from nonmember medical staffs that pay a registration fee to attend, as was the case for Sutter Medical Center Sacramento last year. The first half of the meeting is a business meeting, which includes election of new board members and officers. CMA House of Delegates resolutions with relevance to medical staffs are reviewed and debated to strategize appropriate support or opposition, as well as to craft changes. OMSS representatives may also submit resolutions for such review. OMSS resolutions that win support at the annual assembly are then submitted to the House of Delegates as emergency resolutions for consideration. The second half of the annual assembly is an educational session. This always includes a legislative update, which is usually highly entertaining. Last year’s update was given by Senior Vice President, CMA Government Relations, Dustin Corcoran, who detailed the inside story on the failure of the California run at health care reform. He also highlighted CMA’s recent legislative successes including whistleblower protection for physicians, the prohibition on rescinding treatment authorizations after service provided, the closure of a loophole that offset DMHC fines against HMO’s, and multiple scope of practice victories. Other agenda items vary from year to year, just as issues of interest to medical staffs vary. At the most recent annual assembly there was a presentation on the results of the medical board’s study on peer review (the Lumetra Report). The report concluded that peer review in California was “broken.” There were status reports on legal battles against Medi-Cal cuts and the Department of Managed Health Care’s regulations against balance billing. There were also discussions on a couple of new standards put forth by The Joint Commission. These included LD 03.01.01 that calls on hospitals to establish processes for managing disruptive physician behavior, and MS 1.20, a standard relating to medical staff bylaws, which assures the independence of medical staffs via self-governance.

Sierra Sacramento Valley Medicine

There was additionally an update for new hospital reporting requirements on adverse events to the California Department of Public Health, and discussion of problems surrounding the transition to Palmetto for Medi-Care claims. In summary, the CMA’s Organized Medical Staff Section provides education, advocacy resources, and communication for the medical staffs of hospitals, other health facilities, and emerging delivery systems. These benefits are simply vital as health care is transformed in the coming years. Participation requires minimal financial and time commitments, and there are many exceptional communication and leadership development opportunities within the organization. This is what OMSS is all about. For additional information, contact CMA OMSS staff member Taylore Casbarian-Wilson at 916-551-2053 or twilson@cmanet.org. charles@mcdonnell.net

Organized Medical Staff Section

California Medical Association 1201 J Street, Suite 200 Sacramento, CA 95814 (916) 551-2053 twilson@cmanet.org Board member and position: Lytton Smith, MD, Chair; Damodara Rajasekhar, MD, Vice-Chair; Marshall Morgan, MD, Secretary; Richard Rajaratnam, MD, FRCS, FACS, Delegate #1; John Luster, MD, Delegate #2; William Carlson, MD, Alternate Delegate #1; Richard Butcher, MD, Alternate Delegate #2; Robert Pugach, MD, Trustee; and Brian Johnston, MD, Member. CMA Staff: Taylore Casbarian-Wilson, Astrid Meghrigian, Yvonne Choong, and Rachel Smith.


Letter to the Editor

The Stimulus Package and Electronic Health Records The economic stimulus package recently passed by Congress included $19 billion for health information technology (HIT), the vast majority of which will be directed to physicians to subsidize the purchase and usage of Electronic Health Records (EHR) systems. Qualifying Medicare providers stand to gain up to $44,000 under the program; qualifying Medi-Cal providers stand to receive as much as $65,000. These funds are predicated on physicians using EHRs, so practices and groups that already have purchased EHR systems can also qualify for funds. In all the conversations about HIT over the years, this is the first real effort to steer substantial resources to physicians to help them with the adoption of technologies to help streamline and improve their practices. CMA has long advocated for such direct assistance, which is critical to physicians’ ability to afford these systems, particularly for solo and small practice doctors. Without physician input, these funds may have been steered through hospitals or health insurers, or not allocated at all. As significant an opportunity as these funds are, they do not come without strings. Physicians will be required to demonstrate meaningful usage of EHR systems, which will include participating in a health information exchange and reporting on quality measures. Additionally, physicians who don’t use EHRs will face a 1 percent cut in Medicare payments beginning in 2015. That cut will grow to 2 percent in 2016 and 3 percent in each year thereafter. Many of you likely have questions about what this means for your practice, and what you need to do to position your practice to receive these funds. While many of the details and standards for qualifying as an EHR user have yet to be worked out, CMA is ready to help you

navigate this process whether you already use an EHR system or are considering purchasing one. For the most up-to-date information, I invite you to visit CMA’s online HIT Resource Center at: www.cmanet.org/HIT. One piece of information is important for you to know right now. I know that many of you have been receiving calls from EHR vendors urging you to buy their product now to take advantage of the federal stimulus funds. However, given the lack of clarity about what EHR systems will qualify a physician to receive the federal subsidy, CMA believes that now is not the time to rush out and purchase an EHR system. There is no benefit in rushing to purchase a system. The standards to determine which EHR systems will qualify for the physician subsidy will be worked out in the coming months. For now, CMA advises that you begin assessing your HIT needs, with an eye on what will work best for your specialty, the size of your practice, the stage in your career, and your comfort level with technology. Once the standards are developed, CMA will develop a marketplace of vendors with federally qualified EHR systems, complete with information about each that will assist you in choosing the right one for your practice. For physicians who already use an EHR system, CMA will provide more information on how to ensure your system qualifies once the standards are developed. For the rest of the information, and answers to your questions, please visit CMA’s HIT Resource Center. CMA is closely monitoring the standards development process, and will be updating the Resource Center as new information becomes available. — Joseph L. Dunn, Chief Executive Officer, California Medical Association March/April 2009

…now is not the time to rush out and purchase an EHR system.

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ARE YOU FINANCIALLY PREPARED FOR

“what if”?

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HELP SECURE YOUR FINANCIAL FUTURE AND PROTECT THE ONES YOU LOVE WITH THE SSVMS SPONSORED LIFE INSURANCE PROGRAM. * Not underwritten by Hartford Life and Accident Insurance Company Underwritten by Hartford Life and Accident Insurance Company Hartford Life and Accident Insurance Company, Simsbury, CT 06089. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGL-1762) • #CMA1-908

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For more information, call 800-842-3761 or visit www.MarshAffinity.com


Editor’s Message

To Families, Associates, and Should-Be-Members A letter from the editor.

By John Loofbourow, MD The growth in readership of our online publication has been dramatic during the past few years, even though mailed issues go to members only. This growth is predominantly local. That is as it should be because physicians do not function alone. We live and work in the company of family, colleagues, and friends; we are professionally and individually dependent on a host of people from every walk of life. In addition to spouses of members, it is very clear that many SSV Medicine readers are nonphysicians, or non-member physicians whom I think of as should-be members. I address this letter to you all because I know you are there, and I know that your ideas, your comments, and your observations, and you yourselves, are important to our members. Recently, Gabrielle Neuberger, president of the Alliance, spoke with me about writing articles. In the past we have published reviews of Alliance activities, usually in with a message from the president, and we look forward to that each year. But I want more from Alliance members, Gabrielle; more from family, secretaries, and receptionists, and nurses, and technicians and housekeepers. To all: We welcome your essays, articles, commentary, letters, insights. There is no doubt at all in my mind that many of you have opinions and are fully capable of expressing them; that many of you are writers, poets, storytellers. In fact, knowing the general level of education among medical people and our families,

and friends, I expect many of you can express yourselves even more clearly and eloquently than those of us who have had our noses buried in mind numbing medical books for so many years, and now put in 90 hour weeks in practice. A receptionist, for one example among many, doing what is likely the single most stressful work in medicine, could tell much that is informative, pathos filled, instructive, curious, or sometimes hilariously funny, especially when it reveals a human quality we all may have overlooked. The letter or article I want to see from any and each of you is: the one that tells of your relationship to your physician father or mother. The one that tells of someone’s medical care in whatever aspect is most significant to you. The poem about illness, loss, recovery, or an inspirational moment. The time you felt the medical system or non system failed you or helped you beyond any expectation. Naturally, as always, we must be selective and an accepted article must be done considerately and without disclosing privileged information. Yet at the same time we appreciate strong opinion well expressed. The process of submitting an article or poem or story or essay is really exceedingly simple. Send it to me by email at the address below. I will read it, comment, and reply. Sometimes I will suggest editing for size, or style, or other details. We will send the article back and forth until we both are satisfied. Then continued on next page March/April 2009

To all: We welcome your essays, articles, commentary, letters, insights.

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When a Physician is Married to a Physician By Michael Stevens, MD This article is reprinted from the January edition of the San Mateo County Medical Association Bulletin. What is it like being a physician married to a physician? Thank goodness we’re in two different fields of medicine! You see, my wife is a pediatrician and I see adult patients. It makes a world of difference to us.

Knowing How To Be Supportive When my physician-wife comes home, exhausted after a day with 30 patients and often twice the number of parents, I listen to her intently. I have nothing to add. I have no suggestions for treatment. After all, these are kids! I don’t do kids and I have no idea what I would do with one if it threw-up all over me. I admire her tact, her expertise and especially her patience with the parents. It’s exhausting work. I know all that and I respect the job she does and the job she has done for almost 20 years now.

And finally, I’m grateful I don’t have her job. When it’s my turn to talk about a case over dinner, I mention the pertinent details, the possible differentials and the most interesting findings. There are always interesting findings in rheumatology (my opinion of course). To her credit, my physician-wife says little. She listens. She asks which way I’m leaning regarding the diagnosis and/or treatments and I know she appreciates the complexity of what I deal with in my field. Mercifully, she rarely has suggestions and never recriminations regarding what I didn’t do or should do. She allows me to review the case out loud to her but I know, she’s really just letting me review the case out loud for me. There is another side to this coin when our medical backgrounds collide. Like the time my wife diagnosed my asthmatic attack as an anxiety disorder. Or, in all fairness, the time I thought her facial rash might have been a manifestation of lupus. It wasn’t. There’s little doubt that our lives are greatly impacted by our professions

Editor continued from previous page it will be reviewed by our editorial committee who decide if it is accepted for publication. We try not to publish articles that are self serving, disguised advertising, abusive, subject to litigation, or legally risky. Due to space limitations we seldom publish more than 2 or 3 pages in length: 500 to 1200 words. We like a passport sized black and white photo, but it is not at all required. This is a magazine or opinion and essay,

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Sierra Sacramento Valley Medicine

dedicated to the lives of physicians, patients, family, community, medical commentary or politics; but not technical articles, so no bibliography or references are required although that is okay if desired and not extensive. Send us your scrivenings. Whenever we can publish them, we will. And when we can’t, the rejection is thoughtful, painless, and secret. john@loofbourrow.com


and we both delve into the great mystery that is medicine on a daily basis at work and home. Sometimes, too much medical knowledge of what can happen is a dangerous thing. We’ve learned to allow for that. Perhaps what saves us from being totally immersed in our work to the exclusion of all else is a sense of humor.

