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PRESIDENT’S MESSAGE The Complete Meaning of “Public Safety”?
Board Member Profile Anthony W. Russell, MD
Stephen F. Melcher, MD
EDITOR’S MESSAGE Introducing Two New Features in SSV Medicine
Don Kurth, MD
e.Letters to SSV Medicine
Loa Loa — A West African Expatriate in California
Gordon Love, MD
Del Meyer, MD 18
STUDENT ESSAY In the Same Boat
The Case of the Moving Body Bag
David Hadden, MD 33
Board Member Profile Demetrios N. Simopoulos, MD Voices of Medicine
A Posit on Peer Review
Writing and Healing
David Gunn, MS IV 15
An Afternoon in Africa
Andrew H. Huang, MD
John Loofbourow, MD
We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.
Communication Important in Hospitalist Model
All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.
Karen Davis 34
SSV Medicine is online at www.ssvms.org/magazine.asp This is another in a series of cover photos by pathologist Dr. Gordon Love. This is an image of microfilaria of Loa loa in blood, magnified 200 times. The eosinophil, below the worm itself, suggests the eosinophilia that often accompanies infection. But Loa loa may circulate in large numbers with little patient discomfort. Infection occurs near the rainforests of Africa. For more information, see the story on page 12.
Volume 61/Number 4 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 Robert Kahle, MD Norman Label, MD John Ostrich, MD Charles McDonnell, MD Stephen Melcher, MD Janet O’Brien, MD Kuldip Sandhu, MD Boone Seto, MD Earl Washburn, MD
Alternate-Delegates District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Anthony Russell, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Russell Jacoby, MD Robert Madrigal, MD Mubashar Mahmood, MD Rajan Merchant, MD Connie Mitchell, 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 AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor George Meyer, MD Robert Forster, MD John Ostrich, MD David Gunn, MS IV Gerald Rogan, MD Nate Hitzman, MD Robert LaPerriere, MD F. James Rybka, MD Gilbert Wright, MD Gordon Love, MD Lydia Wytrzes, MD John McCarthy, MD Del Meyer, MD Managing Editor Webmaster Graphic Design
Ted Fourkas Melissa Darling Planet Kelly
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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2006 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.
Sierra Sacramento Valley Medicine
The Complete Meaning of “Public Safety”? It should include not only law enforcement and fire departments, but also public health and social services.
By Stephen F. Melcher, MD IN WATCHING AND READING about county budget hearings, I am constantly frustrated by talk about public safety (police, fire, sheriff) as if it were separate from public health. Our state constitution prioritizes public safety, which helps pit public safety advocates against public health advocates. But adequately funding public health and social services will make it easier for “public safety” officials to do their job and help provide a safe community. I suspect it will save us a lot of money at the same time.
Mishandling Psychiatric Patients Dr. Richard Pan, SSVMS Past President, 11th District CMA Trustee and the Democratic nominee for the 5th Assembly District, shared an interesting conversation with me recently. Speaking to a group of law enforcement officials, he pointed out that if patients received mental health and chemical dependency treatment, their outcomes would improve and law enforcement would spend less time responding to such calls. That includes taking mental patients to the local emergency rooms (Sacramento County has closed its crisis clinic), which treat and release them, or sending them to a psychiatric hospital for treatment — only to have them discharged back to a community with very limited access and services. Pick–up. Transport. Treat. Release. Repeat. It is a crazy cycle that often ends with the person being channeled into the jail or prison
system, which is a very costly placement. There has to be a better way — and there is. Over 15 years ago, I presented a grand rounds at UC Davis entitled, “Forensic Psychiatry — The New Growth Industry.” I was alarmed at incarceration rates of non-violent drug offenders, and the lack of treatment and rehabilitation opportunities in California. I was especially alarmed at how many severely mentally ill persons were winding up in jails and prisons. Despite multimillion dollar lawsuits, there still is a lot of room for improvement. If we adequately funded our mental health system, many, possibly most, of these people would not end up in jails; 16 percent of inmates have a serious mental illness.1 “Americans with severe mental illness are now three times as likely to be in jail as they are to be in a hospital,” according to a report published in May by the Treatment Advocacy Center.”2 The number of psychiatric beds is declining, and California is significantly underbedded, yet the number of jail and prison beds is increasing. We are filling more of them with psychiatric patients. This same report also shows a correlation between how much a state spends on mental health and “the ratio and likelihood of incarcerating severely mentally ill patients” — the states more likely to have mentally ill patients in jail were also the states spending less on mental health. At budget hearings, it is very hard for a physi-
…16 percent of inmates have a serious mental illness.
cian to advocate more funding for programs that incarcerate the severely mentally ill rather than outpatient programs that provide care and treatment at a much lower cost. Lots of fear mongering helped restore funds to the Sheriff’s Department. I support public safety, but I think public health programs and social services are taking a disproportionate share of the cuts.
The Disappearing Safety Net
If we are not careful, all urgent and emergent care of the mentally ill will be shifted to our local emergency rooms, which is just about the worst place for this service to be delivered.
By now you have all heard that our public safety net has had several more holes torn in it — perhaps it would be more accurate to say that there are only a few threads left of the net. The Sacramento County Board of Supervisors recently voted to cut public health services to our most vulnerable citizens, severely mentally ill patients, medically ill indigent patients and patients prone to abuse and neglect. These cuts will get us through this year, but most experts are not predicting an economic recovery for one or two more years. That means more cuts are likely next year and much of the money “found” this year comes from shifting funds around and delaying paying debts. This could lead to a lower credit rating for our county, which is what happened the last time we did this. Many cuts seem short sighted: the closure of the Sacramento Boys Ranch, further cuts to mental health, primary care clinics closed or cut (prior cuts led to SSVMS’ MD volunteers serving nearly 50 percent fewer patients this year), less tuberculosis tracking. According to a recent article in the Sacramento Bee, there may be more beds closing at Sacramento County Mental Health. Although plans call for other beds to be added in the future, we cannot permit beds to be closed until the future beds are signed, sealed and delivered — and opened. All too often, cuts in services are sold to the public based on promises that never materialize. If we are not careful, all urgent and emergent care of the mentally ill will be shifted to our local emergency rooms, which is just about the worst place for this service to be delivered.
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In addition, some very basic services with potentially huge medical cost savings as well as better patient outcomes are being cut. STD (sexually transmitted disease) prevention and treatment will be virtually eliminated by the new cuts. Luckily for Sacramento, an organization created over 20 years ago by our four hospital systems and the county is stepping in to help fill this gap. CARES, The Center for AIDS Research, Education and Services will be providing a much needed health care service. The April 27 edition of the New England Journal of Medicine has an article entitled “AIDS in America — Forgotten but Not Gone.” Most attention on HIV/AIDS is focused on the global epidemic. But there are places in America where the rates of infection have grown to rival that of Sub-Saharan Africa. CARES is tackling the HIV/AIDS epidemic to make sure it doesn’t get out of control in this area. It is leading the community-wide initiative known as “Are You the Difference?” which aims to significantly reduce, if not eliminate, new cases of HIV over the next 5 years. This is an ambitious goal. CARES is using a strategy gaining traction among those who plan HIV prevention: control infection transmission by keeping the viral loads low among all those infected. This means aggressive testing to find those unaware of their HIV status, finding those who aren’t in medical care but know they are HIV positive, and, finally, keeping people in medical care so that they will be more likely to take their medications. Nationally this is known as Test & Treat or Testing & Linkage to Care, Plus. As physicians, we can help Sacramento put a huge dent in new HIV infections by testing everyone for HIV, especially anyone with an STD and anyone in a high risk group. In Sacramento, that currently includes gay men, African-Americans and Latinos. By taking these steps, we can be the difference. SSVMS is also stepping in to help fill some gaps. Through our 501(c)(3) organization, Community Service, Education and Research Fund (CSERF), we are expanding the SPIRIT Project (Sacramento Physicians’ Initiative to
Reach Out, Innovate & Teach) with the goal of providing specialty services to the medically indigent. You will hear more about this later, but I wanted to end on a positive note — and this is great news for Sacramento. firstname.lastname@example.org
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to eLetterSSVMedicine@gmail.com 1 “Prevalence of Serious Mental Illness Among Jail Inmates,” Henry Steadman, PhD, and colleagues. June 2002 Psychiatric Services 2 Psychiatric News Volume 45 Number 11, June 4, 2010.
Board Member Statement and Profile Demetrios N. Simopoulos, MD Tulane Medical School, 1995 Urology CMA Alternate-Delegate SSVMS Representative for District 4, El Dorado County Please contact me: At my office (530) 626-1277
I was born and raised in California and attended Jesuit High School locally and Pomona College in southern California. I returned to Sacramento to practice urology after earning my medical degree at Tulane Medical School and finishing residency at the Mayo Clinic. I have a number of interests outside of medicine. Throughout my life, I have enjoyed traveling, meeting new people and the great outdoors. In particular, I enjoy skiing and hiking in the Sierras and an occasional sail boat charter with friends. I enjoy the support of a large family who also live in Sacramento. At this time, my extracurricular hobbies and interests are more focused on politics, economics, and health policy. I am an active member at the national level for my urology society, the American Association of Clinical Urologists, and serve as the Society’s California representative through its State Society Network. I joined the board so I could further represent my colleagues in medicine at a time when, perhaps, new ideas are necessary for us to continue to care for patients and to preserve the doctor-patient relationship. I believe there is a growing trend towards third parties outside of medicine attempting to influence and modify that relationship to the detriment of patient care. I want to work to preserve what is great about our profession so that modern medicine continues to offer its best to patients. I am excited to serve as a board member at SSVMS because it gives me an opportunity to represent and serve our physician members and patients at the local level. I hope members will contact me with their ideas, questions and opinions.
