Sierra Sacramento Valley
MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
Independent But Not Alone.
Richard Lewis, M.D. Hill Physicians provider since 1993. Uses Hill inSite, Hill EHR and RelayHealth for eClaims processing, electronic health records, practice management and secure online communications with patients.
Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.
Your health. It’s our mission.
Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
Sierra Sacto Valley (Dr. Lewis).indd 1
2/3/10 9:25:01 AM
Sierra Sacramento Valley
PRESIDENT’S MESSAGE Pyrrhic Victory?
Volunteers In Venezuela
F. James Rybka, MD
BOOK REVIEW The Fatigue Prescription
George Meyer, MD
Another Disastrous Peer Review Failure?
Gerald N. Rogan, MD
Posit on the Corporate Bar to Employing Physicians
Stephen F. Melcher, MD
EDITOR’S MESSAGE Medical Quack-ertizing
John Loofbourow, MD
Consult Clarity and the New CMS Billing Codes
Betsy Nicoletti, MS
Setting the Record Straight on Primary Care
Nathan Hitzeman, MD
IN MEMORIAM William Yan Fong, MD
WINNING STUDENT ESSAY America’s Health: Consumer vs. Corporation
Board Member Profile: Jose Alberto Arevalo, MD
Gasping for Air
Eisha B. Zaid MS III
A Legacy of Support
Managing Personal Finances
David Herbert, MD
Voices of Medicine
Del Meyer, MD
Board Member Profile: Robert A. (Bob) Kahle, MD
We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.
SSV Medicine is online at www.ssvms.org/magazine.asp This is the third in a series of covers by pathologist Dr. Gordon Love, taken with a high resolution microscope. This image is an antinuclear antibody test. It involves making several different diluted samples of a patient’s serum, which are tested on cultured cells by a technique known as an indirect immunofluorescent assay. Any antibodies specific to the cell antigens bind to the cells. A second, man-made antibody is added; if any serum antibodies have bound to the cells, the second antibody binds to them and fluoresces. Little or no antibody (or autoantibody) is found in normal people. But in patients with connective tissue diseases, autoantibodies can produce distinctive patterns, in this case a centomere pattern (a centromere is a region of DNA typically found near the middle of a chromosome, and is involved in cell division). This pattern may be associated with limited systemic sclerosis or scleroderma.
Volume 61/Number 3 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax email@example.com
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. 2010 Officers & Board of Directors Stephen F. Melcher, MD President Alicia Abels, MD, President-Elect Charles McDonnell, III, MD, Immediate Past President District 1 District 5 Robert Kahle, MD John Belko, MD District 2 David Herbert, MD, Jose Arevalo, MD Treasurer Michael Flaningam, MD Robert Madrigal, MD Michael Lucien, MD, David Naliboff, MD Secretary Anthony Russell, MD District 3 District 6 Bhaskara Reddy, MD J. Dale Smith, MD District 4 Demetrios Simopoulos, MD 2010 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 Satya Chatterjee, MD Richard Gray, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Charles McDonnell, MD Stephen Melcher, MD Janet O’Brien, MD Kuldip Sandhu, MD Earl Washburn, MD
Alternate-Delegates District 1 Robert Kahle, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Reinhart Hilzinger, MD Robert Madrigal, MD Mubashar Mahmood, MD Rajan Merchant, MD Connie Mitchell, MD Anthony Russell, MD Gerald Upcraft, MD Vacant Vacant
CMA Trustees 11th District Richard Pan, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, MD Very Large Group Forum Paul Phinney, MD
Travel Immunizations Don’t Have To Be A Pain. The Doctor Center is making it easier for your patients by providing them with necessary travel immunizations seven days a week. Since the Health Department provides these vaccines only during limited weekday hours, our extended hours may be a benefit to your patients with busy schedules. For their convenience, we are open every day from 8:00 a.m. to 10 p.m. In addition to the commonly available vaccines, we stock yellow fever, meningococcal, typhoid fever and other vaccines. We are prepared to handle malaria or diarrhea prophylaxis. Send your patients requiring travel immunizations or other basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients immediate needs, then refer them back to you for on-going care.
The Doctors Center is open from 8:00 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine DAWN M. HAYES, M.D. 20 Years of Urgent Care and Primary Care Experience KIMETTE M. MARTA, M.D. Board certified in Family Medicine
We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287
The Doctors Center Medical Group Inc.
The Doctors Center new hours are 8 a.m. to 10 p.m.
AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor William Peniston, MD Robert Forster, MD Robert LaPerriere, MD Gerald Rogan, MD F. James Rybka, MD Gordon Love, MD Gilbert Wright, MD John McCarthy, MD Lydia Wytrzes, MD Del Meyer, MD George Meyer, MD John Ostrich, MD
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.
Managing Editor Webmaster Graphic Design
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.
Ted Fourkas Melissa Darling Planet Kelly
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
Pyrrhic Victory? By Stephen F. Melcher, MD Our community has managed to keep our remaining Sacramento County psychiatric beds open — for this year — and has even managed to open 12 more. Unfortunately this victory comes at a high cost. Many other mental health services will be closed or reduced. The county funding of privately contracted psychiatric clinics cannot continue as announced recently, and this care will be internalized into a county-run system still in development. Since these clinics will not get county funding, they may have to close. County ordinance 71J has tied the hands of Sacramento County officials in choosing options (see this editorial for more details: http:// www.sacbee.com/2010/03/29/2639412/editorialnonprofit-helps-rescue.html). In addition, the recently announced county budget cuts will mean further reductions in Primary Care Clinics, Dental Clinics, Radiological Services, County Pharmacy, Case Management, Department of Mental Health, including services to children and families, Adult Protective Services, Child Protective Services, Substance Abuse, Public Health (think immunizations, STD tracking and prevention), Emergency Medical Services and more. The departments offering health services and help for the poor are being disproportionately cut of county general funds to preserve the sheriff and district attorney’s office. Many programs of last resort are being cut while at the same time the county pays unavoidable wage increases to many remaining staff, due to contract issues. I wear a lot of hats, and I sometimes have to remember which one is on. I try not to let my psychiatric bias show too much at Board meetings, but I apologize in advance for flagellating you with another article on mental heath/public health. But as a respected colleague said to me at
our last board meeting, “You’ve got the pulpit.” When I see what is happening to our public health system in Sacramento County, I’m stuck between the urge to get up and start yelling, “I’m mad as hell and I’m not going to take it anymore,” and sitting patiently and waiting, telling myself I have to sit at the table and negotiate for the best outcome for all of our patients. We will not be heard if we don’t speak up. We will be forced to live with a broken system if we do not raise our collective voices and participate in the redesign. In an email exchange, Bill Sandberg summed it up well: “Today’s argument is how much more can we cut from discretionary and non-mandated programs to preserve what is left in fire and sheriff budgets.” The Board of Supervisors can’t help but focus on public safety, and it should, but we need to help raise awareness that physical health and mental health contribute to public safety. If you take from any one pot to give to another, you just perpetuate more problems. Unfortunately, there is nothing to stop Sacramento County Supervisors from taking from the public health pot. One of the basic flaws of our system was summed up well by Amy Yanello in a recent Sacramento News and Review article: “Surprisingly, given the very real consequences of not having access to medication and therapeutic support, there is no state law mandating a certain level of care be given to adults or children in counties that receive Medi-Cal funding to provide mental-health services…” (http://www. newsreview.com/sacramento/content?oid=1391419) Our county system of mental health care is in desperate need of a redesign. Our country is undergoing health care reform, and it is time for our county of Sacramento to do the same. Unless you have been living in a cave lately
(I really did spend a day in a cave recently, and would have been tempted to stay there had I known what was waiting for me), you might have noticed that the Sacramento County Public Health system is imploding. If you believe in a god, then give thanks if you have health insurance, no matter how minimal it is. If you don’t have insurance, and you have a mental health problem or medical problem, your life will likely become more hellish as you try to access services. You know things are bad when even Child Protective Services are being cut. There are a variety of diverse opinions that run from rational to conspiracy theory regarding the proposed budget cuts. A lot of people blame the county for these cuts. In my opinion, many critics looking for someone to blame should look into the mirror for not hearing these concerns long ago. These problems have been discussed for years; they are not new. Our economic crisis has just forced them to a head. The Hospital Council of Northern and Central California has gathered all the major stakeholders in this area to try to come up with a solution to this mental health crisis. No one knows what the solution is, but SSVMS is at the table and participating. It is clear that the future of the public health safety net in this county will rely more on collaboration between the county and the private health systems. The private health systems are paying more for this care because there is no coordinated system that helps them leverage collaboration with existing county programs. The system is also missing some essential pieces. Hopefully, the end of this process will lead us to a solution, or at the very least towards a solution. So I don’t devote my entire column to mental health, following are what I think are the best summaries of national health care reform. Please check out the CMA website for links to the CMA summary, its position, and the implementation timeline. http://www.cmanet.org/healthreform/applets/reform_ summary_032510.pdf http://www.cmanet.org/healthreform/applets/reform_position_031910.pdf http://www.cmanet.org/healthreform/applets/reform_timeline_032510.pdf Go to this Kaiser Family Foundation website for some excellent commentary on the new law: http://www.kff.org/healthreform/upload/8061.pdf firstname.lastname@example.org
Sierra Sacramento Valley Medicine
CPLH - an annual publication of CMA’s Center for Legal Affairs answers the legal questions most frequently asked by physicians. CPLH 2010 offers more than 4,500 pages of comprehensive legal information including current laws, regulations, and court decisions related to medical practice in California. CPLH 2010 also includes new sections and forms to help physicians comply with the most recent changes in health care law. The handbook is available in a 7-volume print format and on CD-ROM. The CD-ROM offers all of the content of the print version, plus many enhancements including fully searchable content and hyperlinks that let you navigate within the CD-ROM and onto the web for more information on the cited court cases.
Print _________________ $960 CD-rom _________________ $480 Combination: Print + CD-rom _________________
All orders must be pre-paid. Prices do not include shipping, handling and sales tax.
CPLH 2010 is produced through the generous support of our partners, the Cooperative of American Physicians, Medical Insurance Exchange of California, NORCAL Mutual Insurance Company and The Doctors Company.
To order, call 800.882.1262 or visit CMA’s Bookstore at cmanet.org.