The Kids Are Listening There are some effects of our dual physician relationship on the whole family. So let me tell you about our boys. There was a time I thought our oldest was a hypochondriac. By the time he was nine, he had a fairly impressive knowledge of pediatric diseases and medications. Like a medical student going through rotations, he often complained of symptoms he overheard during his parent’s conversations at home. When he started asking about treatment for his symptoms we decided to make an effort to avoid these family discussions. Our

youngest, who could barely pronounce many of these diseases, parroted the concerns of his older brother as best he could. It took awhile to convince him that phimoses had nothing to do with the Red Sea parting and lupus patients were not related to werewolves. So, what’s it like being married to a physician over 26 years? Ultimately, I suspect it’s the same as every other married couple. There are good times and the not so good times. We work hard and we sometimes miss out on occasions as a family because one of us is called away or the other is scheduled to work. The boys have learned to adapt. I don’t think either of us ever regretted our career choices because of these times. We are physicians and we love our work. We are also parents and we love our kids. I’m not sure how our family differs from other 21st century families since this is the only family I know. When all is said and done, I’m content with that.

March/April 2009

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Sierra Sacramento Valley Medical Society Alliance in cooperation with

Sutter Neuroscience Institute and Sutter Heart & Vascular Institute present

Stroke & Heart Disease: Women are Different Join us for a morning of education about Cardiovascular and Cerebrovascular risks in women. Learn from experts what your risks are, what signs to watch for, and prevention tips. Date:

Saturday, May 2, 2009

Time:

8:00 – 8:25 A.M. Registration & Breakfast 8:30 – 1:30 P.M. Program & Lunch

Place:

Sutter Cancer Center 2800 L Street, Classrooms 1-4, Sacramento, CA 95816

Fee:

$25.00 / $35.00 on or after April 18, 2009

RSVP:

Online: ssvms.org/alliance Phone: (916) 452-2678 U.S. Mail:

Sierra Sacramento Valley Medical Society Alliance 5380 Elvas Avenue Sacramento, CA 95819

SIERRA SACRAMENTO VALLEY

Medical Society Alliance 


Improving Peer Review A legislative committee is working on changes to state peer review laws. Physician input can help achieve what’s needed: a more effective, consistent and just process.

By Gerald Rogan, MD When California enacted the Medical Injury Compensation and Reform Act (MICRA) in 1975, the Legislature expected medical staffs to conduct effective peer review in hospitals under sections 800–809 of the Business and Professions Code. Now the state Senate Committee on Business, Professions, and Economic Development, chaired by Senator Gloria Negrete McLeod, is demanding accountability. The Lumetra Report1 on peer review commissioned by the California Legislature through the Medical Board of California documents peer review too often is ineffective, inconsistent, and occasionally unjust. Lumetra concludes: These variations can result in physicians continuing to provide substandard care (at times for years) impacting the protection of the public.2 On March 9, the Committee held a 3 ½ hour fact-finding hearing at the state Capitol. Twenty experts and stakeholders testified, including me. Senator Sam Aanestad, a member of the Committee and oral surgeon who is experienced in peer review, clarified that the California laws requiring peer review will be revised. Lumetra presented its recommendations. Various stakeholders offered variations of Lumetra’s recommendations and alternative solutions. I sat though the entire hearing and concluded there was a majority view. To improve peer review, auditing by external auditors is necessary. At the hearing, Dr. Bruce Ermann, MD, of Mercy General Hospital, testified that Catholic Healthcare West employs an outside auditing firm, the Greeley Company,3 to help assure peer review is effective and performed as expected by our Legislature. As an additional benefit,

outside peer review can reduce the liability of a medical staff and hospital — such as when a review results in a decision adverse to a physician’s ability to practice medicine, who then responds with a lawsuit for damages. An external peer review resource, available as a back-up, can assure local peer review is performed as required by law, is effective, and is just. The external resource can be used when needed to remove bias and to remove a legal cause of action that alleges bias or an unjust process. Currently, California is unable to effectively enforce its peer review laws because it lacks meaningful intermediate penalties to do so. Our findings from the Redding Medical Center (RMC) disaster, obtained under the Freedom of Information Act, show that in 1999 three agencies — the Licensing and Certification Division of the state Department of Public Health; the San Francisco regional office of the federal Centers for Medicare & Medicaid Services; and the Joint Commission on Healthcare Facilities — were unable to compel RMC to provide effective peer review in its cardiac services sections. Negligent patient care in the cardiac unit continued unabated until 2002, when the FBI raided the facility and employed medical experts to provide effective peer review. RMC, the culpable physicians and their insurers paid over $500 million in damages and fines to over 600 damaged patients, the government, and commercial insurers. RMC was kicked out of the Medicare Program. No hospital can tolerate a repeat of this type of disaster. Under current law, those same three agencies remain unable to assure effective peer

March/April 2009

Currently, California is unable to effectively enforce its peer review laws because it lacks meaningful intermediate penalties to do so.

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Physicians who advocate for patient safety and quality must be free from fear to do so.

review. We have proposed a new law that gives the state’s Licensing and Certfication Division the power to remove the license of a department of a hospital when peer review remains ineffective or is not done. Under such a law, elective services normally performed in these departments could not be provided by the hospital or its medical staff, could not be billed to insurers, and could not be billed to patients until the missing peer review is provided and effective action is taken as appropriate. Physicians must develop effective methods to assure peer review is properly performed and is effective in each institution. For example, it is no longer acceptable to protect a “rainmaker” physician from peer review; by doing so, patient safety cannot be assured. The fear of reporting adverse events, expressed by some physicians, must give way to an effective and safe report-

A Review Committee at Work

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Sierra Sacramento Valley Medicine

ing system. Physicians who advocate for patient safety and quality must be free from fear to do so. Physicians must be part of the solution. Peer review is complicated. It encompasses elements of total quality management, quality assurance, and detailed case review prompted by specific adverse events. Our Legislature must craft new laws that will be effective for many years. The law must anticipate changes yet to come. No one knows more about peer review than those involved in it. These physicians can help our Legislature by considering what can be done and advising the Business and Professions Committee. jerryroganmd@sbcglobal.net 1 Lumetra “Comprehensive Study of Peer Review in California.” 2 Ibid, Page 1 of 122. 3 http://www.greeley.com/epr


After 30 Years, Blood Banking Gets Personal By Michael J. Fuller, CEO, BloodSource This article expands on remarks by Michael Fuller at the SSVMS Annual Meeting. BloodSource recently concluded 60 years of providing safe and reliable blood service to your patients in Northern California. Throughout those decades, BloodSource has initiated many new, innovative programs in support of our hospitals’ programs — such as the stem cells developed at BloodSource and transferred to a hospital, where this investment could be applied to the further development of life saving therapies. For over 30 years I have worked in blood banking, but only recently did I truly understand what gifts BloodSource provides. My best friend, Jay, was also a blood banker. We worked together, attended conferences together, borrowed each other’s ideas and claimed them for our own, argued politics — he was always on the wrong side — played jokes on each other (some I can share and others need to stay with us). Generally, you could say we had a great guy kind of relationship. When Jay was diagnosed with cancer, we were certain, like all of the other crises we had faced, we could get through this one, too. Before Jay’s bone marrow transplant, he was in a Southern California hospital and he requested the blood and platelets be obtained from BloodSource. He said this was because he trusted our quality and knew our reliability. Sometime in the first days of Jay’s transfusions, we both began to understand what our jobs are really about. Our battle with Jay’s cancer lasted almost two years. In spite of his Herculean effort and the best professional care, we couldn’t beat the

cancer. The gifts of so many blood donors and medical professionals gave us time to relive a lifelong friendship, time to say goodbye, and allowed both of us to reach a deeper human level. After 30 years, it’s not just about blood — there’s a deeper connection. It’s about relationships. I wish I could go back and make certain Doctors Yant, Henderson, Setzer and all of the founders of BloodSource knew how many lives were touched by their volunteer effort 60 years ago. I hope those who have served BloodSource, and are currently serving, recognize the difference they have made and are making. I have a unique perspective — the very good fortune to be an employee of a wonderful organization and the recipient of its good work. Yes, you do save lives. Both Jay and I were touched by the need for blood in ways that we didn’t expect. Jay was able to share a wonderful holiday with his granddaughter, Hannah, at Disneyland shortly before he passed away. It was a deeply moving memory — and motivation — for Jay as he fought for his life. This was an example of BloodSource donors providing hope along with blood. My granddaughter, Georgia, underwent open heart surgery when she was just 12 hours old. I actually saw her tiny heart beating since her chest was kept open for many days to allow her to receive various medical procedures, including transfusions of red blood cells and platelets. She is now a happy, healthy 2 year-old. I get to have this perfect little life connected to mine. There’s nothing better than that.

Both Jay and I were touched by the need for blood in ways that we didn’t expect.

Mike.Fuller@bloodsource.org March/April 2009

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Posits on EMR First Posit: “Electronic Medical Records (EMRs) will (or do) reduce the overhead and increase the efficiency of my practice.” Second Posit: “EMRs will (or do) improve the quality of care in my medical practice.”

The theme of these related posits was suggested by SSVMS member Jerry Rogan, who plans to include the results in testimony before legislative committees dealing with EMR. It is timely, considering President Obama’s effort to promote and require EMR for all Medicare billing by 2015. Among 222 responses, 149 agreed with either or both posits, while 57 disagreed with either or both. (A number commented but made only partial yes/no decisions.) Commentary follows: We prefer to allow the writers to speak for themselves, rather than weigh their words down under an editorial burden.

The EMR compares to pen and paper the way my cell phone compares to the “two tin cans connected by a string” I used as a kid!!