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Introducing Two New Features in SSV Medicine By John Loofbourow, MD THE READER WILL FIND TWO new additions in this issue of SSV Medicine:
Exploring e.Letters The first is e.Letters. This seems a natural development in an electronic world where most comments from readers arrive by email often directed to the author, rather than posted in letters to the editor. For example, Dr. Nathan Hitzeman received a number of email comments about his article Setting the Record Straight on Primary Care. He wrote in response to an article by Janell Marshal, MSII, titled, A New Approach to Primary Care, in the March issue, to several prior articles on the same topic, and a posit on primary care. The nature and future of primary care is important, nationally and locally, especially considering the multiple changes projected in health care legislation. Until now, email letter writers needed to address their comments to individual authors, with no understanding they might possibly be published. We hope to improve that process: Members receive an electronic version of the magazine by email. Beginning with this issue, the online version of the magazine will contain a link for e.Letters, a more obvious and direct way to make clear that comments may be published. For those who cannot or who prefer not to use or open their online issue of the magazine, each author’s email appears at the end of every article; now we will add an electronic address for e.Letters. The e.Letters in this issue are those Dr. Hitzeman collected in response to his article.
Regular Interviews The second new item in this issue is a David Gunn interview with John Crandall, the facilitator of Sutterwriters. It is evident that Northern California is home to many interesting people in the medical field, many who are SSVMS members or who work in projects or professions that impact medical care. While we have published interviews occasionally in the past, David has had experience in that field, and has offered to edit this feature. He begins with Crandall. Pat Schneider, who also has worked with Sutterwriters, notes in her book, Writing Alone and With Others, “We are all connected to one another and to the mystery at the heart of the universe through our strange marvelous ability to create words. When we write, we create, and when we offer our creation to one another, we close the wound of loneliness and may participate in healing the broken world. Our words, our truth, our imagining, our dreaming may be the best gifts we have to give.”1 Using the Sutterwriter variation on the Amherst Writers and Artists (AWA) method, people from all walks of life participate in a unique writing process. Participants share experiences in a safe environment, supporting and supported by one another. A broad sector of society, ill or well, professional or unschooled, experienced or beginner, is found in the group. In my first session, one of the most impactful writers was a post stroke patient who could not speak and had her compositions read by Crandall. The concept is that self-expression through writing has a measurable positive effect on both healthy people and patients suffering
from illness. Sutterwriters sessions are two hours long. Though the method traditionally suggests that participants write by hand, they may bring a laptop if preferred. A prompt or stimulus is offered by Crandall, and everyone writes for a specific time (5, 10, 15 minutes). All writings are viewed as fiction. The author is not addressed personally. Comments focus on what was strong, what was liked, providing writers with an opportunity to tell their stories without judgment or criticism. The Editorial Committee always searches for ideas that may make your magazine better. Some experiments seem to work out well, like the Posits, Board Interviews, and High School
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Student Essay Contest. These efforts involve experimentation, and frankly, some risk; but we always try. I hope readers find the new features to be worthwhile. If so, perhaps they will survive the birth and newborn state; but if not, the old adage applies: Nothing ventured, Nothing gained. email@example.com Comments or letters, which may be published in a future issue, should be sent to the authorâ€™s email or to e.LetterSSVMedicine@gmail.com 1 Blood On The Page, Collected Writings of Sutterwriters, Edited by Chip Spann and Jan Haag, March, 2006, ISBN:2006900363
e.Letters to SSV Medicine There were a number of responses to an article in the last issue, “Setting the Record Straight on Primary Care,” by Nathan Hitzeman, MD. That article itself was triggered by one published the previous issue.
compensation, increased workload, etc.). I certainly do not think that attracting students on a more qualitative basis who are motivated to care for people equates to attracting lowbrow, non-overachievers. — Janelle Marshall, MS II
Get a Dialogue Going
Reform the RUC
I saw your response to my editorial piece on line. I wish to better explain the purpose of my piece. The point was to get dialogue going regarding reasons why students are not going into primary care. The statements I made regarding student’s attitude toward primary care are based on perceptions I have discovered while talking to many students from across the country. I made no attempt to pass judgment on primary care physicians. I believe it is an amazing profession that requires hard work, dedication and deserves much more prestige. In fact, I personally do not agree with the perceptions that I wrote about. However, I thought it was important for physicians to know what students are thinking and what we are being told consciously or unconsciously about primary care. These negative perceptions that students have do not seem to be due to lack of positive interactions with primary care physicians. I think that many schools are doing a great job exposing students to primary care. At my University, UC Irvine, I have had many positive experiences. We are lucky to get a ton of exposure to many wonderful primary care physicians; however, the trend toward fewer students going into primary care does not seem to be getting any better. I personally believe that the trend may have something to do with the personality type of incoming medical students in addition to the other factors frequently cited (i.e., reduced
Dr. Hitzeman has written an excellent article on an overlooked issue in healthcare. I was unaware of how the RUC [the federal Resourcebased relative value scale Update Committee] issue is handled: by overwhelming specialty interests! I remember hearing a program on Doctor Radio (NYU Docs on satellite) where a university gastroenterologist opined that the majority of the obese people in the US needed gastric bypass surgery because they had the data to show it would save lives. Well, it might save some lives if there were any money left for the rest of healthcare needs after we paid for all the bypasses! Aren’t a quarter of the adults in the country obese? Can the specialists see the forest for the trees? What specialty can’t find research evidence for providing billions of dollars in care? How many hundreds of millions of arthritic knees would orthopedists want to replace? I was told I needed bilateral knee replacement five years ago; and I managed to ski 75 days this year on my own two arthritic knees. Something wrong there! In psychiatry (my specialty), vast numbers could clearly benefit from intensive long-term psychotherapy! Of course they’ll get their gastric bypass and artificial knee long before they get psychotherapy. We probably aren’t even on the RUC secret committee! But, to whom do the specialists send the cases after the thousands of dollars in procedures? Who gets sent everyone no one wants to deal with anymore? Where is the county sending all the chronically mentally ill it can’t seem
… the trend toward fewer students going into primary care does not seem to be getting any better.
to find the money to treat? Primary care. So the next healthcare reform is to make the RUC a primary care (family medicine/internal medicine/gynecology) committee, and they can solicit information from the specialists and weigh it all. They are the only ones with a global perspective on the whole patient! They should get the highest RUC value. Otherwise the foxes are left to guard the coop! — John McCarthy, MD
Inspiration — for a Future Surgeon
For the right person, there is no greater calling than primary care.
I am a former Clínica Tepati volunteer (2007–2009), and an incoming UC Irvine MS I. I was at the Sierra Sacramento Valley Medicine Society turning in a scholarship application and I came across your article on primary care in the magazine. I just wanted to say that I really enjoyed the article, and although I am walking into medical school with an interest in surgery (because I find it complicated and fascinating — not for the money, I promise), I found your article to be inspiring and necessary. What I witnessed at Clínica, and while volunteering in the Himalayan foothills of India, is that primary care physicians are the true “jacks of all trades” — capable of providing a depth and breadth of care that is not demonstrated by specialists. Thanks for the article and I hope to see you at Clínica someday during my 4th year. — Dattesh Dave, pre-med student
No Greater Calling Thank you so much for your recent article, Dr. Hitzeman, in Sierra Sacramento Valley Medicine. As a family physician who has enjoyed this specialty for 20 years, I read it with great pride. For the right person, there is no greater calling than primary care. Thank you for engaging in clinical practice, teaching residents, and serving at Clinica Tepati. Because of people like you, family physicians will continue to quietly and with a profound sense of purpose provide high quality compassionate care for the lion’s share of our society. — John Chuck, M.D.
After 35 Years of Primary Care… Thanks to Dr. Hitzeman (for the recent
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article in the May/June issue of SSV Medicine on Primary Care) and for making my day better. I slogged home around 7, feeling lucky that I was the first one out of the building at Roseville I.M. The days after a holiday weekend are brutal, and one of the partners is away for three weeks to add to the “in-basket ball-and-chain” that never lets one go. After 35 years of this, you’d think I would stop looking forward to going in early the next day. No way! Every single patient visit today was a positive experience for me. I have known some of these people for over three decades, or took care of their parents or grandparents, siblings or children. There is nothing like it. New ones…add to the adventure, even though I keep telling myself I should learn to say “no” when asked about taking on another patient… I’m 66 now and when I finally retire, [I fear] there will be no one waiting in the wings to take on this marvelous mix of great individuals who have brought me indescribable joy. Perhaps that is why…primary care physicians work until the mind and body finally no longer can pull it off. It is a labor of love, looking for the medical answer and finding the person inside during the search. I feel sorry for those who do not experience those long term relationships;… patients who ask about my family or the garden or the bad shoulder are healing me as much as I am healing them. I would not trade my experiences for any glitzy specialty that would put me on a glossy page of Sacramento Magazine’s “Best Doctors” section. I prefer the company of the much larger group who eschew such limelight in favor of working in the trenches, uncovering rewards appreciated only by the inner circle. — David Sox, MD
Looking Forward to Primary Care I enjoyed reading Dr Hitzeman’s article in SSV Medicine. As a med student, I am surprised that these myths and stereotypes about primary care continue to exist within the medical field. And it’s very disappointing to hear that a medical student actually [expressed] these views... I am proud of going into the primary care field
to serve diverse populations. I look forward to taking care of different age groups, including entire families. I admire the family physicians’ ability to address a wide variety of medical conditions within any given day. I wish that fellow medical students (regardless of their specialty interest) can appreciate the vital role of primary care has in our healthcare system. Thank you for speaking up! —Tonantzin E. Rodriguez, MPH, MS III I’m a third year medical student at UC Davis. I enjoyed your article, Dr. Hitzeman, on primary care and the misconceptions of medical students surrounding the field. I started medical school without any strong feelings towards any specialty in particular, but with the idea in the back of my mind that I wanted to be in primary care. I’ve heard a lot of the discouraging stereotypes about family medicine and primary care, such as the lower income and prestige, etc. It was great to read your article and hear you debunk those myths and share your excitement and passion for primary care. Primary care/ family medicine is my 3rd rotation this year and I’m already excited to start! Many thanks, — Dan Holligan, MS III
Medical Ads, Libertarian Anguish Re Medical Quackertizing, Vol. 61 / No. 3 May/June 2010. The whole subject of advertising puts me often into a confused state of ambivalence and consternation, in particular where it relates to medicines and medical technologies/devices. I believe in caveat emptor (my libertarian soul showing) regarding expending monies of personal choice and regulation (unless there is harm to others or the environment) has no place in an adult and free society. But — and it is a big one — I have strong professional and personal concern for Americans and their continued and expanded capacity to access healthcare and healthcare insurance. Does both over the counter and prescriptive product’s advertising contribute to unaffordable healthcare? The answer is a definitely yes. Is it necessary for population education purposes?