Medical Quack-ertizing By John Loofbourow, MD Quack, n. 1. A fraudulent or ignorant pretender to medical skill. 2. One who pretends, publicly or professionally, to skill, knowledge, or qualification not possessed. A charlatan. (Webster’s Unabridged.) Physicians acknowledge that we don’t have the only answers to all medical problems. History is filled with instances of great advances in medical care or diagnosis made by nonphysicians but initially rejected by us. My favorite modern example along that line is Richard Bernstein, an advanced diabetic and engineer, who found, in about 1970, that he could control his disease and arrest it by using a blood sugar testing machine at home. His claim, and a pilot study he made, were soundly rejected by proper peer-blinded professionals. Yet the personal glucometer is arguably the single most important improvement in diabetes management of the last century. Technology makes that sort of thing ever more likely, and provides all of us with ready access to information about diagnosis, treatment and prevention of disease. It promotes self care, a very significant medical advance in itself. And we should admit that, where quackery is concerned, we are not entirely absolved from that practice. On display in our medical museum are many amusing examples of medical quackery from long ago. Less amusing is the daily bombardment of medical and pharmaceutical circus barker-type sales ads in all our media today; it is more prevalent in the U.S. than any place else I know. As an example, I note that one day’s edition of the Sacramento Bee includes: Section A p 5: Full page ad guaranteeing satisfactory treatment of back pain. p 9: Full page ad for laser treatment, to
”melt away fat.” p 11: Full page ad for hearing testing and sale of hearing aid devices. p 13: Full page Merck ad for Zostavax shingles prevention. Section D p 2: 3/4 page with two ads for Laser wart treatment, and two ads for denture fixative post implants. p 8 ”Health News,” multiple ads in drag, with glowing testimonials and associated sales pitches for laser skin ”rejuvenation,” teeth whitening, vein sclerosis therapy, gastric banding for obesity, mail order Rxs, and non CPAP relief of snoring problems. A virtual epidemc of medical advertising affects not only the print media. Electronic media is also infested. While I don’t find all medical ads objectionable, too often they obscure facts, costs or risks; much of such advertising feeds subtly stated disinformation to us all, even though done carefully, defensively, and technically within the law. This reflects badly on all medical professions. I don’t suggest that every medical advertiser should be thought of as a ”quack.” But I do suggest many advertisers are shameless profiteers who prey on a public that is ingenuous, desperate, or blinded by faddism in health or beauty. The buyer has a right to choose, and the right to overeat or to smoke. But it is not right to mislead, deceive, or seduce. For too many medical advertisers, commercial success relies on hype-driven expectation, and disingenuous, but subtle near lies. That is the very reason high dose advertising is required. Parenthetically, Allison Wallace, this year’s high school student essay winner, emphasizes the like abuse of deceptive commercial advertising, as a big contributor to
...many advertisers are shameless profiteers who prey on a public that is ingenuous, desperate, or blinded by faddism in health or beauty.
We must object to medical quackery or quackertizing whether the ”perps” are profiteers, businesses, politicians, or our own colleagues with letters behind their names.
obesity and diet-related illness. Unfortunately, this is a situation that no law, no congress, no police can control because buyer decisions are private and personal. With due respect for law, it is not medicine. An overdose of law has sickened medicine. To use a dreaded legal term, res ipsa loquitur. Where most of behavior is concerned, the law is impotent. For example, the absurd mention of possible medication side effects is ignored by people, because they are as ridiculous as the fast-speak disclaimers that follow some radio ads; no one hears because the speech is so rapid as to be unintelligible. It is legal to evade the intent of a law about behavior by making it ridiculous. It is not in the nature of the legislatures, or courts, to efficiently or wisely dictate the practice of medicine. Yet they attempt to do so. Result: There is no way to practice medicine today in strict conformity with all the conflicting terms of the thousands of laws and regulations that infest the body of medicine today. Costs ever increase while efficiency ever decreases in an inverse relationship. Some claim technology is to blame; yet technology has ultimately always reduced cost and increased effectiveness of any given medical intervention. Do physicians have an enduring interest or obligation in the matter? Certainly! The same that prompted the founding of our Sacramento Society for Medical Improvement, now SSVMS, some one and one half centuries ago when quackery was exceptionally pervasive. Here is an excerpt from our 1855 CODE OF MEDICAL ETHICS. “SECTION III: It is derogatory to the dignity of the profession, to resort to public advertisements or private cards or hand-bills, inviting the attention of individuals affected with particular diseases — publicly offering medicines to the poor gratis, or promising radical cures; or to publish cases and operations in the daily prints, or suffer such publications to be made; to invite laymen to be present at operations; to boast of cures and remedies; to adduce certificates of skill and success, or to perform any other similar acts. These are the ordinary practices of empirics, and are highly reprehendsible in a regular Physician.
Sierra Sacramento Valley Medicine
“SECTION IV: Equally derogatory to professional character is it, for a Physician to hold a patent for any surgical instrument, or medicine; or to dispense a secret nostrum, whether it be the composition or exclusive property of himself, or of others. For, if such, nostrum be of real efficacy, any concealment regarding it is inconsistent with beneficence and professional liberality; and if mystery alone give it value and importance, such craft implies either disgraceful ignorance, or fraudulent avarice. It is also reprehensible for Physicians to give certificates attesting the efficacy of patent or secret medicines, or in any way to promote the use of them.” To paraphrase an old cigarette ad directed to women: “You’ve come a long ways, doc!” But that was also an ”ad”; it was about money and profit, rather than ethic or logic. Doesn’t it seem, now, that the practice of medicine is very much about profit, commerce, and the law, and too little about the logic and ethic of health? Now, as at the founding of our medical society, physicians have both the right to organize and to speak up. We must continue to do so. We must object to medical quackery or quackertizing whether the ”perps” are profiteers, businesses, politicians, or our own colleagues with letters behind their names. SSVMS is still not simply a trade union, but a voluntary association of professional colleagues who practice medicine. Because of that, our ideas have increased weight. This is the most significant reason for physicians to be involved and active in SSVMS. As our president recently noted, this is the only place where physicians in otherwise isolated specialties regularly work together as colleagues. At base, it is what Hippocrates encouraged in his own way and his own time. Whatever our individual imperfections, though we are never in 100 percent agreement, physicians must speak up, individually and collectively. We must reason together and in public; must act with mutual tolerance and respect, with compassion and passion in accord with our most considered ethical and scientific values. email@example.com
Consult Clarity and the New CMS Billing Codes 2010 will be challenging for physicians in selecting a category of code and level of visit, for those services that were billed as consults.
By Betsy Nicoletti, MS Few physicians would use the words consult and clarity in the same sentence, since Medicare changed its policy and stopped paying for consults on January 1 of this year. In fact, confusion rules the day for many doctors. As part of the Physician Final Rule, the Centers for Medicare & Medicaid Services (CMS) stopped recognizing consultation codes. This rule is for Medicare fee-for-service patients only, although some Medicare Advantage plans and commercial payers immediately followed suit. This guarantees that 2010 will be challenging for physicians in selecting a category of code and level of visit, for those services that were billed as consults. Although physicians don’t like to pay attention to the patient’s insurance when deciding how to bill a patient, someone — the physician or the staff — does need to pay attention. For office services that were outpatient consults (99241–99245), use new (99201– 99205) or established patient (99211–99215) visit codes. CMS’s definition of a new patient is this: Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. Notice that a new problem does not equal a new patient. In an inpatient setting, bill for services that were reported with inpatient consult codes (99251–99255) with initial hospital services codes (99221–99223), with no modifier. The
admitting physician bills for the initial hospital services codes with an AI (capital A, capital I) modifier. These initial hospital services codes are not defined as new or established, and may be billed again in subsequent admissions. All physicians bill for follow up with the subsequent hospital visit codes (99231–99233). If a service and documentation do not meet the minimum requirements for the lowest level initial hospital visit, (a detailed history, detailed exam and straightforward or low medical decision making) use a subsequent hospital visit code. This brief explanation leaves out more “What ifs” than it answers. What category of code should be billed when called to the ED in consultation, and the patient is not admitted? Emergency Department visits. What about being asked to consult on a patient in observation status? New or established patient visits. If asked to consult in a nursing home, what category of code should be billed? Initial nursing facility visits (99304–99306). A chart accompanies the online version of this article and answers more of these “What if” questions. firstname.lastname@example.org Betsy Nicoletti, MS, CPC, is an author and speaker on coding and compliance for physician practices. She founded www.codapedia.com. May/June 2010
The Sierra Sacramento Valley Medical Society/CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the ﬁrst 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000! Now is the time to take a good look at the SSVMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your ﬁnancial planning no longer seem as secure as they once did Sponsored by:
• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave
Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance! Underwritten by:
and 29 County Medical Associations & Societies
Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.
*The initial premium will not change for the ﬁrst 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 49816 (5/10) ©Seabury & Smith Insurance Program Management 2010 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAﬃnity.com
CA Ins. Lic. #0633005 • AR Ins. Lic. #245544
Setting the Record Straight on Primary Care By Nathan Hitzeman, MD I was dismayed to read the commentary on primary care by UC Irvine second year medical student Janelle Marshall in the March/ April issue of Sierra Sacramento Valley Medicine. The author makes blanket assumptions and generalizations about primary care that I do not think are accurate. Her descriptors of primary care include a “lack of prestige, lower pay, and more administrative hassles” in a setting where students would be “bored” with treating “colds and hypertension all day.” I do not think that this encompasses the breadth of primary care. Sadly, she goes on to state, “My classmates and peers seem to share an attitude that students who choose primary care are not as motivated or accomplished as those who choose other specialties… In contrast, many other specialists are the type-A, confident, ambitious and admired physicians with whom students identify.” At the end of the piece, in her call for action, Ms. Marshall states “schools need to attract and recruit students who have the desire and qualitative characteristics that are important for a career in primary care.” Well, does that mean attracting more low-brow, non-overachievers who want to see snotty noses all day? I do not find that inspiring at all for our local students or doctors. Although I am not John Stossel, here’s why I say, “Give me a break!” to set the record straight about primary care. As a family physician, I have worked with dozens of students over the years in volunteer student-run clinics, medical missions abroad, and in my own clinic. I have seen a number of
highly intelligent and motivated students go into primary care. I fear that in many areas there are missed opportunities for supported teaching venues for family medicine. That is unfortunate as family doctors account for over 95,000 of the 788,000 active doctors in the US (second only to IM docs), and family physicians field 22 percent of all ambulatory patient visits — more than any other specialty.1,2,3 Generalist IM docs field 17 percent of all ambulatory visits, but it is a field in unfortunate decline. Only 10 percent of first year IM residents end up choosing primary care, and that number is probably dropping as we speak.4 Ok, let’s get it out on the table. Every specialty has its dirty laundry. GI docs loath the poor bowel prep. EM docs deal with a disproportionate amount of psychiatric and substance abuse patients whom they lack the tools to cure. Surgeons grimace at the repeat small bowel obstruction, and furthermore they don’t get to sit down very often. Dermatologists see more neurodermatoses than they would like. And ENT docs probably see even more snotty noses than we do! As for my dirty laundry in family medicine, I see more chronic pain patients, and fill out more disability paperwork, than I would like. During the winters, yes there are a lot of coughs and colds. I am also losing the war on obesity which seems to pervade most medical issues I encounter. However, here is the silver lining. I know my patients like no one else, and they confide in me like they would no one else. I see children, adults, and advanced elderly patients.
Every specialty has its dirty laundry.
No one day is ever the same. I have removed a spider from a kid’s itchy ear, looked at a urinary stone stuck just inside the opening of a man’s urethra, and had to perform CPR on a man who dropped dead in our waiting room.