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The use of computers in medicine has been around long enough for physicians to have figured out the plusses and minuses of their use. They are helpful when they work right, but we still don’t have the paperless society that was promised years ago, and we probably never will. When records are lost or the computer “crashes” we are in trouble. Also, access to a patient’s  records by hackers is always a threat. I am not convinced that the use of computers will save money in our practices. — Byron H. Demorest, MD [Computer use will] reduce overhead but efficiency will be decreased until the system is learned. — Franklin D. Robinson, III, MD We have been electronic for 2 1/2 years and it was a difficult transition. It has not reduced personnel costs, but it has allowed us to capture charges better. And adhering to Medicare quality standards for increased payment is a breeze with an EMR. Electronic prescribing decreases phone time for staff. [Re quality of care,] it is easier to

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track lab work and not let items fall through the cracks. Records can be accessed remotely to assist physicians on call. Legible records make care easier and I can fax a copy of a record to a treating physician with a single keystroke. — Joanne Berkowitz, MD The implementation of the EMR to my practice at Kaiser-Permanente/South Sacramento has been truly a spectacular revolution in my professional life. I could write paragraphs about how much more efficient my care delivery has become, about the ease of access to all aspects of my patient’s medical record, about the absence of illegibility, the vast reduction in medication errors, the ease of data collection, the ease with which I can now communicate with my colleagues about any given patient, even at remote K-P facilities, the ease with which I can communicate, in a secure fashion, with my patients, the ease with which I can practice virtual medicine, where applicable, the tremendous improvement in my life as an on-call surgeon, etc. The EMR compares to pen and paper the way my cell phone compares to the “two tin cans connected by a string” I used as a kid!! — David Manske, MD EMR, in most systems that I have worked at, increase the overhead and decrease the efficiency of practice to some degree. This is balanced by more improved communication, better access, increased ease for patients. EMRs do improve quality of care — better documentation, better access among health care providers, linking to pharmacy records — all improve patient quality of care. — Cheri W.P Leng, MD We have been using them at KP for 3 years — the convenience is remarkable. Being able


to read other provider’s notes is…a big plus. — Victoria F. Akins, MD EMR has added three hours to my work day. — Reinhardt G. Hilzinger, MD I disagree on both. I am at Kaiser so am familiar with EMRs. The utility is limited but it is there. — Mark Zlotlow, MD [EMR will] increase efficiency, but be cost neutral [or] more expensive. [EMR improve] medication safety, legible notes, records always available; no other way to practice in the 21st century. — Thomas J. Russell, MD EMR has a huge time commitment associated with it. This really takes away from practice efficiency. [They] do allow a better look at practice norms. — Donna Freitas, MD It removes almost all postal and transcription costs saving as much as $7,000–$10,000 a year; makes it easy to check on medications; and via e-scripts, I get quick feedback from pharmacies if patients are trying to abuse prescriptions. — Michael H. Robbins, MD An article in the Wall Street Journal, Thursday, March 12, 2009, says it all. It was written by Doctors Groopman and Hartzband on the faculty of Harvard Medical School. They refer to (and discount) the Rand study, published in 2005 and funded by Hewlett Packard and Xerox (hmm?) The Rand policy analysts readily admit in their report that there was no compelling evidence at that time to support their theoretical claims (for EMR). Groopman and Hartzband note that… “in the four years since the report, considerable data have been obtained that undermine their (Rand) claims.” The article should be read by all those who believe the hype that EMR will improve medicine, lead to fewer errors, etc., and that…the government should adopt this as national policy. My own experience, though limited, [was that EMR] did not decrease costs nor did it decrease errors. However, medical prescription writing, loaded with a patient’s drug data, and containing all side effects of those drugs, would be an asset (I think). — Wayne C. Matthews, MD EMRs are not perfect, can detract from patient doctor interactions and make notes seem impersonal, but the efficiency of having

all the pertinent information just a click or two away from any location far outweighs the drawbacks. It is amazing how long it…continues to take modern medicine to move beyond paper charts. — Thomas J. Curran, MD [The issue of improving quality of care] depends on how integrated it is with other providers. — David Z. Tzeng, MD I have beta-tested several and find that they require me to spend more time producing visit notes which I normally can complete in writing before the end of each visit. EMR would also cost me money both front-loaded and in annual costs, that I would not recoup, [because] EMR would not allow me to see more patients than I already do. I do not find that EMR would replace detailed record keeping and attention to detail. I do not need a computer to notify me of standards of care or upcoming/overdue interventions or follow up. I say this as a technologic early adopter with an in-office computer system, three networked wireless personal netbooks and laptops and a regular user of the local medical centers VPN. — Mark L. Tong, MD Readability errors due to handwriting are eliminated with EMRs. — Deepu Bindal, MS I [EMR] will increase the “hassle factor” of your practice and decrease the enjoyment time of your practice unless you love typing and computers. It may increase efficiency and overhead. — John W. Kuhn, MD I have an EMR and it has absolutely added to the efficiency of my practice and saved expense. — Dominic M. Erba, MD We’ve been using (EMR) since 11/06 and have seen improvements in efficiency and billing. It took about 6 months for us to be able to chart as quickly as with our previous system. — Kimette M. Marta, MD It makes my overall practice much more inefficient with the exception of availability of hospital and specialist records. Inefficiency is especially noticeable in excessive charting time, (inherent in system), and in hunting down old medical records which are very difficult to find in the system. I have had to reduce the number of patients seen daily to accommodate excessive data entry. Overhead is increased in this way,

March/April 2009

EMR has a huge time commitment associated with it. This really takes away from practice efficiency.

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I want the government to work on software to link databases and software systems rather than mandating the system that we must use.

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[due to] cost of a huge IT Support system. In some ways quality is improved, in other ways it is diminished. The areas where I think it is helpful are: 1) medication/pharmacy; probably reduced medication errors with much better tracking of meds. 2) review specialist records within my group…(still very unhelpful for records outside my practice). Quality is diminished in the area of documentation: I find that clinic notes overall have deteriorated (my own and my colleagues) since we all were asked to become data entry specialists. It is rare that a physician or PA actually bothers to document a differential diagnosis... — name withheld, MD EMR must be standardized in order for our nation to get any cost savings or increase in efficiency as part of the economic stimulus package. I am worried that the EMR that I invested in for my practice 4 years ago will become obsolete and I will be forced to buy something different that may not be specialty specific. I want the government to work on software to link databases and software systems rather than mandating the system that we must use. — Alison A. Bordreaux, MD [My experience has been that the EMR] did reduce the overhead and increase efficiency. [As to quality of care,] I was able to immediately download up-to-date information, which I could share with patients and implement at that time. — Richard N. Gray, Jr., MD Efficiency [is improved but] overhead is more, or at best the same; [one must] keep up the software and equipment. In addition, the efficiency sometimes sacrifices accuracy or the ability to do rapid reasonable reviews. However, EMRs promote and make more efficient information-sharing from various remote locations (lab, x-ray, satellite clinics, etc.) [Re Quality of Care] EMR become mechanical and rote, and sometimes sidetrack the give/take of patient interaction. In peer reviews/audits (part of one of my jobs), it appears that electronic checkboxes sometimes cause errors when physicians “forget” to interact or to thoroughly review the previous notes. — Evalyn Horowitz, MD EMR has definitely improved my efficiency, but a big reason for this is that I know how to

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type. I think it has likely improved quality of care as well. — Michael A. Flaningam, MD EMR can improve the efficiency of a practice and improve billing and charge-capture if done well. There is a learning curve, but with patience it can be quite useful. Templates can be set up to maximize billing and can reduce some paperwork if used properly. I recommend avoiding EMRs that are provided “free of charge”; there are usually strings attached you may not want. The best thing that EMRs can do is help cut down on medication errors and allow a physician to be up to date on all medications the patient may be taking to avoid drug interactions. Finally, it can be useful to help insure a patient is getting all recommended preventive medical care. This can be profitable if the practice has a pay for performance contract. — Sidney A. Scudder, MD Initially efficiency will decrease because of cumbersome data entry; eventually should improve overall. — Rick Wakamiya, MD [I Agree with both posits] BUT, not during the transition (the benefits come later.) — William L. Bargar, MD I disagree with both posits. The cost of setting up EMR and paying licensing and maintenance fees will never be made up. I’m also concerned it will be that much easier for insurance companies and the government to monitor medical care and enforce treatment protocols in order to limit care. — Sidney Yassinger, MD Recently I was at my [spouse’s] hospital visit.... I learned first hand how it is to be on the “other side” of a doctor clicking away on a computer. I found the two doctors we saw (especially the specialist), seemed frustrated with the system. There were awkward silences and less eye contact. There were frustrating gaps in the visit as the doctors would “hunt” for things they couldn’t find in the computer. The simplest tasks just seemed to take too long. The specialist told us he had had to reduce his daily visits by 30% to accommodate [the EMR]. — Member MD This is especially hard on a small individual practice. [The] physician is so busy typing the history he will lose valuable time [and neglect] establishing communication with the patient.


Dr. Osler might turn over in his grave. Critics also caution that the long term cost will far exceed the $60,000 incentive the government [offers] to entice us to use the EHR. It may be cost effective to large group practices. Can CMA give us a cost breakdown? — J.M. Young, MD At present there is no published evidence other than anecdotal or speculative musings to support [either of these] propositions. — David Gibson, MD As a patient, I have not felt inconvenienced or slighted by my physician’s use of the computer during my visits. In fact, I feel that it is a benefi-

cial tool in our relationship. Someday, I hope to have total access to my records, even if it’s just read only. Total access by the patient would solve a lot of problems. As Executive Director, I believe that for the majority of small offices, the investment in a system (that may not even be around in a year or two) for a couple of extra points in reimbursement is probably a wasted effort. When Microsoft offers a program, it will be a good time for a small office to buy an EMR package. — Bill Sandberg

2009 Medical History Lecture Series Sierra Sacramento Valley Museum of Medical History April 22, Wednesday, 7 pm Dr. Sidney Garfield and the Pre-History of Kaiser Permanente, presented by Steve Gilford. Steve Gilford has studied Kaiser-Permante for more than 20 years. After a brief review of the better-known history, he will explore lesser known stories, including his work in locating the “lost” site of the first Kaiser Permanente hospital story, now a state Historic Site. His book, Henry J. Kaiser, The Legacy Continues, details the accomplishments of Henry Kaiser, his engineers, and the company responsible for many great civil engineering projects. He was also a major contributor to The First Fifty Years: A History of the Southern California Permanente Medical Group and also an upcoming biography of Sidney Garfield, the physician founder of Kaiser Permanente. Mr. Gilford is a Senior History Consultant to Kaiser Permanente. He was the history consultant for the Henry Kaiser exhibit at the Oakland Museum and he is working with the National Park Service on the Rosie the Riveter National Park at the old Kaiser Shipyards in Richmond. August 27, Thursday, 7 pm A Brief History of Transfusion Medicine, presented by Christopher Gresens, MD. The evolution of transfusion medicine is fascinating, sometimes predictable, more often surprising, and (rarely) even bizarre. Its history is entwined among those

of the world and of medicine in general, and has been especially rich since the beginning of the 20th Century. The major three “eras” covered in this presentation will be: pre-1665; 1665–1899; and 1900 and beyond. The speaker will stress the richness, complexity, and occasionally fantastic aspects of this ever-growing medical subspecialty. Dr. Gresens is a 1991 graduate from the UCLA School of Medicine, where he also did his internship plus four years of residency in anatomic and clinical pathology (he is board certified in both specialties, as well as in blood banking/transfusion medicine). He joined BloodSource in 1996, and is currently Vice President and Medical Director of Clinical Services. November 4, Wednesday, 7 pm Magical Medical History Tour, presented by Faith Fitzgerald, MD Dr. Fitzgerald discusses famous people, their illnesses, their accomplishments and associated interesting things. These “cases” illustrate the rich access all doctors have, through their patients, to history, literature, art, philosophy, music, poetry, religion, in fact, all things pertinent to human beings. Faith Fitzgerald is an Internist and Professor of Medicine and Assistant Dean of Humanities and Bioethics at the University of California Davis.