Definitely not. Is it free enterprise? Definitely yes. Where is my libertarian soul now?. Americans spend as much on OTC drugs and medical paraphernalia as they do for prescriptive items (meaning drugs +DME) each year. This did not change for decades. What may surprise you is that the total spent (cost) out of pocket for all healthcare expenditures now exceeds the American family’s expenditures for entertainment starting in 2007. Pharma made more profit in CY 2005 than all health plans capitalization since 1944 to now — in one year!!!! And our profession is worried about for profit health plans’ profit!!! Go figure. Advertising for OTC drugs and items should be regulated for efficacy, especially for pharmaceuticals with a focus on quackery. Inform and educate Americans!... Once physicians began to examine their moral hazard, Pharma discovered the power of consumerism on physician prescribing habits and the media revealed this unholy alliance, most per physician expenditures were transferred to the more effective Direct to Consumer Advertising (DTCA). This advertising contributes to faux knowledge, consumer misinformation and patient expectations, and much to physician prescribing habits (sorry, but it is a fact). It is effective or $2.5–$4 billion (yes, “billion”) a year would not be spent this way — twice their research budget. Despite my soul, DTCA should be banned like tobacco, since it both depreciates the quality of medicine and adds tremendous unnecessary cost to the system which we can ill afford (not a pun). It also would reinforce the physician’s real accountability as a medical and medical fiscal advocate/advisor for their patients. At least remove it from TV, since in California 60+ percent of our population receive all of their medical information from TV — mostly cable CNN. More than 40 percent admit knowing absolutely nothing about PPACA (reform bills), yet know what short eye lashes are and what drug to suggest to their physician and not to mention ED. — Robert Forster, MD
Pharma made more profit in CY 2005 than all health plans capitalization since 1944 to now — in one year!!!!
Loa Loa — A West African Expatriate in California By Gordon Love, MD
The Loa loa microfilaria in blood demonstrate the space occupied by the unstained sheath (between arrows) as well as nuclei that extend to the base of the tail. These features help differentiate Loa loa from other microfilariae (Wright-giemsa stain, x400).
LOA LOA, A PARASITIC FILARIAL WORM, is known by many names, but the most evocative is “African eye worm” due to the proclivity of the adult worm to pass through the subconjuctiva. The blood specimen below came from a patient who had worked in Nigeria for several years. After moving to California, he noticed transitory skin swellings. When eosinophilia was found in his complete blood count, he advised his physician to test for Loa loa. The cover photograph presents a microfilaria of Loa loa that circulates in the blood. Typical forms measure about 250 μm in length. In this particular patient, several dozen organisms per blood smear were seen. Assuming five liters of blood volume in adults, the total load would be in the millions. Numbers vary and may be influenced by the diurnal circulation Loa loa demonstrates in blood. In spite of sometimes large numbers of microfilaria, most infections by Loa loa are without significant symptoms. Transitory swelling
due to angioedema — also known as Calabar swellings — may develop in extremities. Over long periods of time, masses of worms can accumulate in the lymphatics producing lymphedema. Eosinophilia is common but is not specific for loaiasis. Subconjunctival migration of the larger adult worm (up to 70 mm long) frequently occurs and usually does not diminish vision. Occasionally, the worm produces pain while passing across the bridge of the nose after exiting one eyeball before entering the other. Humans are the primary reservoir for Loa loa. Human disease is restricted to the rainforests areas of West Africa, including Cameroon and Nigeria. Estimates suggest over 10 million human Loa loa infections. Loa loa is transmitted by the bite of several species of infected flies of the Chrysops genus. Behavior studies show that these flies live in the rainforests but do their biting in open areas outside of the rainforest canopy. The flies may be attracted to smoke from wood fires and sense carbon dioxide to home in on humans. Loa loa larvae migrate into the subcutaneous tissue after a bite and mature into adults in about one year. Adult worms mate sexually and produce small microfilaria that circulate in the blood. Adult worms can live almost 20 years. Loa loa can be found in blood or cerebrospinal fluid. Concentration techniques may be helpful when small numbers of microfilaria are present. Diethylcarbamazine is often used to treat Loa loa, and care must be taken when treating patients with high loads of microfilaria to avoid encephalopathy. firstname.lastname@example.org
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Writing and Healing An interview with John Crandall of Sutterwriters.
By David Gunn, MS IV
June 3, 2010; 11 a.m. DG: Since 2003 you’ve been working every Tuesday evening with cancer survivors, caregivers, nurses, physicians and healthy writers, who are writing. Why do you meet? JC: It’s funny, a lot of folks come to write. But there’s something about telling your story that has some proven effects of healing; when I have my story heard by others it adds more healing, and when I hear other people’s story it adds a little more to my healing, too. John Pennebaker, whom I consider the father of “The American Writing is Healing Movement,” is the guy who pointed out the fact that we need to tell our story. It’s the community that’s important. Healing might be from a physical injury (arthritis, cancer), but it can also be from survivors of childhood trauma. The idea is that healing is not just physical, it’s spiritual and the process involves a community. DG: Where and when in your life were you first introduced to this topic, through Pennebaker, or...? JC: Actually, through Chuck Spann. He started Sutterwriters back in about 2000. It was his doctoral thesis. He brought that, and the AWA [Amherst Writers and Artists] training together. DG: How did you meet Chuck? JC: I met him at a cardiac disease group at Sutter (I had cardiac disease); every month we’d get together and talk as a group. He presented to the group on writing about our experience. DG: What year was that? JC: Around 2001. I started coming regularly to the groups here. My background is psychology, and I’ve used a similar group process in facilitating domestic violence rehabilitation.
When I first got here, I had to sit on my hands. We don’t do therapy here — it’s therapeutic, but we don’t do therapy. DG: How did you become interested in domestic violence? In your studies on psychology? JC: That’s what I focused my study of psychology on. I had a domestic violence agency from the mid to late 1980s, with over 300 clients. It was called the Western Institute of Therapeutic Studies. It was for perpetrators of DV, to rehabilitate them — give them tools to stop. I still have a small group on Monday nights, it’s so rewarding. DG: Do you notice any similarities between that group and the stories you hear at the Sutterwriters group? JC: The DV group stories are usually pretty intense. I don’t get that kind of intensity here, the content is a lot different — it’s all emotional, but a different type of intensity. While I understand a lot of how and why things happen to and with the DV folks, what is going on with them is not always spoken about; and I have to elicit sharing of their childhood abuse and other things that just aren’t talked about. DV is learned behavior. DG: What other types of learned behaviors do new writers exhibit? JC: I hang my hat on Bandura’s social learning theory. It’s basically that we learn what we do through a social context. Dad has a role, Mom has a role, and sometimes we get stuck in those roles. It’s good that I can be the hero child, or the jokester, but if that’s the only way that I can approach the world, then I have some issues. DG: This goes to the codependency and
Adult Children of Alcoholics model. JC: I like his methods. I apply them to the group in that people come in and proceed through a mono-curriculum, and then they go at it again, and the curriculum just repeats. What’s nice about that is you’ve got a guy whose really resistant and afraid, and the facilitator approaches him and shuts him down and they’ve got some negative transference. But if another client, whose been here a while, says something, it’s a lot more positive. So as a therapist you don’t have to work as hard, and a lot more work happens. So you get the person who says, ”I could never write like that person.” Well, the reality is the other person who wrote something so inspiring was saying the same thing last week about someone else’s work. And you get people who’ve been around a while who take other people under their wing, just like the domestic violence unit. You start off the new kid, then you’re the old dog. It happens here as well. DG: It’s so interesting to me that you mention the different reactions a participant would take given a piece of advice that would come from a facilitator or a co-participant. It sounds just like the chronic disease model that’s used with diabetes, asthma or heart failure. What do you make of that? JC: One of my “things” about therapy and this group is that I have an egalitarian approach to things. I’m not an authority. I’m here to serve you, I have different information that I can offer you. It might be my job to keep the group safe, but it doesn’t mean I’m better than you are. That seems to slip in past a lot of resistance. The nice thing about writing is I don’t have to worry about resistance to me so much as it’s more resistance to their own selves. My job is to help them find their own voice here. DG: Who would want to come to this? Who would not want to come? JC: Some people don’t come here because it’s in the hospital. Sometimes the healing part turns people off. It’s a hard one to talk about for some people. We’re also doing this at UCD Extension, the art of self-expression. But we don’t use ‘healing’, per se, because it’s a turn off.
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DG: What about for the folks who are toying around at home, who have been meaning to start writing. JC: That’s one of the reasons I started facilitating, because I had a group of people I was accountable to, so I had to write. There are some people who have said to me, ”You know, I’ve written more here in the past 8 weeks than I have in the past 8 years.” DG: Do you think it’s inertia, or an inability to express themselves? JC: Inability to express, I think, and that self-critical voice, of this is bad, this is good. We don’t talk about what’s wrong here. They’re all beautiful babies — even if they have a wart, it’s still a beautiful baby. DG: So what’s the format, exactly? JC: We meet for two hours on Tuesday [but there are groups most every day of the week, see sutterwriters.com], from 6:30–8:30 p.m. in the 6th floor Cancer Center Library at 2800 L St. We start off the night with a prompt, and we write for 30 minutes or so to that prompt — or you can write on whatever you want to. That’s the great thing: there are no rules. You can write to the prompt or not. The one hard and fast rule is everyone writes. No one has to read or share, but everyone has to write. We even have the notebooks and pencils. It’s pretty easy for people to show up. We also have workshops for people who want a little more of a critically supportive atmosphere. Those go for 8 weeks or so, and are held here and there. More info on that is on the sutterwriters.com website. Not all of the groups are free, I should say; most are low-cost ($5-$10). This one on Tuesday, though, is free. DG: Favorite thing about Sacramento? JC: [laughs] Yeah, there’s no snow! I’m from Michigan. It’s a nice small town. DG: One of the more memorable stories you’ve heard in your time here? JC: Every night there’s a new one. Last night there was an OB nurse who wrote about how she was doing everything that she does, and realizes that the child is dead. And at some point the mother realizes it, too. It was a tear jerker.