I am often the first person patients tell about marital problems, erectile dysfunction, depression, abuse, and “this thing that has been growing on my side.” I get to do the detective sleuth work to uncover cancers and other diseases. I get the satisfaction of knowing I have done preventive care that will keep Mr. Jones from dying of colon cancer or pneumonia. I smile inside and out when I pat my kiddos on the head as they get their stickers after their shots, and I feel like a faith healer after resetting a nursemaid’s elbow. Like the very first health providers in history, I enjoy the time-honored acts of lancing boils, splinting limbs, removing ingrown toenails, and cutting out skin growths. I enjoy other office procedures like joint injections, vasectomies, circumcision, colposcopy, and some limited endoscopy procedures. I also do home visits, inpatient care, nursing home care, and urgent care clinic shifts to keep those skills up. Furthermore, many other specialists know family doctors as the hub of their patients’ care and often consult us on a course of action. My Latino patients often bring me homemade treats like crispy tacos, and an elderly patient of mine knits mittens for my daughters. I am going to a patient’s 100th birthday party this September barring any catastrophes. No one day is ever the same. I have removed a spider from a kid’s itchy ear, looked at a urinary stone stuck just inside the opening of a man’s urethra, and had to perform CPR on a man who dropped dead in our waiting room. Using counseling and medication, I have helped some folks keep their jobs and their sanity. My medical instruments are often my head and my hands when I volunteer abroad — where antibiotics, sanitation education, and oral rehydration fluids go much further in helping people than high tech approaches. In my medical group, I am proud to say that I have family medicine colleagues who are experts in HIV care, alternative and complementary medicine, women’s health, hospital care, sports medicine, occupational health, travel medicine, healthcare policy, and elec-
Sierra Sacramento Valley Medicine
tronic medical records. On medical missions, I have seen many volunteers from family medicine. The field lends itself well to humanitarian efforts. And yes, here at home we work long days and have busy clinics. However, with the growing need for primary care docs, more of my colleagues are job sharing or working part time to balance their work with family. Open the “want ads” of any medical journal and you will see that primary care doctors are in high demand and are in a great position to negotiate the type of practice they want. It is true that primary care docs do not earn nearly as much as other specialists. (Salary breakdowns among specialties can be found online.5) This pay differential between primary care physicians and specialists has been cited by doctors from the RAND Corporation as one of the biggest dissuaders of US medical students going into primary care.6 These physicians have stated in no uncertain terms that any viable healthcare reform that is economical and sustainable must lessen this disparity. On a personal note, I live in Natomas while many of my specialist friends live in Rocklin, Granite Bay, or El Dorado Hills. However, I am still making a very comfortable living during these rocky economic times while my Ph.D. friends are flipping burgers. None of us are starving — not even family docs with student loans included. I also find it interesting that whenever healthcare reform talk comes around, my family medicine colleagues are often the first to embrace change that would ensure more access to healthcare even if it threatens their personal reimbursement. To students out there listening, take heed, if your goal is the pursuit of ghastly amounts of money (which I’m sure you did not mention on your personal statement), then family medicine may not be for you. But if you want to make a comfortable living, to help a lot of people, and to have lifelong job security and practice versatility, then family medicine may be for you! Still, the larger disparity in pay between primary care docs and specialists in this country
as compared to other countries does give the perception that primary care must not be as valued. Money, apart from buying nice things like iPods, does impart a sense of innate worth. Let’s look at why this disparity exists. To you students, here is the wizard behind the curtain. The Centers for Medicaid & Medicare Services (CMS) assigns values to everything in medicine from talking with patients for 15 minutes to removing their spleen. The value is called an RVU or relative value unit, and it is the form of currency, so to speak, used in healthcare. One RVU translated to about $60 last time I checked, but it may have changed by now. When the CMS assigns or revises the number of RVUs assigned to a procedure or office visit, health insurance companies follow suit.4 So who assigns the RVUs? Good question. A little known panel called the Resource-based relative value scale Update Committee (RUC) meets regularly to revise the RVUs and CMS, in
turn, often rubber stamps their recommendations. So who sits on the committee? Of the 30 members, 23 are appointed by “national medical specialty societies.”4 Meetings are not open to the public, and only three seats rotate on a 2-year basis. Not surprisingly, specialty procedures are weighted with many more RVUs than visits spent talking with patients and managing medication. Is it any wonder that some doctors are happy to stent, inject, scope, biopsy, and serially image a condition? They can make numerous times the income by doing several procedures in an hour at hundreds of dollars a pop rather than talking to one patient at length about his or her symptoms. This is not to say that these docs are not good people; it’s just that the action will follow the reimbursement. And it will continue to do so as long as the RUC is biased towards specialty groups or until quality evidence-based medi-
This is not to say that these docs are not good people; it’s just that the action will follow the reimbursement.
Dare to be different. Dare to treat the whole patient.
cine debunks some of these practices — as it has for elective heart caths, renal artery stenting, arthroscopy for knee arthritis, vertebroplasty, and various other expensive back pain interventions. Furthermore, for those interested in how Medicare graduate medical education (GME) funding affects institutions and how it discourages primary care, a discussion of this flawed hospital-based payment system was recently described in the New England Journal of Medicine.7 It concerns me that the article I am criticizing came from a student in a publically funded school. I have worked closely with students from various medical schools around the country. Disparaging comments about primary care seem pervasive in medical school training. Every school wants to portray itself to the public as “primary care friendly.” It’s much sexier to say they care about the whole patient than to say they are a “liver friendly” school or a “prostate friendly” school. But in many parts of the country, students inside the school walls are somehow getting a different message — a message that primary care is not stimulating or rewarding. Comments such as these are neither fair nor constructive in improving our nation’s healthcare. Shouldn’t we be nurturing primary care at all of our medical schools rather than just giving it lip service to the public? More than 30 million Americans will soon receive health insurance under Obama’s healthcare reform, and they will now be seeking primary care at a doctor’s office rather than at an emergency department. Furthermore, epidemiological research by John Wennberg out of Dartmouth and others shows that populations are healthier in parts of the U.S. where there is lower cost healthcare and a high ratio of primary care physicians to specialists.8,9 Therefore, medical schools should build
Sierra Sacramento Valley Medicine
more bridges with the community to develop innovative ways to promote primary care — in addition to fostering mutual respect among the medical fields. Students need to get a more consistent and honest message. Fortunately, our local medical school has family physicians in high leadership positions who are able to reach out to students and community doctors to promote the breadth and depth of family medicine. Local students also have access to several student-run volunteer clinics as well as international electives which all serve to reinforce the importance of primary care. For all you students who read this journal, don’t be jaded by articles disparaging primary care. Dare to be different. Dare to treat the whole patient. You are not too smart for primary care. Primary care is a lifelong learning experience. You can never be too smart for it. It is a great, challenging, and rewarding way to help people — many people — and isn’t that what we all said in our personal statements? email@example.com 1 American Board of Medical Specialties (ABMS). Certification history: ABMS Member Board general certificates issued by decade, 1930-2007. In: ABMS Annual Report and Reference Handbook. Evanston, IL: American Board of Medical Specialties Foundation; 2008: 1, 8. 2 Staiger DO, Auerbach DI, Buerhaus PI. Comparison of Physician Workforce Estimates and Supply Projections. JAMA. 2009; 302(15):1674-1680. 3 Cherry DK, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 Summary. Advance Data. 2007; 387. http://www.cdc.gov/nchs/data/ad/ad387.pdf 4 Goodson JD. Unintended Consequences of Resource-Based Relative Value Scale Reimbursement. JAMA. 2007;298(19):23082310. 5 http://www.cejkasearch.com/compensation/amga_physician_ compensation_survey.htm 6 Brook RH, Young RT. The primary care physician and health care reform. JAMA. 2010; 303(15):1535-1536. 7 Iglehart J. Medicare, Graduate Medical Education, and New Policy Directions. NEJM. 2008; 359(6): 643-650. 8 www.dartmouthatlas.org 9 Starfield, B et al. The effects of specialist supply on populations’ health: assessing the evidence Health Aff (Millwood). 2005 Jan-Jun; Suppl Web Exclusives: W5-97-W5-107.
Winning Student Essay
America’s Health: Consumer vs. Corporation This article won first place in the 2010 SSVMS student essay contest.
By Allison Wallace The author is a junior at Union Mine High School, in Placer County. She is a National Honor Society member and Student Body President. She hopes to study psychology and rhetoric at UC Berkeley. She enjoys skiing and hiking. Six high schools participated in the SSVMS essay competition this year. The second place essay, by Linda Tsan, a junior at Florin High School, will appear in our next issue. Health is a central concern for all Americans. Consumers are constantly bombarded with media forms instructing them how to look, how to get in shape, and what diets to try. Yet, for most consumers, their environment provides an unhealthy lifestyle, filled with inexpensive and processed foods. The struggle to be healthy is a battle between personal choice and the consumer culture; however, both elements are not mutually exclusive, but are collectively responsible for the health of the individual and the nation. A person’s health can largely be attributed to their own dietary habits and exercises, but when 1/5 of almost every state is obese according to the Center for Disease Control, health becomes a national issue. The most obvious factor that contributes to the decline in Americans’ health is diet. According to food critic Chris Woolston, within the last twenty-five years the average American has increased his or her calorie-intake by 304, which “theoretically can add an extra 31 pounds to each person every year.” Further, Woolston claims that in a twelve-year study of more than
69,000 women, the “American diet” raised the risk of coronary heart disease, colon cancer, and diabetes. America’s poor dietary habits can be traced to the ambiguous term that defines the food culture. The “American diet,” unlike other cultures, is not bound to any specific food types. While Italians eat pastas and breads, and the Japanese eat rice and seafood, America’s food culture has become a melting pot filled with unlimited options and unlimited quantities. Because the “American diet” has no restrictions or customs, consumers clutter their plates with the most accessible and inexpensive products: junk food. Cheeseburgers, pizzas, and hotdogs, become priority over broccoli, fish, and watermelon. Barbara Gollman, dietician and spokesperson for the American Dietetic Association stated that, “Twenty years ago, the [American] diet wasn’t as varied as it is today…But the portions were more in line with what people really needed.” In a country where the buffet table is the solution for a well-balanced meal, restraint and portion control become difficult tasks. Undoubtedly unhealthy food governs the American food culture, but is a person’s health the responsibility of the food producers, or the individuals who choose to eat them? The companies fueling the “American diet” are certainly not force-feeding the entire nation, people are individually choosing to eat the unhealthy products; however, the food advertisers, fast-food companies, lawyers, and lobbyists May/June 2010
This advertising scheme of making unhealthy products appear healthy is known as “nutriwashing” and is filtering into processed foods as well.