Open to the Public. Free admission. Reservations are requested to ensure adequate seating; please call (916) 452-2671. All lectures are held at the Medical Society 5380 Elvas Avenue, Sacramento LECTURES SPONSORED BY AMGEN, INC.

March/April 2009

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In My Opinion

The Case Against the Electronic Medical Record By David J. Gibson, MD, and Jenifer Shaw Gibson

“information technology does not require subsidization unless it is not ready for deployment.”

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President Barack Obama convened a healthcare summit in Washington on March 5 to identify programs that would improve quality and restrain burgeoning costs. His flagship proposal was national adoption of the electronic medical record (EMR). This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill. The point of this article is to discuss the value of the EMR itself. But it must be pointed out that none of the President’s assertions is true. Obama has based his proposal on a now discredited 2005 RAND study on EHRs.1 From the time of its publication to the present, there has been no compelling evidence to support the study’s theoretical benefits. If, as RAND asserts, the EMR improves efficiency, enhances productivity, decreases overhead cost and improves the quality of health care, why are only 4 percent of doctors using functional electronic records that can provide any kind of clinical recommendations,2 and why are only 1.5 percent of nearly 3,000 hospitals currently equipped with comprehensive electronic records? 3 As a group, health care professionals have been on the forefront in embracing information technology, including beepers, fax machines, cellular phones, desk top computing, data mining and the use of the Internet for both personal and business use. Yet there is a gap between information technology’s deployments in health care as opposed

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to most other industries. There are several reasons for this.

The Technology Issue. EMR systems are difficult to maintain in the small practice setting. Furthermore, most studies document a reduction in physician productivity following installation of EMRs. These systems generally add a half-hour or more to a physician’s day for tasks such as electronic ordering, and responding to the false alerts that all of these EMR systems generate.4 Physicians need an EMR that does not yet exist. They need a mobile, voice-activated, heuristic, architecture-based system rather than a keyboard and mouse-based interface with the EMR. A friend of ours once made the observation that “information technology does not require subsidization unless it is not ready for deployment.”

The Business Model Issue. For hospitals, declining revenues and deteriorating investment returns, coupled with accelerating capital costs, make investing in EMRs problematic. The Sutter Health System expects to spend a billion dollars to implement EMRs in its Northern California hospitals. The UC Davis health care system began digitizing its medical records about six years ago — at a cost of $90 million. Kaiser Permanente and Veterans Administration Hospitals have invested billions of dollars to bring their EMR systems online.5 Small hospitals spend at least $20 million to go paperless while larger academic institutions generally spend as much as $200 million. Thus, an EMR system represents a substan-


tial capital investment for hospitals that are also confronting seismic retro-fitting mandates and an economic recession that is resulting in fewer elective admissions. The loss of these elective admissions is devastating to a hospital’s business model. Based on a November 2008 study by the American Hospital Association; elective procedures generally make up 10 percent of total admissions but generate 25 percent of hospital profits.6 The same economic realities confront physicians. Three-fourths of the nation’s doctors practice in small offices with 10 doctors or less. For most of them, investing in digital health records looks like an unreimbursed cost. The Obama Administration’s economic rewards for the EMR are inadequate. A main feature of its budget proposal calls for incentive payments spread over a few years for a physician who buys and uses electronic health records. A new report7 by Avalere Health, an information company serving government and the health care industry, found it would cost about $124,000 for a single doctor or small practice to upgrade to electronic health records over the five-year period (2011–2015) during which the stimulus bill offers incentive payments of up to $44,000. In 2015, Medicare penalties start to kick in for doctors who haven’t switched to electronic record-keeping. The projected starting penalty will be $5,100 a year — far less than the cost, less the incentive, to install and maintain an electronic health system.

EMR Veracity is Compromised. The secret generally unknown outside the health care industry is that the only real business model case that resonates for the EMR in medical practices is the support for documenting (and occasionally up-coding) billed charges. Interest in the EMR was generated by the threat from the Centers for Medicare & Medicaid Services (CMS) that physicians needed to adequately document patient visits. Remember the Evaluation & Management (E&M) Code controversy that arose with the 1996 passage of the Kassebaum-Kennedy Bill?

The purpose of the bill, which criminalizes any miscoding of medical services, was to control fraud and abuse in the Medicare program. To no one’s surprise, the documentation to satisfy E&M coding requirements fit neatly into a computer coding system — the EMR was born. A decade later, another reason for adopting electronic recording of clinical information developed. In 2005, ”Pay for Performance” (P4P) was introduced by the health insurance industry. These P4P plans — which pay doctors, hospitals and other providers more money if they meet certain goals — were seen as a way of boosting health quality. Recent evidence is that P4P plans are ineffective in achieving any of their original goals. Researchers at the RAND Corporation studied a P4P program started in 2003, involving seven major California health plans and 225 physician groups caring for 6.2 million people.8 The study found that the programs appear to be speeding adoption of information technology such as electronic medical records, but these changes have not improved quality. There are now rather unpleasant consequences emerging as a direct result of E&M codes, P4P and the evolving deployment of EMRs: The veracity of the medical record is being compromised. An associate who teaches at a medical school told us that he observed frequent EMR chart entries using macros (one or two key strokes that perform a series of actions) for components of the physical exam that have not been performed. “Mary, it says here you did a neurological exam and it was normal. I was there with you and didn’t see you do a neuro-exam.” The student’s response, “I inserted a macro for my physical exam.” Another associate who practices in a large medical group relates that padding of the chart with superfluous, macro-based information is rendering the chart irrelevant. As this checklist, cut-and-paste, or macroinsertion behavior spreads, the veracity of the medical chart becomes profoundly compromised. How can an attending physician finding

March/April 2009

As this checklist, cut-andpaste, or macro insertion behavior spreads, the veracity of the medical chart becomes profoundly compromised.

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neurological deficits ever rely on the recorded clinical findings six months before if there is a possibility the reported data are compromised or, worse, “dry-labbed”? The answer is they cannot. So the only believable data in these EMRs will be derived from the lab and the objectively recorded diagnostic studies.

Quality of Care.

Once a misdiagnosis enters into the electronic record, it is rapidly and virally propagated.

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There is also no evidence that the EMRs improve the quality of health care. A 2008 study published in Circulation9 assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that “current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.” Similarly, researchers from Brigham and Women’s Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. They concluded, ”As implemented, electronic health records were not associated with better quality ambulatory care.”10 One prominently featured benefit referenced by the Administration is reduction in pharmaceutical-based errors and the resulting reduction in malpractice premium cost. Again, the evidence is lacking. Experience of institutions with EMR is that the impact of medication errors on malpractice costs has been negligible; the vast majority of lawsuits arise not from technical mistakes like incorrect prescriptions but from diagnostic errors, where the physician makes a misdiagnosis and the correct therapy is delayed or never delivered. There is no evidence electronic medical records lower the chances of diagnostic error.11 One of the oldest of computer problems — “garbage in, garbage out” — exacerbates liability exposure. Once a misdiagnosis enters into the electronic record, it is rapidly and virally propagated. A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and

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redundant diagnoses using the computer — 48 compared to seven in the paper-based cohort.12 Propagation of mistakes is not limited to misdiagnoses. Once data are keyed in, they are rarely rechecked for accuracy. Entering a patient’s weight incorrectly will result in a drug dose that is too low or too high, and the computer has no way to correct such human error. Recent studies suggest that adopting computerized systems has not helped but harmed patients. After the Children’s Hospital of Pittsburgh added automated prescribing recommendations to a commercial electronic records system, it documented more than a threefold increase in the death rate of child patients.13 Another leading system contributed to more than 20 different types of medical errors.14

Individual Privacy Once the medical record is in digital form, a couple of mouse clicks on a computer that is connected to the internet can propagate the most private of information to a worldwide audience. Furthermore, not every health care professional with access to the EMR system should have access to every record within the system. Once cleared for record access, not every professional should have access to every part of the record. This conundrum of layered security level setting has not been resolved. Current concern over confidentiality of data is not spurious for providers. The liability relating to disclosing personal health Information (PHI) now stands at up to $1,500,000 per occurrence.15

A Tool for Rationing. A new concern has arisen with the administration’s EMR initiative. Some have speculated that patient data collected in national electronic health records will be mined to assess cost effectiveness of different treatments. This analysis could then be used to dictate which drugs and devices doctors can provide to patients in federal programs like Medicare. Private insurers often follow the lead of the government in such payments.