That kind of thing happens almost every time. That kind of powerful story that really touches you. Every night. I keep saying that I’d love to collect all of these stories that I hear. We did put together a collection of ”Blood on the Page,” a collection of some Sutterwriters. Sometimes when I have a group and things are going well, I’ll collect a few stories from the group into a little book. DG: Most common misperception you hear from new writers, outside of I’m not a writer? JC: I can’t do that. I can never be as good as that. Then next week someone will be saying the same thing about them. We’ve all got a story to tell. DG: Does that mean we’re all brilliant writers?! [laughs] JC: Well, we’re inhibited by what we grew up with. Like the exercise in school, ”Tell me about
your summer vacation,” and you get your paper back and it’s all marked up. Capitalize this, this and that’s wrong and you walk away learning not to write. So because you got a C minus on the paper, you think your vacation was a C minus, your grandparents were a C minus. We’re fighting that all the time. It would be such a different world if we took this AWA method around the world, without the criticism, without trying to one-up each other. email@example.com firstname.lastname@example.org http://www.sutterwriters.com/index.html 916-708-9708 Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSVMedicine@gmail.com
Voices of Medicine A review of various local and regional medical journals.
By Del Meyer, MD
Learning from Our Errors
Maybe the best place to train anesthesia residents isn’t the one with the top surgeons or the most dedicated teaching anesthesiologists.
Karen S. Sibert, MD, the Associate Editor of the CSA Bulletin wonders in the Spring, 2010 issue about “When is the best time for mistakes?” Back in the 1990s, my husband and I spent a year working at one of the largest hospitals in West Virginia. The patients were the nicest people in the world, and the hospital staff was terrific — kind, generous, and hard working. Some of the surgeons were excellent, but others definitely were not. My husband (a cardiac anesthesiologist) and I had to cope with surgical complications the likes of which we had never seen before. Patients walked into the hospital for elective aortic aneurysm repair and left in a hearse because the surgeon could not get the aorta back into one piece. I particularly remember watching the geyser of blood that erupted one day when a surgeon sliced open the right ventricle during what was supposed to be a simple mediastinal debridement. Steve and I thought we were capable anesthesiologists when we arrived in West Virginia, but we were better by the time we left. Maybe the best place to train anesthesia residents isn’t the one with the top surgeons or the most dedicated teaching anesthesiologists. If surgeons are skillful and supervise their residents closely, the anesthesiologist won’t face surgical disaster often and may be unaccustomed to dealing with it. Likewise, if attending anesthesiologists guide their residents’ hands at every opportunity, anesthetic missteps will be rare. That may not be a blessing for the anesthesia resident who should learn how to manage both surgical and anesthetic mayhem. If you’re in private practice and don’t work
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with residents, you may not realize just how much pressure there is today to watch the resident’s every move during a case. We’re compelled to chart our presence at the preoperative assessment, induction, line placement, emergence, and any “critical event.” Many of us whip out the fiberoptic bronchoscope at the first whiff of a problem airway rather than let the resident have another try. Attending surgeons rarely leave their residents alone in the operating room except to close skin. To do otherwise could be interpreted as poor quality care. Certainly I don’t want a resident to make every mistake I’ve made; it’s better to learn some things by hearing tales of horror than by living them. That is the point of a good “morbidity and mortality” conference. But we had far less supervision as residents years ago, and nothing focuses the mind better than the need to fix a mess of one’s own making… Today’s arbitrary restriction of “duty hours” worries me too. In case you haven’t heard, there is a limit of 80 hours a week for the residents of any specialty to be in the hospital, and that may soon drop to 60 hours. This includes night call hours when they may be asleep. Surgical residents now break scrub abruptly in the middle of a case, like Cinderella when the clock strikes twelve, lest they overstay their legal time limit. If they work up a patient at night in the ER, they can’t scrub in on that patient’s surgery the next day. Anesthesia residents rarely interview their inpatients the night before surgery. The concept of continuity of care, or taking ownership of one’s patients, apparently has gone for good… For the first time, we’re starting to see residents graduate, go into practice, and then come back to do fellowships
because they realize how much they didn’t know. One private anesthesia practice near Los Angeles no longer hires anyone directly out of residency because they have found new graduates unable to function independently. The question I have for the talking heads who make the residency rules is this: Is it better to make decisions and face the consequences when you’re a resident, or to make all your mistakes later when there may be no one around to help you? The entire article can be read online at www. csahq.org/pdf/bulletin/sibert_59_2.pdf
Politics and Medicine Philip R. Alper, MD, discusses “The Obama Health Act and the Further Politicization of Medicine” in the April issue of the Bulletin of the San Mateo County Medical Association. Ever since the enactment of Medicare in 1965, government and politics have become major forces in reshaping American medicine. Only a handful of physicians have been able to avoid the rules, regulations, blandishments and threats of the Medicare program. These are now administered by CMS, the Center for Medicare and Medicaid Services. Some 25 years after the debut of Medicare, physicians discovered that while Hilary Clinton’s health initiative went down to defeat, its section on physician fraud and abuse lived on. It was adopted in its entirety by Medicare as administrative law, which is just as binding as legislative law. Many of the provisions are so Draconian that they appear not to have been enforced. Which is, more or less, how the interaction of law and politics works as usual. If this leaves physicians unsure where they stand, everyone seems to have learned to live with it. Next we come to President Obama’s 2010 Patient Protection and Affordable Health Care Act. Like Hilary Clinton’s bill, it contains some measures that physicians generally support, but the overall structure is similarly legalistic, complicated and unwieldy. (It is 1,000 pages longer than Hilary’s bill.) The new law offers many job opportunities in the more than 120 health care agencies that it creates. It also invites the Internal Revenue Service to participate. One
would have to ignore all past experience to believe that such an expanded corps of regulators will have a benign impact on physicians… Clearly, the new law attempts to be supportive of primary care. The devil, however, remains in the details. For example, a bonus of 10% is awarded to primary physicians. But it is only for five years and it only applies if 60% of services to Medicare patients are “primary care services.” How will these ultimately be defined? Who can predict or depend upon a bonus that is statistical and opaque in the course of practice? Will this and similar measures entice young physicians into careers in primary care? My guess is that the horse-trading and outright bribery that were so prominent in Congress during the creation of the legislation will not work in enhancing primary care. Nor are new primary physicians likely to be very popular with their specialist colleagues who will be squeezed by the promise of $500 billion dollars in savings from the Medicare program and who will then see primary physicians as not sharing their pain. Whatever shred of collegiality that is left after nearly three decades of managed care will further unravel. The new law also promotes large group practice with cash incentives that small group or individual physicians cannot hope to obtain because of their limited ability to comply with the complex regulations governing statistical assessments of their practice activities. Furthermore, only a minority of practicing physicians are in large group practices and since government seems to favor this mode, the majority of physicians may be disadvantaged in future payment schemes. All physicians will be affected in one way or another and it is impossible to predict all the ramifications of the Obama health bill. Nevertheless, the thrust remains an increase in documentation and greater standardization of care in the service of “best practices.”… Read the entire article by Dr. Alper at www. smcma.org/bulletin/issues/April2010.pdf
Clearly, the new law attempts to be supportive of primary care. The devil, however, remains in the details.
In the Same Boat This is the runner-up article in this year’s student essay contest.
By Linda Tsan The author is a junior at Florin High School, in Sacramento County. She is the president of her school’s MESA and Science Olympiad. She hopes to study the biological and physical sciences at UCLA. She enjoys playing tennis and volunteering as a 4-H Youth Experiences in Science teen teacher. “Treat others as we would wish to be treated ourselves” is the Ethics of Reciprocity, or the Golden Rule that has been emphasized throughout the world. It is the premise on which democratic governments state their human rights. The Universal Declaration of Human Rights, adopted by the United Nations, includes many basic moral obligations such as the right to a nationality, a fair and public hearing, and property, but most importantly, in Article 25, “the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” In sum, every person has a right to live a healthy life, but there can be unprecedented situations that prevent one from having this privilege. Some of these situations can be compensated for with the help of society. Thus, each person’s health should be a combination of individual and collective responsibility. In general, most people do not want to be ill. They are not asking for a virus to invade and replicate within them or for a car accident. They cannot help it that they are born with commonly inherited diseases such as Huntington’s, cystic fibrosis, or mental disorders. The point is that there are various ways in which someone’s life can be unexpectedly 18
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impeded by their health. According to the Center for Disease Control and Prevention, about 43 million people in the United States in 2008 were uninsured. A study done at Harvard Medical School and Cambridge Health Alliance suggests that 45,000 of these people die each year solely because they lack health insurance. In other words, the price of their lives is out of their price range. It is evident that money is a factor in having a salutary life and it is unfortunate for those who cannot afford it given their circumstances. It can be somewhat unfair for people at the very start of their lives to be born into unhealthy conditions or poverty. Chances are if they are hindered by another obstacle thrown at them such as an illness and further medical costs, then they will not recuperate from the impact. Society is only as good as the people who make it up. If this part of our society doesn’t get the care they deserve as human beings, then that speaks lowly of us as a whole. As a group, it should be part of our responsibilities and moral obligations to ensure that these individuals are helped. Life is what it is, but that doesn’t mean it can’t be changed. Of course, a person should be responsible for their own health as well. People cannot expect to receive help to better their health if they are unwilling to prove they actually want it. One of the most convincing ways to prove this is to take care of their bodies. There are plenty of ways to maintain or improve health of individuals. They can get a good night’s sleep, stretch when they wake up from sleeping, eat breakfast every morning, and exercise for an hour a day. It is only fair that people at least contribute by learning about healthy living and eating and then apply some
of these concepts to their daily lives. As a group, people cannot not only push the idea of having a healthier lifestyle, but also put emphasis on how people can do it easily and efficiently perhaps through a tip a day on television and radio or in schools. As individuals, people can then assume their duty by listening and following through. In the end, each person’s health should be the product of individual effort as well as a group following through on their responsibilities. All in all, it is unfair for such an immense, unpredictable part of our lives to rely restrictively on either the responsibility of ourselves as an individual or the responsibility of everyone.