seem to have immense persuasive abilities and control over the food environment. Fast food chains such as McDonald’s, Burger King, and Taco Bell, seem to flourish in urban areas, and they are slowly spreading to more rural regions. According to Michele Simon, nutrition specialist and public health attorney, McDonald’s alone operates in 120 countries, with thirty thousand restaurants serving fifty million customers each day. Fast food restaurants provide convenience, instant satisfaction, and are inexpensive. For most Americans, restaurants such as McDonald’s are more prevalent in their communities than farmer’s markets. Because consumers do not have the resources to healthy food, they must settle for unhealthy alternatives. However, it is not merely the fast food chains that supply Americans with unhealthy products, large supermarkets rarely carry any organic or local produce and are limited with their variety of grains. Natural food chains such as Whole Foods are slowly spreading, but their products are much higher in price that people naturally buy lower quality foods from supermarkets. Responding to the health-conscience nation, major food corporations are attempting to modify their products to appear healthy, when in reality they are very unhealthy. According to Michelle Simon, in April of 2004, McDonald’s announced its “Balanced, Active Lifestyle Platform,” in which they vowed to end supersizing and distributed their new salads. The salads seem to be a healthy alternative to the Big Mac; however, the Bacon Ranch Salad with Crispy Chicken racks up 510 calories and 31 grams of fat. What appears to be a healthy solution for consumers, is literally fried chicken atop lettuce, slathered with ranch sauce. This advertising scheme of making unhealthy products appear healthy is known as “nutriwashing” and is filtering into processed foods as well. General Mills recently launched a “whole grain” campaign on their cereals. Suddenly Reese’s Puffs, Lucky Charms, and Cocoa Puffs became healthy breakfast options due to the “whole grain” seal on the box, when
Sierra Sacramento Valley Medicine
in reality the products contain less than one gram of fiber. Similarly, Pepsi and Kraft created labels entitled Smart Choices and Sensible Solutions, which are tagged onto such processed products as Fritos and Lunchables, signaling to the consumer that the products are “healthy snacks”..Consumers rely heavily on these health labels, as the Washington Post noted in 2005, “Product packaging is the second most common place where people get their nutrition advice, after their doctors.” Even when consumers refrain from eating fast food, they are easily duped into eating processed foods that claim to be healthy. While the corporate players in the food industry continue to manipulate their products and the consumer, eventually the individual must take responsibility and stand up against the commercial food system. Each person can take control of their own health by choosing to buy more conscientiously. Instead of a fast food restaurant, opt for cooking your own meal. Instead of buying nonlocal and processed produce, try to find a local farmer or even start growing a few vegetables in your backyard. In order for the consumer to reclaim his or her health from the major food industries, he or she must first make individual steps to promote a healthier lifestyle. Michael Pollan, author and whole food expert, encourages consumers to take more initiative with their health, claiming that consumers get “three votes a day,” when choosing their meals. Each individual is not expected to eat local, organic produce at every meal, but Pollan says, “…as long as you vote with conciseness, things will change.” Works Cited “Interview with Michael Pollan.” Prod. Ellen Rakieten. Harpo. Oprah Winfrey Show. 16 Mar. 2010. “Overweight and Obesity Trends.” Centers for Disease Control and Prevention. 20 Nov. 2009. United States Government. 20 Mar. 2010. http://www.cdc.gov/obesity/date/trends.html. Simon, Michele. Appetite for Profit: How the food industry undermines our health and how to fight back. New York: Nation Books, 2006. Woolston, Chris. “What’s wrong with the American diet?”. AHealthyMe. 28 Oct. 2009. 21 Mar. 2010. http://www.ahealthyme. com/topic/usdiet.
Gasping for Air By Eisha B. Zaid MS III This article originally appeared in the March issue of San Francisco Medicine. It had been raining all week. The soggy gray weather had shrouded the city in a wet blanket of haze. Today, the sun was actually shining. I got a glimpse of a crisp San Francisco morning through the window of Mr. W’s new room. Earlier that morning, I had walked into his old room. As I made my way to this room, halfstumbling through early morning sleepiness, I looked in the corner, where he usually lay. I was surprised to find an empty bed covered in freshly laundered white sheets. I searched the room, identifying the three other patients, only to realize Mr. W was not there. I turned my attention to the sitter, who was staring at me from behind a computer in the middle of the room. “They moved Mr. W’s body to Room 10,” she said. *** Mr. W had died earlier that morning. I heard the words echoing in my head as I sat and listened to our resident dictate the discharge/ death note, “He expired at 5:50 a.m.” I had been following Mr. W through the later course of his illness during the previous week. I never directly spoke to him; I made use of translator phone, which connected me remotely to an interpreter, who echoed my questions in Cantonese. This eight-four-year-old man had been admitted to our neurology service two weeks earlier after he had been found unresponsive in his bathroom. The CT would later show that he had suffered a right-sided stroke after a major artery (middle cerebral artery) had been acutely occluded. As a result of the ischemia and subse
quent brain damage, he was left with a left-sided paralysis. Even before his stroke, his days had been numbered. He had advanced lung cancer with metastasis to his liver and bones. He was initially observed in the ICU and later transferred to our ward team. When he first came out of the ICU, he was coherent, answering our questions, verbalizing his complaints, and actively trying to move his flaccid left arm with his good arm. Initially, he was set on participating in acute rehab, despite the intensity. His family remained committed to recovery and was even interested in continuing chemotherapy for his lung cancer. But within a couple of days, his health started to decline, and he expressed a desire to die. *** Mr. W finally got his own room with a window that overlooked a busy San Francisco highway. As the cars buzzed by, the stillness in Mr. W’s room could be palpated. A big red sign that said, “Caution, Fall Risk” hung over his bed. I could not help but note the irony in the message that hung over the body of a dead man. His gray hair was disheveled. His mouth was still open, as though he were gasping for air. His two large brown front teeth and a row of overcrowded bottom teeth were visible. His face had a yellow hue and his eyes were closed. His frail body looked stiff. A name tag was tied around his right big toe and a large white bag was folded below his feet. I walked up to his body. I lay my hand on his right side; his skin was still moist and slightly warm. I stood there alone, lamenting his death and wondering how much he suffered while he gasped for his last breaths. I closed my eyes and prayed he would find the peace he had May/June 2010
been denied during the last days of his life. And I said good-bye. *** When making medical decisions, physicians must ask if the patient has the capacity to make decisions, or if he has impaired decision making. A patient is presumed competent until proven otherwise. The same reasoning must be applied during end-of-life care discussions. To determine decision-making capacity, a patient must have the following abilities: communicate a choice, understand the relevant information, appreciate the situation and its consequences, reason about treatment options (Appelbaum 2007). A fine balancing act must be achieved, whereby physicians respect patient autonomy but prevent patients from making decisions that lead to undue harm. During the end of life, the question is mainly about when to withdraw lifesustaining measures and transition to comfort care with a focus on symptom management. If it is deemed that a patient has impaired judgment and lacks capacity, we rely on a substitute decision maker. A conflict emerges when a patient lacks capacity, did not draft an advanced directive, and a surrogate decision maker acts against the patient’s wishes or the medical team’s advice, which, during the end of life, often results in an escalation of care when little improvement can be expected. At this point, we must ask if we are actually doing harm and making our patients suffer. *** In the week that I took care of Mr. W, I had become familiar with his neurologic exam. He could not move the left side of his body and did not even withdraw from painful stimuli. He had a left facial droop and looked to the right. Sadly, during the last week of his life, I watched him decline, becoming more delirious and agitated. Initially, he was alert and oriented and would follow commands. But he became hypoxic and required more oxygen to be comfortable.
Sierra Sacramento Valley Medicine
Because he was at risk for aspirating the food he ingested, he required a feeding tube, which was placed in his nose. He had to be restrained because he tried to pull out the plastic tube. And he was flailing his right leg and tugging at his restraints to be freed. A shrill moan was audible from the hallway any time you passed by his room. He was miserable. Each morning, I could hear him groaning. And each day his mental status declined. He went from verbalizing his complaints to responding to yes/no questions to becoming completely unresponsive and only communicating with mumbling. The translator could not make out his responses. He needed a diaper because of his incontinence and would swat me when I examined him. He lay in a room surrounded by three other patients; a sitter was in the middle of the room. When I watched him flailing his leg and his restrained arm, which was contained in a large white mitten tied to the bed, I felt pity for this man. It was undignified to keep him tied down during the last days of life. He was suffering, and a part of me wanted to tell his family that he would be better off at home surrounded by his loved ones than surrounded by strangers and tied down in an impersonal hospital room. But his family could not make the decision that we, the neurologists, felt was in the best interests of the patient. *** Doctors are not very good at prognosticating, especially when it comes to predicting someone’s life expectancy. Thus, lifespan is presented in ranges — days to weeks, weeks to months, and months to years. We gave Mr. W weeks to live. His death did not come as a total surprise. The writing was on the wall from the day he came out of the ICU. We, the neurologists, could all could see it, but the family did not. He was not a good candidate for acute rehab due to his weakness. And when his health started to decline, we all knew he would be better served by comfort measures.
Despite the inevitable, we were not able to communicate our expectations to his daughter early in the course of his hospitalization, nor to conduct a candid discussion about his prognosis. The daughter, who was charged with making medical decisions, initially insisted on acute rehab and chemotherapy because she did not realize his days were numbered. We did not discuss goals of care until after Mr. W had become restrained and started to decompensate. It was only after he had repeatedly expressed, “Please let me die. Please let me die,” that we consulted the palliative care service. Even when we presented the options relating to removing life-sustaining measures to the daughter, she could not make the decision we all wanted her to make — she could not withdraw care. And she wanted to suspend making a decision.
only wish we could have included Mr. W in the discussion earlier to better understand what his wishes were. I kept replaying the conversations we should have had with the patient and family. But in the end, I realized that we sometimes just need to accept death as it comes, even if it does not meet our criteria for a dignified or comfortable death. It is a sad truth. As I drove away, the rain started again. Eisha.Zaid@ucsf.edu Eisha Zaid is a third-year medical student at UCSF and author of Eisha’z Inner World, a blog about her journey through medical school: http:// eishazinnerworld.blogspot.com. Reference: Appelbaum P. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357:1834-40.
*** At the end of life, we place a large burden on the families of our patients. We look to them to make decisions based on limited information, because we expect them to know what the patient would want. As easy as it is for us to make our recommendations, we do not have to live with the consequences of such decisions. I can only imagine the anxiety Mr. W’s daughter faced when she had to make the final decision about Mr. W’s end-of-life care. We ended up agreeing on comfort measures, such as Haldol to help the agitation and morphine for pain. But his feeding tube remained in place and he still had to be restrained. He continued to groan. In the end, Mr. W died of respiratory compromise, gasping for air.
Porn stars and prostitutes are in the news: Which has most affected our nation’s economy?
Uhhh… The Goldman Sex scandal?
*** When I left the hospital, I felt a heaviness inside me, along with feelings of guilt and sadness. I wondered what I could have done differently to help Mr. W in the last days of life. Mr. W lacked the capacity to make medical decisions, and I respected the family’s wishes. I
A Legacy of Support From modest beginnings, BloodSource has grown into a premier blood center.
By Katherine Elorduy, Director of Communications, BloodSource On July 15, 1947, the Sacramento Society for Medical Improvement, better known now as the Sierra Sacramento Valley Medical Society, founded the Sacramento Medical Foundation, now named BloodSource. The bylaws of BloodSource make any licensed physician who is an active member in good standing in the Medical Society an automatic regular member of BloodSource. Regular members can amend, adopt or repeal the bylaws of the corporation. Later this year, BloodSource will present members with proposed amendments to its bylaws. The following is historical background and current information about BloodSource. After World War II stimulated many new medical advances, the residents of Northern California realized they needed a community blood supply for the area’s growing population. At the time, the only blood bank was at one of the Sutter Hospitals, but it was unrealistic to think that it alone, could provide enough blood to serve the entire region. Spearheaded by members of the Medical Society, the entire community rallied behind this need to form the Sacramento Medical Foundation. The city of Sacramento provided a site on the ground floor of the water tower on J Street, individuals donated money and labor, and several companies provided materials. On November 2, 1948, the blood center opened its doors and collected 39 units of blood on the first day. By the end of the year, it had collected a total of 5,919 units. Many Sacramento Medical Foundation members volunteered countless hours and
Sierra Sacramento Valley Medicine
resources to help ensure the success of the blood bank. Support of volunteers from the Board and area residents is still part of the culture today. And what began as a single blood bank beneath a water tower has become one of the premier blood centers in the world. In the spring of 2002, the Sacramento Medical Foundation changed its name to BloodSource. The name was selected to reflect the source of blood and transfusion medicine support to area hospitals; a source of advancement in blood services technology; and — thanks to the generosity of thousands of donors — the source for nearly every drop of blood used in nearly 40 hospitals in 25 counties in Central and Northern California. This year, expectations are that 225,000 units will be collected. BloodSource employs more than 500 persons including nurses, clinical laboratory scientists and three full-time physicians. With more than four decades of combined experience, its physicians are internationally recognized for numerous contributions in blood banking and transfusion medicine. Dr. Patricia Kopko, Executive Vice-President of Medical Affairs and Histocompatability Laboratory Director, researched a rare, potentially fatal side-effect of blood transfusions generated from female plasma donors called TRALI (transfusion-related acute lung injury). This led to BloodSource being one of the first blood centers in the United States to collect all-male plasma. Dr. Kopko’s research led to increased safety in blood collection and testing, as well as increased recognition and treatment of this side-effect.