Conclusion. The fact is there is no objective peer reviewed and published evidence that EMRs improve quality or reduce costs. What lessons can we learn from all of the above? One is that public policy should not drive market development before thorough predeployment testing has determined effectiveness and detected unintended consequences. It should be noted that though we are critical, we are not opposed to the EMR — in fact, we recognize clear benefits from deploying an EMR in the clinical setting. Today, patients are frequently seen without physicians having access to the patient’s paper records. With EMR, health professionals can readily access all information on their patients from a single site. Particularly helpful are alerts in the system that warn of potential toxicity in prescribing certain drugs for a patient already on other therapies. Rather, our objection is to the opportunistic and abusive use of discredited data and bogus projections for political purposes. The cynical presentation of unsubstantiated or, worse, known inaccurate cost savings and improved quality of care data being used to justify breathtaking increases in taxpayer funding for increased health care spending by the government is patently disingenuous. DJGibson@winfirst.com Jennifer Gibson traded energy commodity 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 http://content.healthaffairs.org/cgi/content/abstract/24/5/1103 2 http://content.nejm.org/cgi/content/full/NEJMsa0802005 3 http://content.nejm.org/cgi/content/full/ NEJMsa0900592?query=TOC 4 http://www.jamia.org/cgi/content/abstract/12/5/505 5 http://www.sacbee.com/topstories/story/1729785.html 6 http://www.aha.org/aha/content/2008/pdf/081119econcrisisreport. pdf 7 http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2009/03/09/ national/w151537D80.DTL&type=politics

8 http://www.randcompare.org/publications/abstract/taking_stock_ of_payforperformance_a_candid_assessment_from_the_front_ lines 9 http://circheartfailure.ahajournals.org/cgi/content/abstract/1/2/98?ij key=2f06e4d763e3c2b48d6521ad4198fea32dd6ae7b&keytype2= tf_ipsecsha 10 http://archinte.highwire.org/cgi/content/abstract/167/13/1400 11 Source: based on experience at the Harvard teaching hospitals, where electronic medical records have been in use for years; http://online.wsj.com/article/SB123681586452302125.html 12 http://www.pubmedcentral.nih.gov/articlerender. fcgi?artid=1538581 13 http://pediatrics.aappublications.org/cgi/content/ abstract/116/6/1506 14 http://jama.ama-assn.org/cgi/content/abstract/293/10/1197 15 http://www.mcguirewoods.com/news-resources/item. asp?item=3751

Medical Practices Face Rising Workers’ Compensation Costs In the current economic climate, spending more than you have to for workers’ compensation insurance doesn’t make sense. Workers’ compensation premiums are on the rise again, right at a time when reducing practice expenses must be a priority for every physician. The Workers’ Compensation Insurance Rating Bureau is recommending a 24.4 percent average increase in rates effective July 1, 2009 following its recommended 16.0 percent increase for January 1, 2009. The Department of Insurance countered that increase with a 5 percent recommendation. Neither the WCIRB’s nor DOI’s recommendations are binding on insurance companies. The Sierra Sacramento Valley Medical Society’s sponsored Workers’ Compensation program, with its 5 percent member discount, (possibly 15 percent depending upon where you have your group medical coverage) will be even more important to members this year. The program is underwritten by Employers Compensation Insurance Company, (rated “A-“ by AM Best). Rather than guess what your savings could be, take a moment to contact Marsh. Let them show you how your association membership can translate into savings. Call a Client Service Representative at 800-842-3761.

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Voices of Medicine A doctor’s first novel, memories of a grandmother, caring for Pakistani earthquake victims.

By Del Meyer, MD

A Blockbuster First Novel Stephen Jackson, MD, editor of the CSA Bulletin, reviews a book in the Fall 2008 issue: OXYGEN. Carol Wiley Cassella, M.D., has written a blockbuster first novel — Oxygen — a spellbinding tale which recounts with stunning realism the professional and personal trials and tribulations of a woman anesthesiologist who becomes caught up, unexpectedly and inexplicably, in an anesthetic mishap involving a mildly retarded 8-year-old. Dr. Cassella, herself an anesthesiologist, is in private practice with the Virginia Mason group in Seattle… Dr. Cassella has hit pay dirt with her novel that is written engagingly in the first person. With her unexpected fame as a physician author has come the opportunity to be interviewed on radio talk shows, an experience that has led her, unintentionally and inadvertently, to become a spokesperson for our specialty, one that her interviewers consider to be largely hidden from the public. They repeatedly address her with a sense of respect, reverence and a fascination for her knowledge as an “insider.” And, I can attest to the fact that Dr. Cassella has been superb in representing our specialty. These interviews can be accessed on her web site at www.carolcassella. com… I strongly urge each of you to read Oxygen, especially because it examines in great depth the gamut of the important and too-often-neglected topic of physician wellbeing. Indeed, while engaging the reader with a mesmerizing plot that has full relevance to the art and science of the practice of anesthesiology, she explores life’s personal and professional choices as we progress through our careers as physicians and

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anesthesiologists. In fact, from a wellness point of view, I will be bold enough to suggest that Oxygen be required reading for all of us… So, with the author’s blessing, we reprint (with Simon and Schuster’s permission) the first chapter of Oxygen for your enjoyment. People feel so strong, so durable. I anesthetize airline pilots, corporate executives, high school principals, mothers of well-brought-up children, judges and janitors, psychiatrists and salespeople, mountain climbers and musicians. People who have strutted and struggled and breathed on this planet for twenty, thirty, seventy years defying the inexorable, entropic decay of all living things. All of them clinging to existence by one molecule: oxygen. The entire complex human machine pivots on the pinnacle of oxygen. The bucket brigade of energy metabolism that keeps us all alive ends with oxygen as the final electron acceptor. Take it away, and the cascade clogs up in minutes, backing up the whole precisely tuned engine until it collapses, choked, cold and blue. Two portals connect us to oxygen — the mouth and the nose — appreciated more for all their other uses: tasting, smelling, smiling, whistling, blowing smoke and blowing kisses, supporting sunglasses and lipstick designers, perfumeries and plastic surgeons. Seal them for the duration of the morning weather report and everything you had planned for the rest of your life evaporates in a puff of imagination. There is a moment during the induction of general anesthesia when I am intimately bonded to my patient. A moment of transferred power. I squeeze the drug out of the syringe, into the IV line, and watch the face slacken, watch the last organized thoughts slip from consciousness, see breathing shallow, slow, stop. If I deserted my patient—deep in that swale


of sleep, as suffocation colored blood blue—the lips would turn violet, pink skin would dull to gray, and the steady beep, beep, beep of the heart monitor would fade, then falter. Like an archaeological ruin, the brain would die in levels; personality, judgment, memory, movement collapsing like falling bricks to crush the brainstem’s steady pulse of breath and blood. There are points in an otherwise routine day when I am struck by how precariously this unconscious patient dangles, like a hapless fly on a spider’s thread. It is like drowning, but blessed unconsciousness precedes desperate air hunger. At the last instant I swoop in and deliver a rescuing breath, adjust my machine to take over what the brainstem can no longer command... The entire review and book’s first chapter are at www.csahq.org/pdf/bulletin/casella_57_4.pdf

A Grandmother’s Wisdom In the Winter issue of Sonoma Medicine, the magazine of the Sonoma County Medical Association, Sanjay Dhar, MD, asks the question, “Are you smarter than my grandmother?” My grandmother passed away several years ago, but I am reminded of her almost every day. My memories of her are more relevant than ever in these times of financial crisis, cost-cutting, global warming, overuse of natural resources, limited health care, lack of trust in government, lack of jobs, and uncertainty about our future and that of our kids. My grandmother used to be looked down upon by her neighbors because she grew “misshapen” tomatoes in her backyard. Today I pay a lot of money to buy these misshapen heirloom organic tomatoes that she grew. She also grew herbs in her kitchen garden and would always sing to them. Today some scientists claim that music can make plants more productive. She always said that we should eat food the way it is produced in nature: raw. Today a growing subculture promotes the consumption of uncooked, unprocessed, organic foods… My grandmother would always buy things only after she was sure she had the money to spend. Today with the credit crunch, we may want to follow her example. Her slogan was, “If you don’t have the money, you don’t need it.”

Everything got recycled in my grandmother’s house. Newspaper was used for packaging, stuffing and wrapping; old clothes were stuffed into pillows, bedding and insulation; vegetable and garden waste was given to the animals. Today we pay to send our waste to the local garbage companies for recycling and pay even more to buy it back (as 100% consumer recycled paper). How about using newspaper to wrap your gifts this winter holiday season? My grandmother objected to moving into our larger new home. She always said that she could only sleep in one bedroom. Today, after a few decades of growth in home sizes, we are considering how we can reduce our carbon footprint by building smaller and more energy efficient homes. My grandmother asked her cousins to stay with us because she thought their presence would maximize the use of space in the new house, while helping them save money for the future. How many of us today can think of getting extended families together to live under one roof peacefully? Almost 40 years ago, when the nearest grocery store started packaging items in recycled brown paper bags, my grandmother became very upset. She thought the bags were extremely wasteful. She spent day and night making burlap grocery bags for each member of the family, with their names carefully embossed on them. Every three days, all the grandkids would follow her in a line to the grocery store and carry the produce home, with everyone carrying a small load. Obviously, we would all walk to and from the store. After all these years of going through fancy plastic and paper bags, my wife just bought a couple of green canvas bags (with the logo of the grocery store). We don’t have to use paper or plastic bags any more, although we still end up driving to the grocery store. My grandmother was always “green” without claiming to be so. I don’t know how she would react if she were here to see people who claim they are green by buying $30,000 hybrid cars and drinking $5 cups of coffee from recycled paper cups, or large corporations “going green” while their CEOs still fly around the globe in corporate jets.

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My grandmother objected to moving into our larger new home. She always said that she could only sleep in one bedroom.

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All we could see were piles of

Destruction and Beauty in Pakistan

rubble and debris, a sea of innumerable tents and the sheered mountains in the background. This was all juxtaposed against a magnificent background of clear blue skies, beautiful snow covered mountain peaks...

My grandmother taught me values and habits that are so needed in our current era: the importance of “being a family”; the importance of an education; the importance of respect, of self-reliance, of being ethical and conscientious, and of sharing with people less fortunate than me. But I know that even now I am not as smart as my grandmother. To read the entire article, go to at http://scma. org/magazine/articles/?articleid=317