There must be a proper balance, a combination of the efforts of both sides to guarantee the basic right of living in good health. It is a given that everyone is born into responsibility for their health, but as a society, we also have an influence over their well being and it matters that we try to assume our responsibility even if the results seem insignificant. When a person needs treatment and can barely afford medications, let us reflect back on the Golden Rule. Let us ask ourselves, if that was the case for us, would we want to be placed in that situation? email@example.com
Board Member Statement and Profile Anthony W. Russell, MD University of South Carolina Medical School Pediatrics SSVMS Representative for District 5, TPMG CMA Alternate-Delegate Why do I serve on the Board? To be an advocate for my patients and colleagues. Please contact me by email at: firstname.lastname@example.org I grew up along the East Coast from Florida to Connecticut, but primarily in South Carolina. I have always been interested in caring for people, so it was natural for me to pursue the practice of medicine. I completed a Masters in Public Health with a focus on vaccines, health policy, and managing health service organizations at Johns Hopkins, and a pediatric residency in California. I feel blessed to have a wonderful family with an 8-year-old daughter. I practice general pediatrics and travel medicine, and am certified in Medical Quality (CMQ) by the American Board of Medical Quality; and I’ve worked on projects to improve physician efficiencies utilizing quality improvement tools. Involvement in organized medicine has provided me the opportunity to advocate for my patients and colleagues, and to work in areas that I am passionate about including healthcare policy, immunizations, politics, quality improvement, and health care innovation. I am a member of the Public Health Advisory Board to the Sacramento County Board of Supervisors, and the Preventive Action Committee for Sacramento County Child Death Review Team. I’ve worked on the California Immunization Coalition (CIC) advocacy and legislative committee and the Northern California Partnership for Influenza Prevention (NCPIP). I feel very satisfied with all that I have accomplished through my work in organized medicine.
Physician Invictus From heroin addict to addiction physician.
By Don Kurth, MD
“We’ve got a pulse and he is starting to breathe on his own. I think he might be OK!”
This article is reprinted from the June 2010 issue of San Francisco Medicine. April 5, 1969. The red and white ambulance races through the early morning hours of the dark North Jersey night. Sirens are screaming and red lights are flashing, casting revolving shadows against the trees and houses as the medics race through the darkened suburban neighborhoods. The rain has just stopped falling and a hazy mist rises from the black pavement. In the back of the ambulance lies a young man, barely out of his teens. His lips are blue and his skin is pale gray, but the paramedics continue to pump on his chest and force oxygen into his lungs with the plastic face mask and ambu bag. Bloody vomit drips out of the mask and down his cheek. There are no signs of life, no respirations, no pulse. His dark blood is filled with drugs and alcohol and his lungs are filled with vomit and beer. Behind the ambulance the young man’s parents are following, trying to keep up with the racing van. Neither speaks. They are remembering all the hopes and dreams they had had for their firstborn, their only son. His mom thinks about when she dropped him off for his first day of kindergarten, when he cried and called for his mother not to leave him. His dad remembers the first time his boy caught a trout by himself and how proud he was of his son and the photos they took of the speckled fish before they slipped him back into the creek. They both remember their dreams of college and a profession for their son, and maybe grandchildren of their own someday. And another round of siren screams fills the night air as they race to follow the ambulance through the night.
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Finally they arrive at the hospital and their son is whisked into the treatment area, the paramedics still trying to pump life back into his dying body. The parents park to the side and are directed to the reception clerk to fill out the forms and paperwork. Then they are asked to take a seat and wait. As they sit, silent in the empty waiting area, neither speaks; neither lifts their eyes to look at the other; each is lost in private thoughts. Quietly both pray to their own God, isolated in their grief over the loss of their son, wondering if they should have done something differently, wishing they could do something more now. Finally, the young ER doctor walks through the swinging double doors from the treatment area, looks around the waiting room, and walks toward the grieving pair. “I am so sorry,” he says slowly, deliberately. “I don’t think he is going to make it. He was dead by the time he arrived. There just wasn’t anything more we could do. He didn’t have oxygen to his brain. I am sorry.” The doctor feels the grip of both sets of eyes on his own. He feels the sorrow of their loss in his own heart. Then, after a quick moment, he turns on his heel and hurries back through the double doors into the treatment area of the emergency room. An agonizing twenty more minutes pass before he returns with a different look on his face. “I think he is going to make it!” he exclaims. “We’ve got a pulse and he is starting to breathe on his own. I think he might be OK!” That young man was me, and I did not die of that overdose in 1969. But I was not done yet, either. I still had more overdoses to survive and jails to visit. And I still had to stumble my
way into drug rehab and have a chance to turn my life around. On August 12, 1969 — three days before Woodstock — I slammed my last speedball just before the police surrounded my parent’s home and a new phase of my life began. Later that year I entered drug treatment at Daytop Village in New York and started to get my life back on track. I had already flunked out of college twice by the time I overdosed in 1969. In fact, I had actually achieved a perfect GPA at my first college — 0.00. I had split for California to visit the Haight and neglected to inform my registrar that I might not be returning to complete my final exams. Apparently, my professors were not listening as intently as I was to the “Turn on, tune in, and drop out,” call of Dr. Timothy Leary. They failed to recognize the value of my desire to join in the “Summer of Love” and manifested their misunderstanding by awarding me F’s in every single class. But by the summer of 1972, I had completed drug rehab and begged my way back into college. Without drugs in my bloodstream, my grades improved dramatically and by 1975 I had snagged an academic scholarship to Columbia University in New York City. I worked as a gardener to pay for my living expenses and scrimped every penny I could. I couldn’t afford a car, so I bought a used Suzuki motorcycle to get around. I managed to save $200 over my next month’s rent, so I bought a chain saw and a hundred feet of rope and became a tree cutter. After each hurricane or blizzard, I would tie the chain saw and rope to the back of my motorcycle and ride around looking for fallen trees to cut. There was always somebody who needed my help, and eventually I found a partner and bought a pickup truck to expand the business. It was hard work, but I enjoyed what I did and made enough money to get through school. I eventually graduated, Phi Beta Kappa and cum laude, and went on to medical school at Columbia. I had to work hard to get good grades. I had a lot of remedial work to do just to catch up with the other students. And I had to make the
sacrifices that we all have had to make to dedicate our lives to medicine and patient care. I trained at Hopkins and UCLA and found myself seduced by the California sunshine. I opened an urgent care practice in Rancho Cucamonga, California. But I have always had a soft spot in my heart for those who suffer from addictive disease, and eventually I found myself on the faculty of Loma Linda University, where I have run the addiction treatment program since the mid-nineties. I got involved with the Rancho Cucamonga Chamber of Commerce, really just to get to know people in my community and to build up my own practice. The more I got involved, though, the more I began to realize the importance of being involved on a political level. It became more and more clear to me that many of the challenges we face, not just in addiction medicine but throughout medicine, are challenges that can only be met on a public policy level. Scope of practice, corporate bar, and MICRA are all issues that must be defended on a public policy level. But our political responsibility as physicians goes far beyond that. Who but physicians can better fight the battle to ensure greater access to care for our patients? Who but physicians can articulate the importance of our physician-patient relationship remaining unfettered by burdensome government interference and regulations? If we cannot or will not advocate for ourselves, who do we expect to speak for us? The questions we must ask ourselves are these: If not us, then who? If not now, then when? As in the poem “Invictus,” by William Ernest Henley, we must be the masters of our fates; we must be the captains of our souls. I suppose my career path has been one of unlikely twists and turns. But believe me, I did not plan it this way. Following my chamber involvement I was elected to the local water district board. After eight years of elected office, I moved on to the city council in Rancho Cucamonga (population 180,000) and was then elected mayor in 2006. Concurrently though, as my skills have sharpened in this world of public policy, I have done my best to pull my physi-
The questions we must ask ourselves are these: If not us, then who? If not now, then when?
As physicians, our challenges for the future are the realm of public policy.
cian colleagues along with me, and together we have achieved some degree of success. I helped create our Addiction Treatment Legislative Days, first in California and then in Washington, D.C. Working together, we greatly improved access to care and our Addiction Treatment Parity Bill was signed into law by then-President George Bush on October 5, 2008. Greater access to medical care for those suffering from addiction is now the law of the land in the United States of America. I was honored by my colleagues to be elected president of the California Society of Addiction Medicine and now serve as presidentelect of the American Society of Addiction Medicine. But my work has really just begun. The greatest frontiers of medicine are not in research or clinical skills, as important as both of these areas are. As physicians, our challenges for the future are the realm of public policy. And we must be a part of shaping that future, or some-
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body else will do it for us. If we do not make it our business to participate in the process, we may find that we do not like the final result. And remember, whatever happens at the federal level will still have to be implemented in each state. Toward the goal of sensible health care policy, I am currently running for the California State Assembly from the 63rd Assembly District. Come join me on the road to a better tomorrow for ourselves and for our patients. Donald J. Kurth, MD, MBA, MPA, FASAM, is an associate professor at Loma Linda University and president-elect of the American Society of Addiction Medicine. He is also mayor of the City of Rancho Cucamonga, California: in June 2010, he placed third in the Republican primary for the 63rd Assembly District seat. This article originally appeared in San Francisco Medicine, the official publication of the San Francisco Medical Society. To learn more, visit www.sfms.org.