BloodSource also supports safe blood banking across the world and is involved with Rotary International’s Safe Blood Africa Project. The Project’s mission is to enable and support voluntary blood donor programs in Africa, where blood is not readily available from blood banks. Dr. Chris Gresens, Vice President and Medical Director of Clinical Services at BloodSource says, “We envision helping professionals focus on donor recruitment, hospital transfusion practices and improving lab practices.” While BloodSource was built around providing a safe and plentiful blood supply, medical and technological advancement has provided growth in new areas. BloodSource has a high-capacity, green technology facility, built in 2008, committed to state-of-the art blood products manufacturing. BloodSource Laboratories is designed to quickly adapt to constant advancements in transfusion medicine. BloodSource also offers the largest Donor Testing Laboratory in California and is one of only 50 accredited Immunohematology Reference Laboratories in the United States. It helps find blood donors for patients with rare and unusual antibodies. Additionally, BloodSource runs a Histocompatability Laboratory providing tests for marrow/blood stem cell transplantation, solid organ transplantation, as well as HLA-matched platelets. Despite many changes and technological advancements in blood banking and transfusion medicine, BloodSource remains a community-based, not-for-profit blood bank. Its mission is simple and purposeful: dedicated to providing blood and services to those in need. And it is with the same community-based support instilled by original members of the Sacramento Medical Foundation that its legacy is carried on today. “We are committed to doing what’s right, a simple philosophy that has helped us grow and be a player in blood banking and transfusion medicine,” said Mike Fuller, BloodSource CEO.
This was the original location of the Sacramento Medical Foundation, where blood was collected “under water.”
“Our very foundation will always be linked to the doctors and founding board members of the Sacramento Medical Foundation. They are integral part of who we are today.” firstname.lastname@example.org
This is the new headquarters of BloodSource, at the former Mather Air Force Base.
Voices of Medicine A review of various local and regional medical journals.
By Del Meyer, MD
The Regulatory Mess
How did we get into this mess in the first place?
Hal Grotke, MD, asked, “Should I Trust the Government?” on the President’s Page of the March 2010 Bulletin of the Humboldt-Del Norte County Medical Society. Statutory laws and regulations have been hard on us, to say nothing of case law. Thanks to Medicare, if we choose to provide medical care for people over 65 years old, or with permanent disability, we must submit bills electronically. Of course, most of us have people for that, but we still do it by extension. Thanks to HIPPA we can no longer tell a spouse, without specific permission from a patient, that a patient has herpes simplex virus infection. Thanks to new regulation from California Department of Managed Healthcare, if we cannot offer an appointment to a patient in a prescribed timeframe we may have civil liability. And thanks to MICRA if our doctor harms us with some egregious neglect we are severely limited in how much we can be compensated financially. (I include that last one a bit tongue in cheek.) All of those laws and regulations, with the possible exception of electronic billing, exist because of large scale and repeated failure to do the right thing. None of those laws and regulations work entirely the way they were intended anyway. The greatest failure of those specific laws, to my knowledge, is the second P in HIPPA. Although there is now a federal mandate for COBRA coverage for people leaving a job at which they were lucky enough to have employer provided health insurance there is no regulation of premiums. Very few recently unemployed people can afford to buy such coverage. As for the new California regulation regarding timely access, the loophole for doctors is that we can
Sierra Sacramento Valley Medicine
simply document why we think the patient is unharmed by delay. The much bigger loophole for insurance companies is that they are not the ones being regulated. If there is an insured person in the area who needs to be seen it doesn’t matter that the insurance company pays so little that no doctor is willing to see a patient with that insurance. This regulation only applies to patients with insurance specifically regulated by DMHC and to physicians who contract with such health plans. As far as that regulation is concerned we can still delay indefinitely scheduling patients who are uninsured or have indemnity coverage such as Medicare without a managed care supplement… How did we get into this mess in the first place? Read all of this article, and the next item, at http://www.sonic.net/~medsoc/images/bulletins/2010-3 MARCH BULLETIN_web.pdf
Obesity Rates In the same Bulletin, Ann Lindsay, MD, Humboldt County Public Health Officer, discussed obesity. According to data from the Centers for Disease Control and Prevention the national obesity rate has held steady for the past five years. The new data are based on health surveys involving height and weight measurements of 5,700 adults and 4,000 children. The results shows 68 percent of adults are overweight, with African American having the highest rates of obesity, followed by Hispanics and Whites. About one-third of children aged 2 to 19 were overweight, with the percentage of extremely obese children steadily increasing…. We have yet to see the leveling off trend in Humboldt County.
The GIGO Factor Karen S. Sibert, MD, Associate Editor of the CSA Bulletin wrote on “Peering over the Ether Screen; The Electronic Medical Record: Garbage In, Garbage Out” in the Winter, 2010 issue. My first patient of the day was a congenial man in his 50s with a history of prostate cancer and radical prostatectomy, scheduled for replacement of a defective penile prosthesis. The history and physical in his chart was a pleasure to read because it was printed and legible, as opposed to the handwritten scrawls we often encounter. Imagine my surprise, however, at reaching the section about this patient’s previous surgical history, and finding that he was supposed to have had none. I looked twice to make sure I was reading it correctly. No prior surgery. Impossible, of course — he had had both prostate surgery and the initial penile prosthesis placement. Then I realized the obvious truth: We were sabotaged once again by the fatal ease of data entry error in a computerized record… Worse still is the potential propagation of errors in the patient’s medication list. The other day we had two patients in preop with the same, quite common, first and last names. Looking over the computer printout of my patient’s medications and seeing Keppra listed, I asked him if he was doing well on Keppra and how long it had been since he had a seizure. He looked puzzled. He didn’t take Keppra, he said, and to his knowledge had never had a seizure. We quickly figured out that the nurse had merged his med list with that of the other “John Smith.” That was the easy part. The hard part was fixing the mistake. It turns out that once the nurse “closes out” and prints the record, apparently it takes an act of God to undo it. In the meantime, Keppra remains on the med list… Back to my patient with the penile prosthesis: Once I had determined that everything in his H & P was going to require independent verification before it could be relied upon, I took a longer look at the internist’s recommendations for perioperative care. I include them verbatim: “Pt is at low risk for surgery. Please avoid
shifts in Blood Pressure and Volume. As is true with all surgery the anesthesiologist should mind the blood pressure as this will reduce any unknown cardiac risk the patient may have. A profound anemia would add further risk, which this patient has no evidence of. Should heavier than expected bleeding occur, please keep Hct over 30 for further cardiac risk reduction.” Although I don’t know for sure, I would bet money that this internist had a check-off list on his computer with someone’s idea of appropriate advice for the anesthesiologist. How would I ever have managed the case without it? Is this really the quality of information we can expect from a completely paperless system? Computers, after all, don’t generate content; they only store it and make it available for retrieval. At the end of the day, if you put garbage in, you’ll get garbage out, and any time we thought we saved will be spent sorting through the trash. The entire article by Dr. Sibert is available at http://www.csahq.org/pdf/bulletin/sibert_59_1.pdf
We were sabotaged once again by the fatal ease of data
On Breathing The Spring 2010 issue of Sonoma Medicine is devoted to breathing. This is part of the introduction by pulmonologist James Gude, MD. The word pneuma, literally meaning “that which is breathed or blown,” was used by ancient philosophers to describe the soul or vital spirit of a person… Breath and breathing matters are the themes of the contributors to this issue of Sonoma Medicine. As a consultant to five rural intensive care units in Northern California, I value the role of respiratory specialists. Indeed, four of the top 10 rural ICU diagnoses involve respiratory distress: acute and chronic respiratory failure, community acquired pneumonia, chronic bronchitis and emphysema (COPD), and asthma. All four of those ICU pulmonary diagnoses involve smoking… All his comments, and the entire issue, is at http://www.scma.org/magazine/?vol=66&num=2
entry error in a computerized record…
Volunteers In Venezuela By F. James Rybka, MD
Dr. Mel Spira and a Venezuelan surgical resident.
In the spring of 2008, I served for two weeks in Venezuela as part of Rotoplast, a corps of medical volunteers sponsored by the Rotary Club with the mission to repair the cleft lips and cleft palates on children in other countries. I found it to be a second-world country with a sizeable middle class, but we never visited Caracas where, I understand, there are some miserable slums. Our mission was in Barquisimento, the third largest city in the country, located in an agricultural valley (sugar cane) with a population of 1.5 million, about the size of Sacramento. Our team, largely from Northern California, consisted of four plastic surgeons. One of these, Dr. Mel Spira, age 84, had been the chief of plastic surgery at Baylor in Houston for many years. The four anesthesiologists were mostly from UC Davis, and four nurses were from hospitals around the Bay Area. Our mission was sponsored by the Rotary Club in southeastern PA, just north of Philadelphia. They had raised about $65,000 to fund this venture, so all of our travel and lodging expenses were paid for. This PA Rotarian group also had 12 volunteers, including a dentist. But the other Rotarians were men whose occupations varied from a CEO, stock manager, and an accountant, to a college professor. They just volunteered their time and worked as orderlies or secretaries, moving crates, registering and wheeling patients, and cleaning up.