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The San Mateo County Medical Association Bulletin devoted its November-December issue to medical volunteerism. In “Living the Dream, and More,” Naveen Mahmood, MD, told of her October 2005 trip to Pakistan. Ever since I can remember I wanted to become a doctor who could travel all over the world to help people. During medical school and residency I was involved with patient education and basic health care in rural Pakistan. However, three years ago, the ultimate experience came unexpectedly. In October 2005, a 7.6 magnitude earthquake hit northern Pakistan. By December my family and I traveled to Pakistan, at our own expense, to volunteer at remote locales. We collected 700 pounds of medications and supplies in the U.S. In Pakistan we rented a van and drove for a day to get to Abbotabad, one of the northern cities hit hard by the earthquake. We visited the local university hospital that had been turned into an outdoor trauma center. Volunteers from all over the world were present, working tirelessly; large tents were converted into operating suites and temporary wards to accommodate the large post-operative patient population. The scene was surreal. In Balakot, not a single building was left standing. All we could see were piles of rubble and debris, a sea of innumerable tents and the sheered mountains in the background. This was all juxtaposed against a magnificent background of clear blue skies, beautiful snow covered mountain peaks, and the famous River Neelam flowing through the destroyed city. Despite so much destruction, life continued — people cooking in their tents, classrooms Sierra Sacramento Valley Medicine

being held outdoors, children playing among the ruins, and the predictable five daily prayer calls heard over the speakers. The local people were so calm and so friendly. As we began our daily routine of setting up our “mobile clinic”, everyone came by to offer their help. As soon as the local people heard that there was a medical team available they came down with their remaining families in tow. We saw over 200–300 patients per day and worked without a break. We were there as a pediatric team but essentially saw whole families. In fact we ended up seeing a large number of female patients since by cultural norms, they only go to female doctors. Apart from the usual acute care issues such as bronchitis, ear infections, pneumonias and urinary tract infections, we also had to deal with depressed, anxious and traumatized patients. Every patient had a story to tell — children losing parents, parents losing children, young wives losing their husbands and caretakers, now having to figure how to survive on their own. More often than not we felt inadequate to deal with these issues and wondered how these people would move on. However, at the same time, we witnessed this cohesive sense of community and camaraderie amongst the locals — everyone watched over the local orphans, and over each other. In one instance, my niece gave a box of cookies to a nine/ten year old young girl. She immediately began passing out the cookies to all the other young kids and only took one for herself when my sister urged her to — how amazing to witness such selflessness in such dire circumstances!… Finally, it is experiences like these which define us — as a family we have learnt to appreciate what we have, learnt to never take anything for granted and have learnt humility by working with amazing people — those who choose to do this for a living and those who move forward despite the adversities in their lives. Read the entire article at: www.smcma.org/ Bulletin/BulletinIssues/Nov-Dec08issue_copy(1)/ BULLETIN-08NovDecR6.pdf DelMeyer@HealthCareCom.net


O Asilo Novo: Caconde, Brazil, February 2009 By John Loofbourow, MD See the inside back cover for photos of the trip. We are 15 people with luggage, and rent four small station wagons at the airport, two Chevrolets and two VWs. The process is slow but we survive. The cars smell like alcohol when starting up; they are flex fuel, can automatically adjust to any mix of ETOH and gasoline. Alcohol is about 1/5 less efficient but cheaper; it smells so friendly that during the next two weeks we never buy any gasoline. The overall cost per mile is roughly equivalent to the US. The automatic Brazil built Chevy compares very favorably in every respect with the VW. The road north from Sao Paulo is fairly typical in this state; it is a new four lane freeway, built and operated by private investors. The traffic is heavy and typically threatening at first but in an hour we are out of town, despite it being a 6 p.m. weekday. We are on a toll road where about one or two dollars is the common charge. The freeway concession is multi-year, but temporary, and carefully drawn. The Brazilians seem to suspect it is good for foreigners to spend a lot of money to build their roads. We begin to pass dozens of electronic industrial campuses among glitzy residential communities and shopping malls. It is a Silicon Valley, and I am later able to do some elegant shopping which may help to atone for my being here most of February.

Subtropical Brazil. The road climbs gradually in brilliant green low rolling hills, pasted with row crops, sugar cane fields, and eucalyptus or radiata pine hortas, or orchards. These are only a few years old, expected to be ready for pulp harvesting at

15 or 20 years. Both the private toll road and pulp industries were pioneered in South America by Chile 35 years ago, which has a long and mutually beneficial relationship with Brazil that is, unfortunately, unusual for the continent. Even so, everything Brazilian seems to be so large scale, and there are so many young pulp forests that one wonders: Will there be a glut when these are ready for harvest? But I used to think that about sugar cane, and now I am riding in an alcohol driven Chevrolet, and cane is far more efficient for alcohol production than anything else so far. Apparently Brazil does not need to import oil even though it has little of its own. So up and on with alcohol we go. It is the height of summer, equivalent to our August, but here, sub tropical. The sky boils with restless afternoon cumulus clouds that hide the sun and provide a light breeze. We leave the prosperous electronic industrial region and climb to about 1000 meters. More Brazilian Brahma humped cattle are seen. Facendas or haciendas appear, towns become sparse, the hills are dotted with blossoming jacaranda trees, and populated with wild fruit trees, vines, shrubs, that nourish parrots and brightly colored big beaked birds that I think are toucans. White and black buzzards search the green vegetation and the red earth for a meal. Everywhere is water: ponds, lakes, brown rivers, and the watrous sky itself. Bananas and coffee become more frequent, and for some reason the coffee plantations are bordered by bananas, like wind breaks. The afternoon and evening tropical rains appear. Roadside papayas

March/April 2009

The Brazilians seem to suspect it is good for foreigners to spend a lot of money to build their roads.

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Asilo Novo, an expansion of the

Who, How, Why.

old home, had been conceived and begun by a local Catholic priest but was abandoned 30 years ago shortly after the shell had been constructed.

trees are full with clusters of ripening fruit. A walk among the dripping vegetation reveals ‘wild’ avocados, several varieties of ripe delicious guava, and many fruits and birds I can neither name nor recognize. I think of the now Panamanian Panama Canal Zone where I interned and learned that the tropics above 2000 feet is heaven on earth: soft gentle moist air scrubbed each afternoon by sometimes torrential yet kind rains. Skirts of clouds clinging to a wild thorny green world where there is no north or south, up or down, and one is mud encased, thorn scathed, and utterly lost in minutes.

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My companions are mostly from my daughter Amy’s Methodist Church in Los Gatos. Our destination is a rural town of about 15,000 near the Minas Gerais-Sao Paulo border. Caconde (CaCONjhe) is one of the poorest communities in the state of Sao Paulo. There is little work except in coffee for about six months a year. Yet the roads are paved, the sidewalks reasonably sound, it is orderly, and clean, dressed in the patina of old mining money. We hope to help resuscitate an asilo project, an ambitious expansion of small existing homes for the elderly or disabled. Asilos are often found in rural Brazil, and preferably are community built and operated. Asilo Novo, an expansion of the old home, had been conceived and begun by a local Catholic priest but was abandoned 30 years ago shortly after the shell had been constructed. The new project originally had been funded by an annual 10 day, church-sponsored Festival; but the priest was moved, and a decision was made to devote the income to some other purpose. Nonetheless, the community continued to support the adjacent old facility, built for 20 people, and now housing and feeding 50 residents. Eliana Vasconcelos Brown is a member of the Los Gatos church born and raised in Caconde, who visited San Jose to see and learn the world some 20 years ago, and never left. However the asilo was ever on her mind. She led an international effort, raising $20,000 in Califonia and

Sierra Sacramento Valley Medicine

$35,000 in Caconde, enough to complete one third of the Asilo Novo, which would provide for about 60 people. Most of the construction would be done by a local contractor. After a couple of trips to Caconde to verify the situation, the project moved forward and a Methodist Volunteers in Mission, VIM, sponsorship provided valuable non-profit authenticity. Participants paid their own travel and shared expenses, and on January 10, 2009, we went.

The Asilo. The Brazilian concept for an asilo is to become independent of government, or any other agency; to take it out of the political/ economic miasma and make it self supporting. We visited a nearby asilo with 100 residents, which had succeeded through many ingenious interrelationships in the community. It had seven small rental units for income. These were one bedroom units available with or without meals. That asilo provided two classes of elder care, one paid, and one free, though all payments were very small by our standards. It recruited local business people to sponsor every aspect of the asilo in return for advertising on murals, chairs, and the like. It had a privileged location with fine views, and a rental hall where Rotary and other organizations meet, where parties and weddings are held. Much of the food is donated; the key, obviously, was community; the village matters. In Caconde, strong local support was evident, making the likelihood of long term success reasonable. A nearby university school of environmental architecture provided revamped plans for the full development, with particular attention to access for the disabled, and social/ environmental/esthetic considerations. An interesting fund raising detail is that a local person had donated a nice piece of land for a raffle. However, not all tickets were bought in time for the raffle; an unsold ticket won. So another raffle will be held, because the asilo won! Original ticket holders automatically participate but more tickets will be sold until gone.1 We were convinced that a resurrection of the Asilo Novo would be a Caconde project, and


we would only provide some assistance and encouragement if we could. With the local and outside funds at hand, one third of the Asilo Novo would be finished, with 30 more single rooms for residents. Later, rental units can be built. The remaining two large units, for which solid structure shells are already there, can be finished. The enthusiasm and energy provided by the rebirth of the project should be very significant.

The Work; and so forth. For two weeks, we work daily from about 7 a.m. to 5 p.m., assisting with plastering, and preparing interior walls and painting. We manage to finish half of the middle section as projected. Methodists are quite focused in such matters, believing as their founder, John Wesley, that acts speak louder than words. Our project ends as the four day local Carnaval begins. It is very homey and different from its big city cousin. We meet the same people every night and became quite friendly. Three of us go para-sailing with the Brazilian national champion for 2002. Some go rafting. The nearby town of Pocos de Caldos sits (surprise) in an old volcanic caldera; there we do a hot bath in a typical old European style spa. One morning I visit the office of an ophthalmologist to watch him finish the morning with his 13th, 14th and 15th cataract surgeries/ lens implants of the day. The operative equipment seems very up to date, very comparable to the US. He explains he has done 30,000 of these in the past 22 years. He notes there are many differences in the economics of medicine compared to the US. For a revealing example, the surgeon for an indigent patient’s C Section is paid 30 reals, or less than $15 US. Obviously no one does a C Section on a poor person unless it’s really necessary.

Comments: Brazil is a very vigorous young country, average age less than the US and far less than Europe or Japan. While the frontal cortex of the nation — the

money, the power, and the glory are in the large metropolitan centers, the arms and the soul — the resources and the future are in the countryside. Unlike the city slums, no one starves in Caconde. This is a very wealthy country by almost any measure of people, land, water, natural resources, CO2 sinks. (Brazil sells considerable carbon credits to Europe and looks forward to the Obama presidency for another big market.) It is a world leader in exports of iron, coffee, beef, poultry, sugar, ethanol, sugar, and soy. In many respects Brazil is very advanced technologically, with a large and fast growing middle class. It is the world’s 7th largest producer of automobiles, busses, heavy trucks, and the 4th largest producer of regional jet (120 passenger) planes. There is a pervasive confidence and optimism, the sense that the future is now. If I were younger, I would dollar cost average invest modestly in Brazil, one way or another, and hold on for 20 years. The returns, I think, would be startling. There are three practical languages of the Americas: English, Spanish, and Brazilian Portuguese. Ambitious young people would be wise to learn all three. These are reasonably closely related members of the Indo-European group of languages, so that to learn one is a big leg up to the others. To learn two is to nearly know the third. (After a few weeks, as a Spanish and English literate who has learned only about 400 Brazilian words not common to either language, I can read 95 percent of what is found in Brazilian newspapers, understand about 60 percent of TV news anchors, and speak enough to be understood; but understand only 30 or 40 percent of street talk because the phonetics are still very difficult for me.) I found people very friendly and tolerant. At the Carnaval, 80 percent of the early morning crowd were beer-drinking youngsters whose frenetic but curiously gentle and happy behavior was herd-like. Each morning as we walked to our cars, we passed a certain garage door lined

March/April 2009

The author in Caconde, dressed in beekeeper’s attire, not a Carnaval costume.