An Afternoon in Africa Kukata, Kuponya, Kuomba: to Cut, to Heal, to Pray
By Andrew H. Huang, MD The author took a year off from his general surgery residency to work with expatriate missionaries and Kenyan doctors in Kapsowar, Kenya. He is currently a resident at UC Davis Medical Center. I stayed out of the operating room all afternoon, just trying to keep my head afloat with all the surgical outpatients. I was stretching thin the short limits of my orthopedic knowledge base. There was a supracondylar humerus fracture, a greenstick both bones forearm fracture, a tibial plateau fracture, a shoulder dislocation... As the last patient walked out the door, I collapsed into the single chair in the changing room adjacent to the OR. John, one of the nurses, opened the door from the OR and beckoned me. “They need you in theatre.” I knew that Kibet, the Kenyan medical officer, had been doing a Caesarian section. Despite having even less graduate medical education than I did, Kibet was infinitely more knowledgeable and capable of practicing medicine (including obstetrics) in Africa — a result of his upbringing and education in the East African country. I got up, put on my cap and mask, and walked into the main (and only) OR. Matthew, the capable Kenyan nurse anesthetist, was looking concernedly at the monitor. The patient’s uterus was delivered onto the abdomen, and Kibet was placing large chromic gut sutures onto the posterior wall of the uterus. “Hey, guys. What’s up?” I asked, trying to sound cool and confident. “Bleeding,” Kibet said in his usual taciturn fashion. “She bled after the placenta came out. Can’t stop.” “How long has this been going on?”
“An hour.” “You want me to scrub?” “Yes.” I walked to the sink and started washing my hands with the bar soap that was perpetually next to the faucet. I gowned and gloved and then stood opposite Kibet. Kibet took his hands off of the uterus, and immediately a rush of blood poured forth from the endometrial wall, a dreadful torrent of arterial and venous pumping vessels. Kibet quickly packed the inside of the uterus again with laparotomy pads, which were soaked within a few seconds. I looked at the patient monitor. The pulse was in the 150s and the systolic blood pressure was in the 60s. Matthew had begun transfusing the patient. I took a deep breath and tried to think aloud. “OK. Alright. Let’s see. The way I see it, we have three options. We can close the uterus incision and hope that the uterus will contract down and the bleeding will stop. Or we can tie off the internal iliac arteries bilaterally. Or we can do a hysterectomy.” “Yah, yah, let’s do that,” Kibet said. “Do what?” “Internal iliac.” “Uh, OK. Alright, let’s go for that.” I looked at Matthew for affirmation. He nodded, but his eyes flickered toward the monitor. The blood pressure was still dropping. The scrub nurse provided me with the best instruments she had: a dull Metzenbaum scissors and a long packing forceps. It occurred to me that I had never tied off the internal iliac artery before. In fact, although I had watched it a couple time as a resident, I
He hesitated. “Sawa. OK. If it is her life, then it is her life. Do what you must do.”
had never before personally dissected out the iliac vessels through a laparotomy incision. I hesitated for a minute, then picked up the peritoneum and started cutting, attempting to find any tubular structure that resembled the internal iliac artery. With only a Balfour retractor and a large bleeding uterus, blood quickly filled up the operative field, making visualization of any anatomy nearly impossible. Finally, after what seemed like an eternity, I stopped and placed my hand on the uterus. “Guys, this isn’t working. I can’t see anything. She’s losing too much blood. I’m not going to be able to tie off the internal iliac.” It was quiet. “I think we need to do a hysterectomy.” “I gave her some ketamine,” Matthew said, indicating that the patient was unconscious. “Perhaps we should call in the husband.” “Yes, let’s do that.” The husband appeared at the theatre doorway a minute later. He was dressed in jeans and a polo shirt — the sort of thing that a welleducated, English-speaking Kenyan wears. “Sir, I need to tell you — there is bleeding. There is a lot of bleeding. Your wife is very sick. Her blood pressure is very low. If we do not stop the bleeding, she will die.” “Oh!” “We have to stop the bleeding. We have tried everything possible, but we cannot stop it. The only thing I can think of to do now is to remove the uterus, do a hysterectomy. If we take out her uterus, she will never be able to have children again. Umeelewa? Do you understand?” “Yes, I understand.” “Ni sawa? Is this OK?” “There is no other way?” “I am so sorry, sir. I cannot think of any other way.” “She will die if you don’t do this?” “Yes.” He hesitated. “Sawa. OK. If it is her life, then it is her life. Do what you must do.” The husband left the room. I looked up at the theatre staff. “Are we all in agreement? This patient needs a hysterectomy.”
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Matthew didn’t hesitate. “Yes. Go. Now.” Kibet nodded his head. I pursued my lips under my mask. “OK then. Give me two clamps and lots of ties.” The uterus is not a terribly complex organ, and I knew the basic rules for getting it out: tie off the vessels feeding it; don’t bag the ureter; no need to chase the cervix. However, the technical aspects of a hysterectomy were a little fuzzy in my head. Did I want to preserve the ovaries? How do I do that? Where do I incise the broad ligament? Where do I find the uterine vessels? How do I feel the cervix if it is completely dilated? What do I dissect bluntly? What do I dissect sharply? I looked over the drapes to the monitor. Matthew was transfusing a second unit of blood. Her blood pressure was better, around 70. “Hey, Matthew, how old is she?” “Twenty-two,” Matthew murmured. “Oh! Young. So we want to probably keep her ovaries. I’ll try to do that. If I can figure out how to do that.” Slowly, Kibet and I made our way from the ovarian vessels down the broad ligament and to the peritoneal reflection. I asked Kibet, “What happened to the baby? You got the baby out before I came in?” Kibet responded, “Yeah, but it was intrauterine fetal demise.” “Oh! Oh, no, I didn’t realize that.” “Yes,” he said coolly. “Did she know that coming into the case?” “Yes.” “Oh, that’s sad! Doubly so.” “Yes.” “Does she have other children?” “No. She’s G1.” “G1? This was her first pregnancy?!” “Yes.” “And we’re taking out her uterus?” “Yes.” The gravity of the situation hit me hard. I was condemning the woman to a barren life — a modern-day African curse. We progressed slowly. It was dark outside.
Every once in a while, I would glance at the clock, knowing that a good surgeon could easily do a hysterectomy in 60 to 90 minutes. After an hour, we hadn’t even finished one side of the hysterectomy. Eventually, we came down to what I thought was the cervix. “I need two big clamps. The absolute biggest clamps you have.” The scrub nurse handed me two long, fiercelooking hemostats. I clamped just above the cervix then used a scalpel to cut the uterus out out. I checked the monitor. Matthew was infusing the third unit of blood. The blood pressure had improved to the low 100s. After oversewing the vaginal cuff a couple times, the bleeding finally and completely stopped. By the time we moved the patient to the gurney, it was 9 p.m. We had been operating for four hours. I found the patient’s husband outside the theatre building, surrounded by multiple family members. I brought him into the building and sat him in the chair that I myself had collapsed into earlier that evening. “Sir, your wife is alive. We took out her uterus. She is stable now. However, we’re not out of the woods yet. She is still very sick, and very likely to have complications. Her life is still in danger. The next 24 to 48 hours are critical. If she recovers, she’ll probably be here in the hospital for a couple weeks.” I let the words hang in the air, wondering if he knew what sort of complications she could have. Probably not. He probably had no idea — ileus, obstruction, abscess, cuff leak, fistula... Complications. It was a simple term, but it weighed heavily on me. They weren’t just any complications. They were my complications. Mine and mine alone. I wish I actually knew how to do hysterectomies. If only I had seen more of them, or done one in a postpartum patient. Should I have used Vicryl instead of chromic? Should I have excised the bleeding ovary instead of oversewing it? Should I have tee’d off the Pfannenstiel incision? Everyone in the room began speaking in rapid Kiswahili. I looked to Matthew for translation.
“They say, it is better not to tell her yet what happened, but first let her recover, and then, later, when she is better, you will tell her with the husband and mother and chaplain.” I nodded in acknowledgment, knowing that such issues as informed consent and autonomy were not the dominant ethical principles in Africa. It was surprisingly uncommon for patients here to sign a surgical consent themselves. More often it was the father, husband, or eldest son who signed, depending on the age of the patient. The next day I went to the maternity ward. Betsy was lying in Bed 5. She was surrounded by five mothers with their newborn babies. “Habari yako, Betsy?” How are you? “Nzuri.” Fine. “Unasikia uchungu?” Are you feeling pain? “Tumbo, lakini kidogo.” My tummy, but just a little. For whatever reason — a miraculous intervention of Providence, most likely, since I can safely say it wasn’t my technical expertise — Betsy did amazingly well postoperatively. By the fourth day after the operation, she was eating a regular diet and walking around unassisted. By the fifth day, she was asking if she could go home. I caught Naomi, one of the maternity nurses in the hallway. “Naomi, uh, when are we going to break the news to Betsy?” “Oh, yes. It should be done.” “Yeah, it needs to be done. But when? How?” Naomi, usually very confident and selfassured, looked uncharacteristically perplexed. “I think when the husband is here, and we can call chaplain.” About a half-hour later, the husband arrived. I accompanied Betsy, her husband, and a gaggle of other family members and hospital workers into a back room. “Betsy, I need to tell you something. The operation you had. It was a very big operation. Much bigger than you realize. There was a lot of bleeding. You lost so much blood, you almost died.”
Complications. It was a simple term, but it weighed heavily on me. They weren’t just any complications. They were my complications.