Sierra Sacramento Valley Medicine
What was beautiful to see were two things: the excellent coordination between the US Rotarians and their Venezuelan counterparts, and the enthusiastic, warm reception given to us by the young staff of Venezuelan nurses and other personnel at the hospital. After an all-day flight from San Francisco to Miami, and then Caracas, we finally arrived via Venezuelan military transport plane into Barquisimento at 2 a.m. the next day. Considering the hour, we were taken aback by the enthusiastic reception given to us by about 20 young nurses, orderlies and others who cheered us, and then helped unload the 28 large boxes containing our hospital supplies â€” everything from sutures, drugs, sterile supplies, instruments, on to computers and records. We were housed in military quarters rather like an R&R motel used by Venezuelan military officers. However, about the only military people we saw were some young guys playing basketball. No guns or any military equipment was seen. In fact, the whole city was far less militarized than, say, Mexico City, Tel Aviv, or even New York. The Venezuelan people are quite religious, particularly the indigenous population, and they love colorful pageants and festivals. The center of town was inviting and very neat. We did not see downright poverty, but were told that there were poor barrios in the surrounding hills. We saw many children going to school, all neatly dressed in uniforms. Art and music education is valued much more in Venezuela than in the US. The famous systema educational system teaches children to read music, and to take up a musical instrument, and then organizes orchestras of the better players. The current new director of the LA Philharmonic, Gustavo Dudamel,
age 28, is a product of this education and he is from Barquisimento. We also noted many colorful posters of interesting, fine quality graphic art by students. These were placed in all the public buildings, including the airport and hospital. There were a surprising number of new automobiles and many SUVs (gas was about 25 cents US a gallon). However, we saw evidence that the middle class was quite jumpy about the increasingly socialized political situation. A number of them confided in private that they had one foot out the door with contingency plans to go either to Spain or to Florida. We were told that a house in Spain would cost about twice what a comparable home would cost in Florida. Venezuela is more closely tied to Spain culturally than is Mexico or Central America. Our mission had been announced in the local papers, radio and in the churches, so the message had gone out to the mountain villages where mostly “Indian,” or mestizo Venezuelan populations resided. It took a day or two for most of them to get into town; many had to camp around the hospital grounds for a couple of nights while their child was being treated. The basic hospital was quite large, rather old, somber, and basic bare-bones: four patients to a room with only one bathroom, no individualized meals — just a food cart with a server who ladles out a meal in a bowl to each patient. The operating rooms, however, were totally different: shiny and equipped with the latest supplies in both surgery and anesthesia, so we all felt as comfortable as if back in the U.S. The children were examined by our team of pediatricians, anesthesiologists and plastic surgeons a day or two before surgery, and were screened and prioritized. We worked long hours, from about 7 a.m. to 6 p.m. and performed about 130 procedures over the two weeks without any complications. All children stayed in the hospital overnight and were sent home the next day. There was a medical school next door, and Venezuelan resident surgeons in plastic surgery (and oral surgery) scrubbed in with us; we showed them our methods and they also
provided some follow up on the patients. They seemed intelligent and very earnest in their work. One socialized service that the Venezuelan government had set up was a program to help indigenous Nicaraguans have free cataract extractions. We saw a contingent of about 40 of them lined up, and over two days, one Venezuelan ophthalmologist operated on all of them. The Rotary Club in the U.S. has sponsored numerous missions like ours to Venezuela and many developing countries. The goodwill there was palpable, particularly the gratitude of the parents. During the two weeks, we never had any difficulty with anti-American Chavistas, at least as far as I could tell. In fact, the governor of the State of Lara (where Barquisimento is located) came to greet us, and then have his photo taken with a group of pretty young nurses. (Since I was there, I have been disappointed to read about Chavez’s increasing abuse of power, and also the degeneration of the economy.) Most of the Venezuelans I encountered were young and proud of their country. But not so proud not to deeply appreciate our help, and it may not be long before they will take over these cleft repairs on their own.
A girl with cleft lip and also a rare third nostril.
The Fatigue Prescription This book is probably best suited for those individuals who are burned out, depressed or out of sorts. By George Meyer, MD THE FATIGUE PRESCRIPTION Linda H. Clever, MD Viva Editions, Berkeley, CA ISBN: 978-1-57344-380-7 186 pages; $16.95 softback Linda Clever, MD, MACP, has been working with patients and doctors who are depressed and overstressed for many years. Her RENEW program has been very popular — so popular that she has written a book based on her experiences. Though some of the material seems quite obvious, when people are depressed or burned out they may not be able to function well enough to access these principles. She mentions an energy bucket. For some it is quite full yet for others it may be very low. The key is to understand why the bucket is low and how to fix it. Learn where the energy holes are, plug them with “corks,” then add new energy. Corks could include such interventions as getting counseling, going to the doctor, or getting domestic help. New energy sources might include going for a walk, talking to a friend, doing sports, playing with a child, or playing catch with a dog. One patient of mine, over 350 pounds, went back to playing amateur baseball and lost 150 pounds and developed a new image and self confidence. It changed his life! Her step by step fatigue prescription requires four steps, not unlike a Total Quality Management cycle. We must become AWARE of the problem; then we need to REFLECT about the issue; the most important step is CONVERSATION with those close to you in order to test your observa-
Sierra Sacramento Valley Medicine
tions and to hear others’ input. Finally, after due consideration, PLAN-AND-ACT on your input to make the transformation. One of Dr. Clever’s key points is that no matter how busy you are, you always need to schedule “me “ time for thinking as well as for other personal activities! Attitude is everything. She quotes Viktor Frankl, a holocaust survivor, “Everything can be taken from a man but one thing: the last of the human freedoms — to choose one’s attitude.” In one study, those with pessimistic outlooks for 30 years had poorer mental and physical function than those with better attitudes. One chapter asks us to understand our values. Another reviews using those values to determine what it is you want and how you will get there. The chapter on “Get in Shape” is more than getting exercise. It discusses spirituality and relationships, as well as eating a healthy diet and getting regular exercise. Your attitude includes your self esteem, your ability to control the outside inputs, and how important it is to laugh. Finally, Dr. Clever gives us a prescription on how to maintain our mental and physical health in order to stay renewed. This is an inexpensive book in the paperback version. There are loads of pearls. Anyone can benefit from reading it, but it is best for those who feel burned out, depressed or out of sorts. It might be valuable particularly for primary care physicians to help their patients deal with life. email@example.com
Another Disastrous Peer Review Failure? By Gerald N. Rogan, MD Some of you may have read stories in the Baltimore Business Journal about Dr. Mark G. Midei, a cardiologist, who allegedly overtreated as many as 538 cardiac patients while practicing at St. Joseph Medical Center in Towson, Maryland. 1 A Maryland man and his wife, Thomas and Sharon Chaffee, sued Dr. Midei and St. Joseph’s alleging Midei inserted two unnecessary stent implants into Mr. Chaffee. The Chaffees allege Midei deceived them about the necessity of the treatment, and that St. Joseph officials were aware that Midei was misleading patients. Following the complaint, the federal and state officials are investigating the hospital. Officials discovered many other patients did not need the stents they received.2 None of the patients died. Some lawyers are soliciting Midei’s patients to file class-action and individual lawsuits. Meanwhile, a website has been created to support the doctor, www.MarkMidei. com. Dr. Midei was suspended and eventually fired by St. Joseph, along with hospital CEO John K. Tolmie and two other executives.3 Dr. Midei was chief of cardiology between May 2007 and 2009. At St. Joseph, the treating cardiologist may interpret catheterization films alone. A second opinion is not required, even for auditing under peer review. Stent placements are lucrative interventions, earning up to $15,000 per stent. Also, some stent patients took Plavix, potentially for no reason, which costs $150 for thirty 75 milligram tablets. The investigation has prompted the St. Joseph medical staff to ramp up its peer review
process to include audits of cases without complications to determine medical necessity.4 Cases are blinded so the group of peer reviewers do not know the names of the patients or treating physicians. Relevant questions include: • Why did Maryland and Federal officials not require peer review during Dr. Midei’s department chairmanship? • Is peer review required under Maryland State Law? If so, what are the penalties for non-compliance? • Did CMS know that peer review was not done and yet do nothing to enforce Medicare’s peer review requirement? • Were any cases audited for medical necessity? • Was external peer review required to expose the problem? • Was Dr. Midei the chairman of his department because of his volume of services? • Could the department chair thwart peer review? • Did St. Joseph have a physician safety officer to ensure that peer review is conducted? • Will the medical staff at St. Joseph now audit the image interpretations made by cardiologists who self-refer patients for stent placement? • Is any agency of government charged with performing a disaster analysis to discover whether there was a failure to enforce patient safety and peer review requirements? • Did any insurance company review the catheterization images to determine medical necessity?
• If an insurance company or Medicare Contractor (e.g., MAC, RAC) had discovered any unnecessary services, would the company have denied payment? • If payment had been denied, would the patient have been liable for payment? • What are the implications of all of the above on the cost of health care and the current proposals to “bend down the cost curve”? The St. Joseph situation is similar to the Redding Medical Center disaster of 1997–2002, previously analyzed by myself and others. At RMC, over 700 patients were mistreated while peer review was thwarted. After discovery, also via a lawsuit, the FBI provided the missing peer review. Following the case, the government refused
to analyze the disaster to determine how our enforcement processes were insufficient to protect patients from unnecessary invasive procedures. It seems our medical community and regulators have yet to learn how to assure patient safety and reasonably control health care costs. firstname.lastname@example.org 1 Several reports by reporter Scott Graham are on the internet. http://baltimore.bizjournals.com/baltimore/stories/2010/03/08/ daily20.html; http://baltimore.bizjournals.com/baltimore/ stories/2010/03/15/story6.html 2 http://baltimore.bizjournals.com/baltimore/stories/2010/03/01/ story3.html 3 http://baltimore.bizjournals.com/baltimore/stories/2009/06/22/ daily51.html 4 http://baltimore.bizjournals.com/baltimore/stories/2010/03/01/ daily44.html
Your care makes all the difference.
Trevor Austin Kott — Oct '06 - Apr '07. Still inspiring people to give hope to patients in need.
There are those who give blood and there are those who stand ready to give marrow should a match be found. To the medical professionals who care for every man, woman and child who receives these precious gifts, www.bloodsource.org
not-for-profit since 1948
Sierra Sacramento Valley Medicine
thank you for your support of every patient in need.
Posit on the Corporate Bar to Employing Physicians “A licensed California physician should be free to practice medicine as an employee.”
Among 136 responses: Agree 86; Disagree 50. Background: As noted on page A3 of the April 19, 2010 Sacramento Bee, California prohibits non-physicians from employing physicians except in medical schools and certain public institutions. Legislation has been introduced that would make it possible for at least some hospitals to hire physicians as employees. Posits are one sided statements intended only to promote discussion. Results reflect individual member opinion, but do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors. Edited commentary follows: The corporate bar on the practice of medicine exists in only a few states. Can anyone show that physicians or patients are adversely affected in all the other states in which physicians are directly employed? If not, is it not time for organized medicine to rethink this part of our dogma? — Earl Washburn, MD Of course they should be able to practice as an employee. I never knew that one couldn’t. — Maynard Johnston, MD How can you tell someone who has spent 8+ years of their life preparing for their life’s goals that they cannot work for whomever they want? — Ron Rogers, MD There are just too many ways that a physician-employee can be influenced by an employer to make judgments that are not in the best interest of the patients. — Joanne Berkowitz, MD It is foolish to think that we have to create special titles and foundations to get around the law. I think that the corporate practice of medicine is here to stay. — Peter Carruth, MD
This is already the practice in our local community; many physicians are medical directors of units and programs, especially intensivists and they serve an important role. —James Margolis, MD Medicine and society are best served if physicians place their patients’ interests first and foremost. Businesses, including hospitals, insurance companies, and retailers are managed by MBAs for profit. A physician employee is not ”free to practice medicine,” but is restricted by his employer’s policies and bottom line. As a profession, we must not allow this type of legislation or we will no longer be a profession with ethical and moral standards. Ever since the federal government began to successfully apply anti-trust against physicians we have steadily lost our ability to…practice in our patients best interests. We need to draw the line here. — Dr. Richard Park, MD This should be restricted to medically underserved rural areas. — Stephen Mandaro, MD It would help small hospitals, but, unless the law is carefully crafted, its abuse could lead to expansion of [the role of] non-physicians, such as hospital administrators, who direct medical decisions. This legislation needs close analysis before I’d back it. — Gregory Joy, MD The inevitable wave of the future for cost containment. — James Affleck, MD Some of the hospitals where I have worked have misused the physicians for the purpose of profiting from patient care. — Hartej Uppal, MD Rural physicians especially are in short supply and would be more likely to move to those areas if they could be salaried by hospiMay/June 2010
Of course they should be able to practice as an employee.