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with at least 5 urinating young men, who created a small rivulet running down toward the distant sea. I never understood the attraction of that particular spot, the choice of disinhibited herd youngsters. Somehow it was not offensive; at worst, the rain would scrub the sidewalk within hours; at best, it was not my garage. The samba, in its variations, has a definite form, but can be whatever you want, so long as you manifestly enjoy yourself; like Brazilian cars it runs well on alcohol. Given the chance, I would make this journey again. john@loofbourow.com 1 The drawing will be held late this year, and the property is suitable for a small coffee operation and a house. For more information email elibrown@sbcglobal.net.

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

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not-for-profit since 1948

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For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.


Book Review

How Doctors Approach Patients — and Vice Versa By George Meyer, MD, FACP, MACG EVIDENCE IN SERVICE: an evidence-based literature review of service and satisfaction in health care, by David Cornish, MD, and Dianne Dukette, PhD, RoseDog Books, Pittsburgh, PA, ISBN: 978-1-4349-9101-0, 192 pages, $18.00 paperback. Evidence-based medicine has been a household word in training programs for about 20 years. Many large organizations have been evaluating the interaction of patients and physicians with tools that have not met the same standards. Cornish and Dukette have reviewed the literature and have put together a very readable softbound book about this issue. The book is organized into several subsections: Evidencebased Dressing (e.g., apparel), Communication, Managing Patient Satisfaction, Empathy, Ethnicity, Information for Patients, Trust, Gender and Miscellaneous. Each section addresses one or more articles and finishes with the authors’ assessment of the value of the article. We all have our prejudices about what we expect from our caregivers. The first section discusses such issues as formal versus less formal clothing, white coats, piercing, and tattoos in the caregivers. The section on communication gives some good suggestions about keeping communication open with the patient. It cites the long known fact that the physician often lets the patient speak for 18 seconds before interrupting. The authors suggest the initial part of the

encounter should be used to make certain the patient has listed all the points to be discussed, then setting an agenda using the time allotted. For instance, when patients list their first complaint, the provider is encouraged to ask, “What else?” to ensure all patient issues are mentioned. They stress the ILS approach to history taking (Invite the patient to discuss the complaint; Listen avidly; and Summarize the history so the patient knows you got it.) There is also good information about communicating with patients across ethnic, gender, and limited education barriers. They also discuss the concept of teaching communication skills to improve interactions. Although the data do not support the cost, some large groups still offer these communication skills sessions. I was interested in the section called, “What if a patient receives a copy of the consultant’s letter to the primary care physician (PCP)?” I was expecting this to discuss the inadvertent missending of a letter to the patient. The study from the United Kingdom actually showed that 83 percent of patients who received a copy of the letter (intended for the patient as well as the PCP) thought it was a good idea and that they were getting better care. Overall I like this book and recommend it for any caregiver who wants to understand the science of how to improve the way we communicate with our patients. geowmeyer1@earthlink.net

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Proving One’s Citizenship This is the English version of letters sent to indigent persons getting health care under CMISP. At the left are methods of proving citizenship, in English and Spanish; contact SSVMS for full-size copies. Due to budget constraints, the County Board of Supervisors recently made a decision regarding medical services covered through the County Medically Indigent Services Program (CMISP). As a result, the County will now seek to confirm the lawful immigration or citizenship status of all applicants. Beginning April 1, 2009, all persons applying for this program must show proof of United States citizenship or their lawful immigration status. If you are a U.S. citizen or national, you must provide proof of citizenship. If you are not a U.S. citizen or national, you must provide proof of your immigration status. There are many documents that we will accept. Enclosed is a list of possible documents that you can submit copies of as proof. The proof, in addition to other verification your worker may request, will be needed for your CMISP eligibility worker to review your application. If you do not already have the proof and will need to order it, please order it as soon as possible since it will take some time before you get it. Your CMISP worker will let you know when you need to submit this information. If you have been on public assistance in Sacramento County before and have already submitted it, let your CMISP worker know so we can try to help you locate this document. You must cooperate with all regulations and program requirements. Failure to do so may result in denial of medical services, or you may be required to pay for services as a private patient. This includes payment for prescriptions. Services for communicable diseases will continue to be treated without requiring you to be eligible for CMISP. Some examples of communicable diseases are tuberculosis, meningitis, and sexually transmitted diseases. If you would like to speak to someone regarding your eligibility for CMISP, you may call (916) 734-1642.

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In Memoriam

Sami Haddad, MD 1926–2009

Dr. Sami Haddad lived a full and fruitful life. Born in Lebanon on May 23, 1926, to a Maronite Catholic family, he was well educated from childhood through medical school by French Jesuits. He often told me of the rigorous schedule on which they kept him. A linguist — French, Arabic, English, Latin, Greek — and a liberally educated physician when he graduated, he came to the US and took an extended surgical residency in New York’s Mt. Sinai Medical Center. Feeling competent in general and trauma surgery, he came west in 1959, was impressed with Sacramento and started his private surgical practice with confidence overflowing. I first met him at Sacramento County Hospital where he, with other surgeons, would make teaching rounds with the family practice residents in their surgical rotations. His insight and support attracted many of the residents to him and those relationships continued with those of us who practiced in the Sacramento area. A highly skilled and dedicated surgeon, his practice flourished. He was available night and day for the acute surgical patient. I still have memories of midnight surgery with him as he pushed the O.R. staff to get the patients ready for surgery. He married Mary Lou Grant in 1967 and the couple raised three beautiful children. His second career began with Methodist Hospital where both his surgical skills and administrative skills contributed greatly to that hospitals success. He was the hospital’s first chief of the medical staff. After retiring from surgical medicine, he entered administrative medicine, serving as medical director for the Mercy Physicians IPA as well as several other IPAs. Rational, friendly and generous, he was also strict in demanding

quality medical care. After associating with George Babbin, MD, for 10 years, he moved his office to Timberlake Drive. He brought three excellent surgeons to Sacramento as his associates; Charles Gordon, Kenneth Ross and Daniel Stuart. His work with Catholic Healthcare West and the River City IPA are still remembered well by his colleagues. He was a retired member of SSVMS and served two terms on its Board of Directors from 1976 to 1979. He nurtured his family and his friends. His love and knowledge of wine and his cellar are famous. We played tennis and poker, hunted and fished and celebrated as the years passed. I watched as he fought deterio- Sami Haddad, MD rating health, yet continued to work as medical executive. His struggles are finally over, but his legacy for his family and for Sacramento healthcare will remain. — Charles French, MD

Take a Virtual Tour of the Museum of Medical History Get an idea of the collection in the Sierra Sacramento Valley Museum of Medical History by taking a computer virtual tour. Click on various exhibit areas to see photos of individual articles. In many cases, there are links for further information on an item. The virtual tour was created by Kent Perryman, PhD, a member of the SSVMS Historical Committee. Go to www. ssvms.org and click on “museum” and then on “virtual museum explorer,” or go directly to this link: http://ssvms.org/museum/virtual_tour/floorplan.html

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In Memoriam

Pierce A. Rooney, Jr. MD 1923-2009

Pierce (Pat) Anthony Rooney, Jr. MD, Past President of the Society and a pioneer in the medical community, died on Jan. 14. A fourth generation Sacramentan, he served in the Pacific Theatre in WWII as a Navy lieutenant junior grade. While in the Navy, he met his wife and lifetime partner, Barbara. When asked how they met, Pat smiled and indicated he “pulled rank” and scolded Barbara, a lowerranking WAVE, when she passed him without saluting. Of course, this was nothing more than a ruse to meet her. At least that was Pat’s version of the story; Barbara contended it was her ploy to initiate contact with Pat by not saluting him. Returning to civilian life, Pat graduPierce A. Rooney, Jr. MD ated from Creighton University Medical School and completed his internship and residency in General Practice in the Bay Area. He was a general practitioner in Sacramento from 1952–56 but developed an interest in pathology which led him to UCSF. There he trained in anatomic, clinical and forensic pathology. He was eventually certified in all three disciplines. Although he joined a pathology group in Sacramento in 1960, as a hospital-based and outpatient pathologist, he retained teaching appointments at UCSF, UOP and, in later years, UCD Medical School. This reflected his interest, skill and enjoyment in teaching. He also was interested in research and collaborated with UCD physicians on several studies and publications on head trauma, SIDS, and heart disease. In 1964 Pat contracted with the Sacramento County Coroner’s office to perform autopsies on homicide victims and other individuals dying under suspicious circumstances. Pat quickly established new standards for autopsy performance and the collection of evidence

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from human remains, both at the autopsy table and at the scene of the crime. He hired and trained an assistant and upgraded badly needed equipment, including the Coroner’s office first x-ray machine. In 1968 he was certified by the American Board of Pathology as a forensic pathologist — the first in Sacramento County. He was a major force behind the evolution of the Sacramento Coroner/Medical Examiner Facility into one of the nation’s finest. Perhaps one of his most notable achievements was establishing a formal residency program in forensic pathology in 1976 at the Sacramento County Coroner’s Office. It was then one of only 39 approved forensic pathology resident positions in the country. Also, it was one of only a very few forensic pathology residency programs approved by the American Board of Pathology that was not directly established or sponsored by a university medical center. Residents who trained in his program went on to practice in Sacramento, other counties and states, and overseas. Pat’s interest in teaching was not limited to forensic pathology residents. He enjoyed teaching anatomy and pathology at the autopsy table to medical students, general pathology residents, physicians of a variety of specialties, nurses and other medical personnel from the UC Medical Center and other institutions. He extended his teaching to involve law enforcement personnel, coroner’s deputies and attorneys. He had a talent of explaining complex medical conditions and injuries to lay persons including jury members, lawyers and judges. Pat’s forensic expertise, teaching ability, relaxed demeanor, composure under stressful conditions, unbiased testimony, and sense of humor are a few of his qualities widely known among lawyers and judges; they resulted in his reputation as a superb and credible


expert witness. During his career he testified at hundreds of hearings and trials, some of which involved cases that received national and international attention. He continued to testify through at least 2007 on several “cold” cases from the 70s and early 80s that were solved using advanced DNA technology. Perhaps far less known than his high profile cases, but certainly indicative of Pat’s reputation as a forensic expert, was his formal consultation at the Vatican regarding damage to the world famous sculpture and masterpiece in St. Peter’s Basilica by Michelangelo, the Pieta. Never one to shy away from additional responsibility, Pat served as President of the Medical Society in 1968, its centennial year. Prior to that, while on the Medical Society Board, he was instrumental in obtaining a native plane tree from Hippocrates home on the Greek island of Cos. In 1966, this tree was planted near the new UC School of Medicine in Davis. When the School of Medicine was moved from Davis to Sacramento, a graft from the original Davis plane tree was planted in 2006 near the Education Building at the Sacramento campus.