The nurse translated my words, and Betsy’s eyes got wider and wider. “Kabisa?” she cried. Completely? The nurse nodded. Betsy screamed and collapsed onto the bed. She wailed loudly. The thin doors of the back room could not shield her distress, and the mothers in the maternity ward all became very quiet. The women attending Betsy immediately came around to comfort her, trying their best to soothe her in Kiswahili. Betsy continued to cry and wail until finally, awhile later, she stopped and lied in bed with a glazed look in her eyes. Everyone stood around her. The men, even her husband, seemed uncomfortable. Nothing was said for ten minutes. Betsy looked defeated. Finally, after I couldn’t stand it any longer, I broke the silence. “Betsy, would it be OK if I prayed for you?” Betsy’s sister translated, and Betsy respectfully sat up in bed and dutifully bowed her
head. “Father in heaven, we thank you for the life of Betsy. We thank you that you chose to preserve it, to save it. We do not understand why things happened the way they did, but we know and trust that you work things together for the good of those who love you. Please, Father, help us in our love for you. Let us find good even in the midst of this sadness. Please bring to Betsy a peace and comfort that cannot be provided by any other means. For we know we have little to offer, but we also know that you can bring that peace and comfort, even in this time of trouble. Thank you for Betsy’s fast recovery, and we ask that you reveal your purpose for her life that you have chosen to save. In Christ’s name, amen.” email@example.com Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSVMedicine@gmail.com
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Trevor Austin Kott — Oct '06 - Apr '07. Still inspiring people to give hope to patients in need.
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A Posit on Peer Review “Upon formal request of a member, the CMA should provide external, timely and independent peer review of any aspect of medical care at the member’s local hospital.”
Background: AB 1235 (Hayashi) is a CMA-sponsored bill providing that the current peer review system be strengthened because improper or biased review can be used to remove physicians for non-quality of care concerns, or peer review can be delayed until patients are endangered by the inability to promptly prevent a physician from providing substandard care. Among 70 member responses, 62 agreed, 8 disagreed. Commentary follows; the first comment is by the originator of this posit. A physician and medical staff should be granted the right to an external peer review process. Reasonable provision for the cost should be developed through appropriate means. The reason is that a peer review hearing pursuant to a pending or proposed disciplinary action can ruin a physician’s career or can result in a lawsuit against the hospital and medical staff. To protect both parties, the matter should be referred upon request by either party to an external service with sophisticated and unbiased ability to provide peer review. State law should also compel a reporting body to retract an unfavorable report to the national practitioner data bank when investigation so determines. The HOD can do this without any legislation or permission from the Legislature, the Governor, or anyone else. CMA can do it, just as any private entity can, by setting up the service. Then the hospitals, physicians, or their medical staffs can decide whether to use it, and pay for it. The hospital bylaws can be changed where needed, but no legislation is required. Physicians at each hospital are in charge of their self-governance, so the Legislature need not be involved. On the other hand, for some
disenfranchised staff members to compel a medical staff to provide outside peer review as a right to any staff member on request would likely require legislation. At least this is how I see it. Under proposed law AB 1235, a peer review body is (only) encouraged to obtain external peer review. See http://www. leginfo.ca.gov/pub/09-10/bill/asm/ab_1201-1250/ ab_1235_bill_20100216_amended_sen_v93.html — Gerald N. Rogan, MD It would be nice to have it as law. SSVMS does offer independent reviews of accusations brought by MBC against physicians. We have done five or so, and none in recent history. I set this up through a signed statement by the accused physician. The case is brought to us with the physician’s consent and by his attorney, therefore protected by attorney client privilege. Our decision is final and the attorney is free to use it or not. The attorneys didn’t like it too much! — Bill Sandberg, Director, SSVMS I think it is important to have an external source of peer review for any time when a physician feels there may be a conflict of interest within their own organization. Many communities or hospitals are too small or closely knit to do unbiased peer review. Often, there is not another physician with the needed expertise to do fair review. Having the body of physicians that the CMA represents as potential peer reviewers provides a much larger pool in which to find physicians with the needed expertise. It would then be incumbent on CMA to do this promptly and in a manner that is fair to all parties. — Joanne Berkowitz, MD Peer review is good in theory but in-house review is always subject to bias. (Just think of the closed door RUC that sets the skewed RVU values for physician compensation!) While rare
I think it is important to have an external source of peer review for any time when a physician feels there may be a conflict of interest within their own organization.
Physicians are like everyone else when it comes to personality conflicts! Furthermore, in-house peer review is largely window dressing without much real impact.
that I think you would need to get the CMA involved, it would be nice to have recourse if someone on your local hospital peer review has it in for you! Physicians are like everyone else when it comes to personality conflicts! Furthermore, in-house peer review is largely window dressing without much real impact. An article by Edwards MT and Benjamin EM in the October 2009 issue of Journal of Clinical Outcomes Management gives results of a nationwide survey on how different hospitals do their peer review. Not surprisingly, there is lots of variation in the scales used to evaluate peers. Most hospitals do not have adequate administrative staff to assist in peer review, often review too few cases to make a difference (<1% of admissions), and few acknowledge excellence (21%) and instead focus more on whether care was “appropriate” or not. — Nate Hitzeman, MD I would change the wording a bit: the word “should” amended to “may, if called upon,” — because all hospitals have their own peer review boards and do not need the CMA interfering with the process. But if called upon for assistance, it is a great source and opportunity for an organized body of physicians to muster up individuals from any specialty to opine, evaluate and recommend courses of action in the delivery of medical care in an appropriate, indicated, effective and economic manner and to maintain the integrity of the practice of medicine and protection of both the practitioner and the patient. I wonder what the legal nuances would be? — Elisabeth Matthew, MD As I read the POSIT, I detect some bothersome vagueness: A “formal request” means a written and signed request, or what? “Timely” means what? Is there a statute of limitations consideration? As such a request is nearly a type of accusatory action, should more than one member be required to present such a request for review of medical care? I don’t know the law on this, but biblical requirements for an accusation requires two (or more) persons to initiate such action. — Ray F. Fitch, MD In correctional care, we have been working with peer review standards for many years. In order to be “accredited,” this is a necessary
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process. It is also extremely helpful in learning and growing in a medical practice, i.e., sharing of information. However, this entails both internal and external review. This is also independent of “adverse” or disciplinary action but the results are discussed in a quality management meeting with all staff (w/o names) to begin a Corrective Action plan (CAP)…. If it is ongoing and the CAP review shows noncompliance, then supervisory involvement (“independent review”) is initiated. There is also a “for cause” review for “sentinel events” and unusual medical occurrences, which is a supervisory review. Here there is an independent and later multi-supervisory staff review for provider failures. — Evalyn Horowitz, MD A good idea, but legislators will oppose it. We hope to improve patient care while lawyers hope to improve their incomes. — Byron Demorest, MD Suggest multidisciplinary review committee to evaluate if care provided meets current community standard of care. — Jonathan Wardell, MD Unless the hospital’s QA department agrees to the review and appropriate confidentiality measures are taken, SSVMS would not have access to all of the necessary relevant material and could not do a meaningful review. — David Herbert, MD I think hospitals already have quality of care committees and keep close watch on the care delivered. The Joint Commission is always on the scene. I can see CMA being requested to step in…if there is disagreement on the issue, or further clarification is necessary and issues are not addressed. — R.J. Frink, MD Physicians, their patients, and their institution could be better served by such independent, timely, and thorough peer review. — Lee Welter, MD I do not agree with external peer review in lieu of hospital-based peer review. — Douglas Kirk, MD The devil, of course, is in the details of the bill. It should strive to protect both patients and physicians. How the bill is to be worded would determine whether I would support it or
oppose it. In concept, though, it seems reasonable. —— Sidney Scudder, MD Sacto MDs should be able to monitor their own collegues. — M. Eugene Speicher, MD I believe in general a like colleague —
academic to review academic MD, community MD to review community MD — as different capacities exist in these different facilities. — Peter Murphy, MD
CMA Foundation Continues to Fight Childhood Obesity in Partnership with the Network for a Healthy California and RecreationRx Program By Carol A. Lee, Esq., President & CEO, CMA Foundation The CMA Foundation Obesity Prevention Project is working to reduce the prevalence of overweight and obesity in children and their families. The Obesity Prevention Project continues to carry out its purpose by working with the Network for a Healthy California to disseminate Supplemental Nutrition Assistance Program (SNAP) information and 5-2-1-0 messaging and by working with the RecreationRx Program. SNAP provides a basic safety net to millions of people. The program provides monthly benefits to eligible low-income families which can be used to purchase food. Through the electronic benefit transfer systems (EBT) the use of food stamp “coupons” is no longer the means in which a client receives their benefits. EBT replaces paper coupons through use of a benefits card, similar to a bank card. For more information, please visit www.fns.usda.gov/ snap. 5-2-1-0 is a simple message for you and your family to eat healthy and be active. 5 — Eat 5 servings of fruits and vegetables each day. 2 — Limit screen time (unrelated to school) to two hours or less every day. Children under two years of age should not watch TV. 1 — Get one hour or more of moderate to vigorous physical activity every day. Make gradual changes each day to increase your activity level. 0 — Limit sweetened drinks (to near 0 a day). Drink less sugar. Try water and low-fat or fat-free milk instead of sugar-sweetened drinks and whole milk. For more information about the 5-2-1-0 campaign, please visit www.beahealthyhero.org The RecreationRx initiative is working to provide the CMA Foundation’s “Physician Champion” program with the RecreationRx Health Provider Implementation Guide. In this way, those California physicians that are already advocating for health and obesity prevention in their communities will have one more tool to work with. Through diverse partnerships with businesses, government, health plans, community organizations and others, the CMA Foundation will utilize physicians’ expertise and credibility to maximize their impact on the obesity epidemic. For more information about the RecreationRx Program, please visit www.recreationrx. org. For more information about the CMA Foundation’s Obesity Prevention Project, please contact (916) 779-6620 or firstname.lastname@example.org.