Businessmen should not employ doctors.
tals, clinics, etc. — Barbara Rounds, MD Businessmen should not employ doctors. This violates the corporate bar. — Demetrios Simopoulos, MD This is a curious wording of the posit. Quite independent of the freedom to be an employee is the obligation of a physician to stand as a bastion between patient and corporation in the delivery of medicine. Employees are expected to advance the goals of their employer. Physicians should be expected to advance the goals of their patients. And not always shall the twain meet. — Wendy Forrest, MD A physician-employee may feel obligated to place the financial interests of the employer over the best interests of his/her patients. — Debra Johnson, MD The bar on corporate practice of medicine has worked well for Californians. — Kuldip Sandhu, MD Politics! The pay-for-work ethic, previously held in high esteem by America, has been destroyed by the complex federal regulations in many industries, and most assuredly in healthcare. Federal policy and intrusiveness of insurance has made independent practice impossible anywhere outside of deserted rural areas. Even there, Federal rules make house calls and caring Dr. talks cost prohibitive. A Dr. who wants to practice medicine without a PhD or Masters in Business Admin or Law must seek salary.… Why prohibit the practice with pretense of ”supervision” by clinicians when U.S. ”supervision” is 99% fiscal? — Evalyn Horowitz MD Talk about crossing the Rubicon. “UC Davis
1-800-901-5830 • • • • • •
33 years of medical experience 1,600 Northern California physicians 45 well-trained & professional operators State of the art computer technology Discounted rates for new SSVMS accounts Spanish, Chinese and Russian spoken
Sierra Sacramento Valley Medicine
Medical School” will become “UC Davis Doctor Job School.” Great idea. We’re one step away from complete erosion of the doctor-patient relationship. — Philip Poor, MD Once hospitals are in the business of hiring physicians, the physician is responsible to an employer that that does not share the same level of risk or responsibility for patient care. They could be controlled by shareholder needs and not patient needs. This sets up an ethical dilemma between the needs of one’s patients and the dictates of one’s employer. The only true employer of the physician should be the patient, or the patient’s proxy. For quality assurance, there has always been a separation between hospital and medical staff. When administrators run the show, you can have sudden changes in the level of care or care networks that have nothing to do with patient care, but rather strategic corporate decisions. If the physicians are employees, they have no power to challenge these decisions. — Richard Gould, MD I can see a problem if a physician is hired to push a commercial product or treatment. — E. T. Rulison, MD Because most physicians receive a pay check from some corporate body, they are defacto employees right now. No way has “Organized Medicine” been able to stop the take over and buying up of practices that have succumbed to extortion under the law. Hence, let Doctors become legalized employees of the systems that control or own them.… Forget Hippocrates: it’s the SIEU for me. — Cleve Baker, MD Sutter, Mercy, Kaiser already do it. I stayed independent. — Allan Galbreath, MD Those MDs who want a single payer plan might like being employed as it is easier to practice without the worry of sending a bill or not being paid. Things are changing! — Byron Demorest, MD That is removing a layer of protection, or responsibility, regarding safe and responsible medical practices which may run counter to corporate interests and profits. — Janet Abshire, MD
William Yan Fong, MD 1923–2010
Dr. William Fong became president of the Medical Society in January 1974 on the eve of the professional liability crisis of 1975. During his career, he served on nearly all of the Medical Society’s committees and was a Delegate to the California Medical Association and a member of its Board of Trustees. Not only was he committed to organized medicine, he served as director and chairman to many community-based health organizations including Easter Seals, the Heart Association and the Blood Bank, now known as BloodSource. He served as chief of staff at Sacramento Medical Center and Mercy General. He served as a Trustee on the Sutter Community Hospital Board and later served as a founding member of Sutter Health’s Board. Dr. Fong received the Society’s highest honor in 1987 when he was presented the Golden Stethoscope Award. This is just a sampling of his community and professional activities, and they illustrate why Dr. Fong was so widely known in the community and respected by his peers. Bill Fong was a Sacramento High School graduate; he received his BA from UC Berkeley in 1945 and his MD from UC San Francisco in 1948. In 1954, while completing his medical training at Bellevue Hospital in New York, he met and married Ruby Marie Yee. He joined the Air Force in 1955 and completed his service as a Captain. He returned to Sacramento in 1957 as one of our first physicians of Chinese descent practicing internal medicine and chest diseases. Dr. Fong had eight children and 20 grandchildren. He was a founding member of the Sacramento Internal Medicine Medical Group. Dr. Fong began semi-retirement in 1993 but
continued as medical director two days a week at the Asian Community Nursing Home. When not working, his favorite activity was gardening. The Seasons Came and Went with Bill: Fifty Years. In the Spring of my professional life, the Asian doctors would all sit for dinner at one table or two. Bill took me in like an elder brother, perhaps I was the prodigal son: he, the elder brother. The Summer came. We did politics, built families. It was more than making a living. It was leadership, breaking molds, and making a life. I got hypertension, Bill lost all his hair. He continued to William Fong, MD shepherd. In the Fall, the children grew into adults with substance and education, and they would be our legacy. As we would be all here, we are part of that. Winter came. The gow choy he gave me still grows at my home. In the garden of our hearts, all that Bill was endures as memories of a life welllived, our gift from Bill. — Henry Go, MD My memories of Bill Fong go back to when we both came to Sacramento, and continue to impress me with the greatness of his friendship. Whenever I called him, he came. His thoughts always impressed me. I thought of him as my brother in everything we did. He never let me down. I’ll never forget his friendship. — Edward A. Smeloff, MD Bill was probably the least pretentious, most soft spoken physician I have ever known. He was very kind and gentle. If he had an ego at all, he
did not show it. He was simply a very dedicated, very nice man, and smart as well. We shall all miss him. — David H. Lehman, MD From the “Fong Bee” family newspaper, March 13, 2010 Today we need to remember this good man for his outstanding accomplishments AND DEVOTION TO MEDICINE. William set the bar for excellence in life and it is our responsibility to carry it on. — Gordon A. Wong, MD From the “Fong Bee” family newspaper, March 13, 2010 The second Sacramento physician I met on my first Sacramento visit was William Fong, MD. At that time, he was monitoring the perfusion pressures during cardiopulmonary bypass at Sutter Memorial’s cardiac surgery program. At the end of his part of the operation, he came over to me and
suggested that we have a cup of coffee. During that conversation, he fully discussed the pros and cons of the program and how I might fit in. I would have to say that this conversation was primary in my decision to join Dr. Ed Smeloff in practice. My first thought on hearing William’s name was the fact that he was always available, night and day. You could always reach him, and within 15 minutes of the call, you could be assured he would round the corner on the first floor of Sutter Memorial in suit and tie, ready to solve whatever the problem. WILLIAM WAS ALWAYS AVAILABLE. In my mind he will always be the consummate physician. — George E. Miller, Jr., MD When I arrived in Sacramento in 1971, to start my Cardiac Surgical career, I was met at the door of Sutter’s OR 8 by Dr. William Fong. Bill was the Cardiologist and ran the Heart Lung Machine for Sutter’s Heart Surgery Team from the team’s inception. Bill squinted at me, smiled and then held out a hand of welcome — apparently I had passed first inspection. I recall William Fong as a good friend when the going got tough, prescient in his quick decisions, a great team player, who provided much good spirit and guidance in the “early days” of Heart Surgery. Thanks for being there when we needed you, Bill! — Paul Kelly, MD You often learn more interesting tidbits about individuals at their memorial than you do in a long career of close association. I appreciated Bill Fong for his commitment to organized medicine and his community. At his service I learned why I liked him so much. He was an accomplished gardener, a busy father and grandfather, a fisherman who did care if he caught fish and a tenacious shopper. My kind of guy. — Bill Sandberg
Sierra Sacramento Valley Medicine
Board Briefs March 7, 2010 The Board: Approved the 2009 Year-End Financial Statements and Investment Reports. Approved the appointment of J. Douglas Kirk, MD, as Vice Chair of the Emergency Care Committee. Approved the Membership Report: For Active Membership — Marcia V. Casas, MD; Chhaya P. Hasyagar, MD; Thomas T. Huang, MD; Laura E. Hufford, MD; Krisztian J. Kapinya, MD; Haw T-H Nguyen, MD; Monica Ruiz-Durant, MD; Jean M. Struthers, MD; Catherine C. Whang, MD. For Multiple Society Membership — Vartan M. Malian, MD For Reinstatement to Active Membership — Shailesh M. Asaikar, MD For Retired Membership — Jack E. Berger, MD; James M. Reese, Sr., MD; Gerald N. Rogan, MD. For Resignation — Michael A. Haight, MD (moved to Fresno); Brian H. Kim, MD (moved to Santa Ana); Thomas P. Whetzel, MD; Hua Zheng, MD (transferred to Solano).
April 12, 2010 The Board: Received a report from the Sacramento County Public Health Officer, Glennah Trochet, MD, regarding community health cuts as a result of the county budget crisis. Dr. Trochet also updated the Board on community flu vaccinations and Sacramento City water fluoridation. Received an annual report from Kris Wallach, Project Manager, concerning the Society’s 501(c)(3) organization, the Community Service, Education and Research Fund (CSERF). CSERF encompasses the SPIRIT Project (created to offer physicians innovative ways to improve the health of Sacramento residents through education and access to services); Continuing Medical Education (provides educational activities designed to improve the competence and practice of local physicians and healthcare providers); the William E. Dochterman Medical Student Scholarship Fund (provides medical student scholarships to gradu-
ates from high schools in El Dorado, Sacramento and Yolo counties); and the Sierra Sacramento Valley Medical History Museum (open for visits from the general public and public school tours). Approved sending a letter to members of the Sacramento City Council in support of continuing the water fluoridation program after reviewing a request from the President of the Sacramento District Dental Society. Reviewed a request from the CMA seeking nominations to 2010–2011 Councils and Committees. Any CMA member is eligible to be nominated by the Medical Society to one or more of the following councils and committees: Council on Ethical Affairs, Council on Information Technology, Council on Judicial Affairs, Council on Legislation, Committee on Medical Services, and Committee on Professional Liability. The deadline for nominations is May 28, 2010. Approved the Membership Report. For Active Membership — Leena G. Adhikesavan, MD; Deepti Behl, MD; Jeremy N. Ciporen, MD; Neuzil Lai, MD; Ian D. McCart, MD; Marilyn H. Price, MD; Farzad Ramin, MD; Lynette A. Scherer, MD; Nakiye T. Yegul, MD. For Reinstatement to Active Membership — Sheila M. Braunstein, MD; Craig S. Ruggles, MD. For a Change in Membership Status from Active to Active 65/20 — Stephen M. Nagy, MD. For a Change in Membership Status from Active to Government Employed — Evalyn Horowitz, MD. For Resignation — Shirin Ahmad, MD; Thomas J. Blumenfeld, MD; Charles Halsted, MD; Kent B. Hart, MD; Margaret E. McCusker, MD (left area); Janice E. Manjuck, MD (moved to San Francisco); Karen Mo, MD; James M. Reece, Jr., MD; Gary Schneiderman, MD; Ardeep K. Sekhon, MD; Bryant N. Sheehy, MD; Spencer Silverbach, MD; Marci L. Snodgrass, MD; Edie Zusman, MD. For Termination of Membership for Nonpayment of 2010 Dues: — Michael M. Aguilar, MD; Thomas B. Alan, MD; Arun P. Amar, MD; Ranjit S. Bajwa, MD; Saraswathy Balasingam, MD; Peter A. Barba, MD; Heather J. Bevan, MD; Mitchell E. Blum, MD; Bruce A. Bob, MD; Robert S. Burgerman, MD; Charles F. Carpenter, MD; William H. Chan, MD; Jason B. Cohen, MD; Paul D. Cox, MD; Debbie A. Dennis-Johnson,
MD; Charles Do, MD; David N. Eckert, MD; Paul J. Fry, II, MD; Kathy G. Gaspar, MD; Stuart H. Hahn, MD; Stanley C. Henjum, II, MD; Ingrid M. Hogberg, MD; Stephen M. Howell, MD; Tammi R. James, MD; Rocky P. Jedick, MD; Andew J. Kaczynski, MD; Michael A. Kasman, MD; Amir M. Khazaielinajafabadi, MD; John W. Kuhn, MD; VanBuren R. Lemons, MD; James T. Lin, MD; Alex J-C Liou, MD; Kwun Shan Lip, MD; Franklin R. Long, MD; T. Wade Maney, MD; Thomas Melchione, MD; Gertrudes P.