In 1985, Pat began to enjoy the rewards of retirement including vacations with Barbara and spending more time with his 6 grown children, 13 grandchildren and 2 great-grandchildren. One of Pat’s passions was the planning and creation of mosaics — pieces of art he prepared from tile, glass and other materials he and Barbara collected on trips throughout California, other states, Mexico and Italy. One of his more interesting works, produced in 1997, “Medicina Tumulta” can be viewed at the SSVMS building on Elvas Avenue. He was also an avid collector of firearms, a hobby he pursued through the last months of his life. He would target practice on one of the local shooting ranges as often as possible and loved sharing these outings with family members, former associates, and friends. Pat will be deeply missed by his large family, numerous friends and former colleagues and associates. His legacy in medicine and forensic pathology will leave an indelible mark on Sacramento for decades to come. — Joseph Masters, MD; Surl Nielsen, MD, and Gary Stuart, MD

One of the things Dr. Pierce Rooney did as SSVMS president was to give the new UC Davis Medical School an instant alumni — as this 1972 Bee article details. The text is original; the masthead and torn bottom have been added.

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Board Briefs February 9, 2009 The Board: Signed the Conflict of Interest Policy approved by the Board of Directors in December in response to new requirements regarding tax exempt accounting standards. Received a report concerning the formation of the Ambassador’s Club and a new strategy for membership recruitment. Approved the appointment of Dr. Alicia Abels to Delegate At-Large Office #14 to fill the vacancy created when Dr. Richard Pan was elected CMA Trustee of the 11th District Delegation. Approved the Bank of Sacramento Online Banking Agreement and Resolution confirming the 2009 signers. Approved the Membership Report: For Active Membership — Lawrence D. Bistrong, MD; Douglas P. Brosnan, MD; NaYoung Kim, MD; Melinda M. Mortenson, MD; Lynn Y. Nakamura, MD; Rick Y. Peng, MD; Robert J. Rhodes, MD; Michael W-S. Su, MD; Sharon N. Tan, MD; Lauro D.C. Tangcuangco, MD; Nicklesh Thakur, DO; Zahra S. Torabian, MD; Derek S. Vien, MD; Jeanine L. Walter, MD. For Reinstatement to Active Membership — Robert J. Forster, MD; Lorenzo Rossaro, MD; Cecille G. Taylor, MD. For Acceptance of Resignation — Karen M. Tait, MD (transferred to Medocino-Lake).

March 9, 2009 The Board: Received an annual report concerning the Community Service, Education and Research Fund’s SPIRIT Project from program manager, Kris Wallach. Approved the 2008 Year-End Un-Audited Financial Statements and Smith Barney Investment Reports. Approved adoption of a new plan document for the Employee Money Purchase Pension

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Sierra Sacramento Valley Medicine

Plan in accordance with changes made by the passage of the Economic Growth and Tax Relief Reconciliation Act. Approved the Membership Report For Active Membership — Angela P. Anantharaj, MD; Jason B. Cohen, MD; Shazia Faiz, MD; Randall J. Finley, MD; Isabella FloresMerritt, MD; Winnie J. Gandingco, MD; Lotfi Hacein-Bey, MD; Kendrick M. Johnson, MD; Christopher J. Laing, MD; Govind Mukundan, MD; Ann B. Nguyen, MD; Kathleen H. Puglia, MD; Janice K. Ryu, MD; Danielle A. Scholze, MD; Rosy Shah, MD; Krishna L. Smith, MD; Desmond Tan, MD; David Z. Tzeng, MD; Ronald T. Whitmore, MD. For Reinstatement to Active Membership — George Emlein, MD; Franklin D. Robinson, MD. For Annual Renewal of a Special Leave of Absence — Derek J. Wong, MD For A Change in Membership Status from Active to Active 65/20 — Benjamin Kaufman, MD For Retired Membership — M. Daniel Flamm, MD For Resignation — Neema Aghamohammadi, DO (transferred to Orange County); Dorrit Ahbel, MD; Jesse D. Babbitz, MD (moved to Arizona); Jim C.S. Chen, MD; Edward Dagher, MD (moved to Washington); David T. Harrison, MD (transferred to Yuba-SutterColusa); Theodore L. Hatch, MD (transferred to Alameda-Contra Costa); Phuong N. Ho, MD (transferred to Alameda/Contra Costa); Rebecca M. Houseman, MD (moved out of state); T. Warner Hudson, III, MD (transferred to Santa Clara); Amitabh C. Joglekar, MD (transferred to Alameda/Contra Costa); Loren A. Johnson, MD (moved to Washington); Jonathan K. Kanz, DO; James O. Myers, MD; Antoine Sayegh, MD (moved to Oregon); Thomas A. Shragg, MD (moved to Sonoma); Sasha L. Szytel, MD (transferred to San Luis Obispo); Onyebuchi B. Tasie, MD (moved to Virginia).


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 Su, Michael W.C., Dermatology, Harvard Medical School 2004, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 631-3010

Anantharaj, Angela P., Internal Medicine, Jefferson Medical College 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Laing, Christopher J., Radiology/Interventional Radiology, University of Tennessee 2002, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

Banez, Maria (Victoria), Pediatrics, University Santo Tomas, Philippines 2002, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5200

Motosue-Brennan, Julie K., Psychiatry, University of Hawaii 2001, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5872

Tan, Desmond T.Y., Internal Medicine, Dalhousie University, Canada 2001, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5100

Mukundan, Govind, Radiology/Neuroradiology, Johns Hopkins 2000, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

Tan, Sharon N., Family Medicine, University of the East Ramon Magsaysay, Philippines 1998, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040

Nakamura, Lynn Y., Physical Medicine & Rehabilitation, Albany 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Tangcuangco, Lauro D., Family Medicine, University of the East Ramon Magsaysay, Philippines 1998, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040

Nguyen, Ann B., Pediatrics, Marshall University 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Torabian, Sima Z., Dermatology, UC Davis 2003, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6853

Peng, Rick Y., General/Thoracic Surgery, University of Illinois 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Tzeng, David Z., Pulmonary/Critical Care Medicine, Tufts University 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821

Bistrong, Lawrence D., Pulmonary/Critical Care Medicine, St. George’s University 2001, Pulmonary Medicine Associates, 3637 Mission Ave #7, Carmichael 95608 (916) 482-7623 Brosnan, Douglas P., Emergency Medicine, UC Irvine 2005, California Emergency Physicians/Mercy Folsom Hospital, 1650 Creekside Dr., Folsom 95630 (916) 983-7470 Cohen, Jason B., Nuclear Medicine, University of Michigan 1999, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Dhingra, Kapil R., Emergency Medicine, Tulane 2007, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-2011 (Resident) Dizon, Sammy A., Internal Medicine, University Santo Tomas, Philippines 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Faiz, Shazia, Endocrinology, Punjab Medical College, Pakistan 2000, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2650 Forster, Robert J., Internal Medicine/Geriatrics Medicine, UC Davis 1972, EDS-Medi-Cal, 3215 Prospect Park, Rancho Cordova 95670 (916) 636-4296 Gandingco, Winnie J., Family Medicine, University of the East, Philippines 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Gargulinski, Matthew J., DO, Orthopedic/Sports Medicine, Kirksville College of Osteopathic 2002, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2630 Hacein-Bey, Lotfi, Radiology/Neuroradiology, Algiers Institute for Medical Sciences, Algeria 1981, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Johnson, Kendrick M., Emergency Medicine, Medical College of Wisconsin 1993, Mercy Hospital of Folsom, 1650 Creekside Dr., Folsom 95630 (916) 983-7470

Puglia, Kathleen H., Radiology, Georgetown University 1999, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Randhawa, Kanwaldeep S., Pulmonary/Critical Medicine, UC Davis 2002, Pulmonary Medicine Associates, 3637 Mission Ave #7, Carmichael 95608 (916) 482-7623 Reed, Marty E., Orthopedic Surgery, University of Southern California 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6321 Robinson, Franklin D., Emergency Medicine, University of Utah 1984, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 Ryu, Janice K-J., Radiation Oncology, UC San Francisco 1987, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Scholze, Danielle A., Pediatrics, University of Wisconsin 2005, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5200 Shah, Rosy, Pediatric Infectious Diseases, Calcutta Medical College, India 1988, Sutter Medical Group, 5301 F St #220, Sacramento 95819 (916) 455-8000 Smith, Krishna L., Internal Medicine, University Southern California 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Vien, Derek S., Vascular & Interventional Radiology, UC Davis 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Walter, Jeanine L., Family Medicine, Loma Linda University 2005, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 784-4050 Whitmore, Ronald T., Family/Occupational Medicine, UC San Diego 1985, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2005 Winn, John N., Radiology/Neuroradiology, University of Missouri 2000, Mercy Radiology Group, 3291 Ramos Cir., Sacramento 95827 (916) 363-4040 Yang, Wendy JU., Family Medicine, Ewha Women’s University, Korea 1997, UC Davis Medical Group, 2660 W. Covell Blvd., Davis 95616 (530) 747-3000

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.

March/April 2009

35


Classified Advertising

Positions Available INTERNIST NEEDED Well-established and respected Northern California cardiology group seeks an exceptional internist to expand our internal medicine team. You will be well paid, practice in a state of the art facility featuring progressive and comprehensive programs and enjoy excellent proximity to cultural and recreational attractions. Fax CV to Administrator at 916.830.2128.

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any of Special Consultant. Physicians will be paid on an hourly basis for their time and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if you may be interested.

Alternate Medical Definitions continued 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.

36

Doctor’s Placement Agency All medical personnel (916) 457-4014

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

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

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

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


John Loofbourow’s Photos from Caconde, Brazil. Story on page 25

Local Hospital

Lake Caconde

Before: Hallway

Construction

After: Single Room

After: Large Room

Brazil Fiat Pickup

Toll Road

Mockup of Asilo

Carnaval

Carnaval

Asilo Resident


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2009-Mar/Apr - SSV Medicine  

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

2009-Mar/Apr - SSV Medicine  

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