Montemayor, MD; Samuel P. Moody, MD; David F. Moore, MD; Edwardo Pagliere, MD; David C. Rausch, MD; Sreenivas R. Ravuri, MD; Vijaya L. Reddy, MD; Paul C. Riggle, MD; Sarita S. Salzberg, MD; Kulwinder S. Sehmbey, MD; Kelly A. Sharrar, MD; Lin Soe, MD; Erik V. Soloff, MD; Lisa S. Sundberg, MD; Nazhiyath Vijayan, MD; David M. Webb, MD; Julie R. Wei-Shatzel, DO; Stephen I. Stark, MD; Kathryn F. Witztum, MD; John K.H. Yen, MD; J. Peter Zegarra, MD; Barry R. Zeitlin, MD.
Board Member Statement and Profile Our Medical Society is among the largest in California. The Board of Directors includes the officers of the society, and representatives from each SSVMS membership district and the CMA and AMA. All are elected by the membership, so that information and access is vital to a well-run and representative organization. For a complete listing of names and addresses of board members please log on to www. SSVMS.org.
Jose Alberto Arevalo Stanford 1980 Family practice SSVMS, Representative for District #2, Central Sacramento Why do I serve on the Board? To help improve the practice of medicine in the Sacramento Valley Region, advocate for physicians and their patients, and create and nurture mutually productive relationships. Please contact me by email at: email@example.com
I am honored to serve on the Board and I hope I can contribute. I am a family doctor who greatly enjoys providing care but who has stepped into a largely administrative role as a medical director for an IPA. As such I have a strong interest in ensuring that independent practices continue to meet the needs of the patients they serve. I am also committed to help these practices improve the clinical and administrative services they provide. I am the father of 7 wonderful kids and 4 incredible grandkids who along with my partner, Sandra, are my vices and my hobbies.
Sierra Sacramento Valley Medicine
Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. â€” Michael Lucien, MD, Secretary Adhikesavan, Leena G., Rheumatology, Coimbatore Medical College, India 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5230
Glaiberman, Craig B., Radiology/Interventional Radiology, University of Texas, San Antonio 1998, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-3068
Malian, Vartan M., Radiology, Eastern Virginia 1998, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 (Multiple Member)
Applebaum, Samuel A., Family Medicine, University of Pennsylvania 2005, The Effort, 1820 J St, Sacramento 95811 (916) 313-8411 (Multiple Member)
Hughes, Thomas L., Anesthesiology, UC Davis 1985, Midtown Surgery Center, 920 â€“ 29th St, Sacramento 95816 (916) 476-3972
Price, Marilynn H., Physical Medicine & Rehabilitation, University of Michigan 1980, PO Box 221240, Sacramento 95822
Braunstein, Sheila M., Dermatology, University of Southern California 1981, One Scripps Dr #300, Sacramento 95825 (916) 920-0871
Kahane, Albert J., OB/GYN, SUNY Downstate 1956 (Retired)
Scherer, Lynette A., Surgery-Trauma & Critical Care, Tufts University 1993, UCDMC, 2315 Stockton Blvd., #4209, Sacramento 95817 (916) 734-4771
Friend, Jeffrey M., Psychiatry, UC Davis 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000
Lai, Neuzil, Neurology, St. Louis University 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2050
Yu, Annie C., Nephrology, UC San Diego 2002, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4050
Physician Well Being And Personal Financial Security A dinner seminar will be held on July 20 on Reaching Your Personal Financial Goals. Contact the Medical Society if you would like to attend.
David Herbert, MD, SSVMS Treasurer Many factors contribute to the sense of well being that most of us strive for. These can include an enjoyable and challenging practice, relationships with patients, colleagues, and family, health, interests outside of work, physical exercise, spirituality, and more. Financial security is an important part of this! Indeed, some of the large groups in town feel that this is important enough for them to sponsor financial seminars as a part of their physician wellness programs. Physicians often feel that managing their personal finances is not that complicated, especially in the first several years of practice when their portfolios are modest. But soon we are faced with mortgages, kids, schools â€” and retirement(!) â€” along with periodic disruptions in the financial markets. Getting competent expert advice can be a big help in weathering these financial storms and preventing financial concerns from detracting from your sense of well being â€” and hopefully also insuring that you have a realistic plan to meet your goals. Physicians who have obtained expert guidance almost invariably report they are very pleased they did so, and often wish they had done so sooner. (That was certainly my experience.) As part of its mission to assist members in achieving a satisfying practice, SSVMS wants to
Sierra Sacramento Valley Medicine
insure that all members have access to financial advice from experts who are very familiar with physician practices and needs, and who have a proven track record of helping our members. While SSVMS does not endorse one financial firm over another, we feel that it is in the best interest of all of our members to be exposed to expert advice so as to make the best decisions possible. We are fortunate that Kanseki Associates has agreed to provide dinner seminars for our members and their partners to review the foundations of effective financial planning. These are modeled after their work with Permanente; they have also worked with physicians from all of the major groups in town as well as small and individual practices. The seminars are free, with no obligation to pursue a relationship with Kaneski or anyone else. I have found these programs to be a very good use of time to learn (and relearn) important concepts in financial planning. The first seminar, Reaching Your Personal Financial Goals, will be held at the medical society at 6:30 p.m, on Tuesday, July 20. Please call Le Pham at 916-452-2671 or email her at firstname.lastname@example.org if you plan to attend. I look forward to seeing many of you there! David.Herbert@kp.org
Board Member Statement and Profile Robert A. (Bob) Kahle, MD Saint Louis University, 1979 Pediatrics, Perinatal and Neonatal medicine SSVMS, Representative for District #1, North Sacramento Why do I serve on the Board? To get involved with our medical community. Please contact me by email at: email@example.com
I am a native Californian, born and raised in the Los Angeles area. After fellowship I worked in the San Fernando Valley; my wife, two children, Paul and Shannon, and I relocated to the Sacramento area in 1989 when I was recruited to develop a neonatal intensive care unit at Mercy San Juan. Paul graduated from USC, worked in Sydney, Australia and still works telecommuting there. Our first grandchild, Tegan Rose, was born weighing 3 pounds, 3 ounces and was in the NICU for 6 weeks, coming home on February 4th. Shannon, after Law School at NYU, is a public defender in juvenile court in Queens. My wife, Janet, an artist, graduated with an MA from Sac State, began in sculpture and moved on to contemporary painting. She has had a number of shows locally, and will contribute a piece to the SSVMS Alliance Art Auction this year. Building her an artist studio at our home has assured that I will continue to work for the next decade. I am a member at El Macero Country Club. Though not able to play as much as I would like, I keep my handicap of 14. But my real dedication is to the babies in our community, to improving their care and achieving the best possible outcomes for them and their families. I feel honored to be a physician and to serve the population I serve.
Maimonides: A Physician’s Prayer God above, before I begin my holy work, healing Your [human] creation I lay my plea before You, that You will grant me the strength of spirit and the vast energy to do my work with faith, and that the aspiration to accumulate wealth will not blind my eyes from seeing one who is suffering, one who comes for my advice, as a human being, [whether] rich or poor, friend or foe, a good or evil person; in his sorrowful moment reveal to me only the human being in him. My love for the learning of medicine should only strengthen my spirit, only the truth shall be the light before my feet, for any weakness in my work might bring about death and illness to Your creation. I beg you, please, compassionate and gracious God, strengthen and focus my body and my soul and plant within me a spirit that is whole. — Moses ben Maimon (The Rambam, 1137–1204).
• • • • • • •
Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning
Since 1973 • Max Uden, Owner • (916) 455-5880
Medical Practices Face Rising Workers’ Compensation Costs – Members Can Fight Back 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 Society’s sponsored Workers’ Compensation program, with its 5% member discount, (possibly 15% depending upon where you have your group medical coverage) is even more important to members this year. The program is underwritten by Employers Compensation Insurance Company, (rated AExcellent by AM Best Company). Rather than guess what your savings could be, take a moment to contact Marsh (dba in California Seabury & Smith Insurance Program Management). Let them show you how your society membership can translate into savings. Call a Client Service Representative at 800-842-3761. Seabury is a subsidiary of Marsh Risk and Insurance Services, CA License No.0633005
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 Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (firstname.lastname@example.org) if interested.
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
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
MBNA 1-866-438-6262 / Priority Code: MPF2
Corporate Express /Brandon Kavrell (916) 419-7813 / email@example.com
Practice Management Supplies
Histacount 1-888-987-9338 Member Code:11831 www.histacount.com
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
Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com
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
UCG Decision Health 1-877-602-3835 / www.decisionhealth.com
Travel Accident Insurance/Free
All Members $100,000 Automatic Policy
42538 (9/09) ©Seabury & Smith Insurance Program Management 2009
Sierra Sacramento Valley Medicine
“RAShasledtheregioninradiology since1917.We’reheretostay.” Charles McDonnell, III, M.D., F.A.C.R
Since introducing the first x-ray equipment to the area, RAS has earned a reputation as the region’s leading radiology practice. Physicians look to RAS for the latest technology, a wide range of imaging and treatment options, and the most comprehensive team of board-certified sub-specialty trained radiologists. RAS’ outpatient imaging centers are conveniently located throughout the greater Sacramento area and are accredited by the AAAHC. Times may change. At RAS, we believe some principles are enduring. That’s why physicians and patients can rely on us for accurate diagnoses, timely results, effective communication and a commitment to the best possible outcome. Diagnostic Imaging Radiation Oncology PET & Nuclear Medicine Interventional Radiology Neurointerventional Radiology
For more information visit radiological.com/RefertoRAS 916-646-8300
3/25/10 3:54 PM
Mutualinterest Your reputation matters. Period.
Some insurers cap their defense costs or take them from your coverage limits. NORCAL Mutual does not. We are committed to protecting you regardless of the cost. There is no cap on the value of the reputation youâ€™ve earned.
Call NORCAL Mutual today at 800.652.1051. Or, visit www.norcalmutual.com. NORCAL Mutual is proud to be endorsed by the Sierra Sacramento Valley Medical Society as the preferred medical professional liability insurer for its members.
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on May 14, 2010
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...