Medical Mixchief By Ted Fourkas ONCE SOMETHING IS CIRCULATED by email, it may float for years through the clouds of the Internet, morphing with additions, subtractions and new variations. One email I’ve seen a half dozen times originated in the Washington Post’s Style Section. It asked readers to create a new word — and definition — by adding, subtracting or changing one letter of a word. The latest email variation listed the “2009 winners” of the Post’s “Mensa Invitational.” Actually, the original appeared in 1998 as part of the newspaper’s “Stool Invitational” (presumably wordplay on “Style Invitational”). The recent email added a new word, probably the result of the collapse of the housing bubble: Cashtration: the act of buying a house, which renders the subject financially impotent for an indefinite period of time. Three other additions: Arachnoleptic Fit: the frantic dance performed just after you’ve accidentally walked through a spider web. Caterpallor: the color you turn after finding half a worm in the fruit you’re eating. Ignoranus (which needs no definition). Other words are unchanged from the orignal, but the definition has been tweaked. Foreploy, for example, has shifted from “any misrepresentation about yourself for the purpose of obtaining sex” to the slangier “any misrepresentation about yourself for the purpose of getting laid.” One of the deletions from the original: Necronancy: communication with the late Ernie Bushmiller. (Perhaps the emailer was too young to know about the Nancy comic strip.) Interestingly, a number of the created words have medical connotations. Here are some from the original Washington Post article:
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Coiterie: a very very close-knit group. Impotience: eager anticipation by men awaiting their Viagra prescription. Reintarnation: coming back to life as a hillbilly. Inoculatte: to take coffee intravenously when you are running late. Hipatitis: terminal coolness. Guillozine: a magazine for executioners. Osteopornosis: a degenerate disease. Emasculathe: a tool for castration. Genitaliar: an image-enhancing object that can be carried in a man’s front pocket. Glibido: all talk and no action. Eunouch: the pain of castration. Acme: a generic skin disease. Dopeler effect: the tendency of stupid ideas to seem smarter when they come at you rapidly. Intaxication: euphoria at getting a refund from the IRS, which lasts until you realize it was your money to start with. Synapple: a perfect beverage to accompany brain food. If you’re interested, the Post’s grand prize winner (of a 2-foot high baby bottle) was: Sarchasm: the gulf between the author of sarcastic wit and the recipient who doesn’t get it. The first runner up: Giraffiti: vandalism spray-painted very, very high, such as the famous “Surrender Dorothy” on the Beltway overpass. Everybody in Washington, D.C., may understand the Beltway reference, but, not surprisingly, it has been cut from recent email versions. The original 1998 article can be found at www.washingtonpost.com/wp-srv/style/invitational/ invit980802.htm email@example.com
The caption for this illustration, from an 1843 book in the Sierra Sacramento Valley Museum of Medical History, says this is a 5’6” man standing next to the leg of an 8’ man. The plate is from the second edition of “A Series of Anatomical Plates; with References and Physiological Comments, illustrating the Structure of Different Parts of the Human Body,” by Jones Quain, MD, and W.J.E. Wilson, MD, published in Philadelphia.
The Moving Body Bag By David Hadden, MD, Fresno County Coroner Reprinted from the February 2010 issue of the Fresno-Madera Medical Society’s Vital Signs. Shortly after 8 a.m., with key in hand, the Coroner’s Deputy approached the morgue. Even though the sun was bright in the unusually clear blue sky of early Spring, there was still a nip in the air, reminding the Deputy of the chill he had experienced from his previous night’s work. As he inserted his key into the morgue door, he sensed movement to his right. A body bag that had been placed next to the morgue wall the previous day for cleaning because of contamination from a prior occupant was moving!
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Fascinated, he stared as a human head peeked out of the small opening at the top of the bag. The head was covered with copious flaming red hair and a beard to match — both in a state of tonsorial anarchy. I like to think that at this point, the Deputy stepped back and asked, “What’s wrong? Change your mind?” In reality, it was more like “What the hell?” The Deputy also noticed that the man was only wearing his hair. Hurriedly, we clothed him in hospital greens from the morgue supply room and then listened to his tale. During the night some thugs accosted him. They had taken everything, clothes and all, and then tossed him into the canal that runs alongside the morgue. With some effort, he was able to crawl out of the water. At some point a car had stopped, but the occupants refused to let the wet and cold apparition into their vehicle. They suggested instead, that he might find shelter in the adjacent building they called a mortuary. Left with few choices, he acted upon their idea and climbed our fence. Three strands of barbwire cover the top of our six-foot tall fence. The thought of a nude man engaging in that climbing exercise excites the theater of the mind, but worse is the thought of spending the night without clothes in a used body bag. Our hapless visitor did not appear to need medical attention, so the police were called to facilitate his departure. Unfortunately, the dispatcher put the call out on the air as follows: “The Coroner wants you to respond to a nude man that crawled out of a body bag.” We had to call again.
Communication Important in Hospitalist Model By Karen Davis, PMSLIC Insurance Company HOSPITALISTS ARE BECOMING well established in the U.S., and the concept of hospital medicine has expanded to pediatrics, obstetrics, and some other fields. Recognized benefits of the hospitalist model have fostered its quick and enthusiastic acceptance across the country. However, one concern about the hospitalist model is that it intentionally disrupts the continuity of care. Risk management experts often advise physicians to concentrate on the continuity of patient care because gaps in physician-patient communication can lead to bad outcomes. The hospitalist model has the potential to disrupt continuity of care by setting up a deliberate break in communication between the patient and his or her usual physician in the form of the transfer to another provider — the hospitalist. Robert M. Wachter, MD, who coined the term “hospitalist” and who has been a leader in the development of the hospitalist concept, notes that from the early days, organizations using hospitalists have had to “[focus] on ensuring a smooth ‘hand off’ to prevent any ‘voltage drops’ at the inpatient-outpatient interface.”1 Because the transfer is premeditated, physicians can develop protocols to bolster and protect communication. Hospitalists and outpatient physicians should discuss the potential for communication failures and make specific plans for transferring patients and for communicating about the care they each render. Communication protocols can include: s A METHOD FOR THE OUTPATIENT PHYSICIAN TO discuss with patients how the hospitalist will be involved in care; a plan for the outpatient physician to communicate with the hospitalist at or
near the time of the patient’s admission; s A PLAN FOR SHARING TREATMENT AND DISCHARGE information; s A PLAN FOR THE HOSPITALIST TO BE AVAILABLE TO the patient if needed between discharge and the first visit back to the outpatient physician; s A PLAN FOR THE HOSPITALIST TO PHONE THE patient after discharge; and s ANY OTHER PROCEDURES THAT FACILITATE CLEAR and timely interaction between the patient and the physicians involved in care. Communication is especially crucial when new information about a patient becomes available after the patient has been discharged from the hospital. How does follow-up occur when, for example, a tissue sample evaluated as benign is subsequently interpreted as showing malignancy? Because follow-up is a known risk area, it is a good strategy to have a protocol for notification when new information comes to light after a patient is discharged. A good protocol has provisions for notification of both the outpatient physician and the patient. Hospitalists and the physicians who refer patients to them should think about areas where their communication with each other and with patients might be vulnerable to collapse. Any actions they can take to identify and diminish risks will improve patient care and decrease the likelihood of lawsuits. 1 Wachter RM. The state of hospital medicine in 2008. Medical Clinics of North America. 2008; 92(2):265-273.
PMSLIC is a wholly owned subsidiary of NORCAL Mutual. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL insureds. To learn more, visit www.norcalmutual.com/cme. July/August 2010
Board Briefs May 10, 2010 The Board: Received the annual report regarding BloodSource activities from Michael Fuller, CEO. The bylaws of BloodSource establish that any licensed physician who is an active member in good standing in SSVMS is also a Regular Member of BloodSource. Regular members can amend, adopt or repeal bylaws of the corporation. Mr. Fuller noted that as a result of joint planning by BloodSource and SSVMS leadership, in the next several months active members will be requested to vote on proposed amendments to the BloodSource Bylaws. Approved the following members of the 2010 Nominating Committee: Chair, Charles McDonnell, MD; District 1: Ruth Haskins, MD; District 2: Pat Samuelson, MD; District 3: Barbara Arnold, MD; District 4: Earl Washburn, MD; District 5: Paul Phinney, MD; District 6: Marcia Gollober, MD; At-Large Members: Richard Jones, MD; Katherine Gillogley, MD. The Nominating Committee is in charge of nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. Approved the following nominations to CMA’s 2010–2011 Councils and Committees: Richard Gray, MD, Council on Ethical Affairs; Ruth Haskins, MD, Council on Legislation; Tom Ormiston, MD, Council on Legislation representing the Large Group Forum; Mary Jess Wilson, MD, Council on Legislation representing the Government Employed Forum. Approved sending a letter of support for the Health Services Advisory Group in its effort to become the Local Extension Center (LEC) for the counties of Sacramento, Placer, Yolo, Yuba and Stanislaus. Approved the Membership Report: For Active Membership — Jeffrey M. Friend, MD; Craig B. Glaiberman, MD; Thomas L.
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Hughes, MD; David K. Roberts, III, MD For Multiple Membership — Samuel A. Applebaum, MD For Retired Membership — Albert J. Kahane, MD For Reinstatement to Membership Following Payment of 2010 Dues — Jackie Agee, MD; Carl C. Hsu, MD; Geoffrey E. Woo-Ming, MD For Reinstatement to Retired Membership — David C. Rausch, MD For Resignation — Caroline M. Schreiber, MD; Patricia B. Sierra, MD.
June 14, 2010 The Board: Approved the 2009 Audit Report following a report from CPA Lindsey Kate Lane. Approved the First Quarter 2010 Financial Statements and Investment Reports and Recommendations. Approved a proposal to expand the SPIRIT Project from a provider of limited surgical services and no procedures to a provider of a wide range of donated outpatient surgeries to meet the ever increasing needs in the community. Approved a contribution to the California Physicians Health, Inc. (CPH), a non-profit corporation formed to replace the Medical Board of California’s former diversion program. The corporation is raising funds to get initial staffing and programs up and running by December 2010. All medical societies have been asked to contribute and the founding partners are contributing as well. Advanced Dr. Boone Seto from CMA Alternate-Delegate Office #5 to CMA Delegate At-Large Office #11, to fill the vacancy created by the resignation of Dr. John Ostrich from the Delegation. Moved Dr. Anthony Russell from Alternate-Delegate At-Large Office #16 to Alternate-Delegate Office #5, filling Dr. Seto’s vacancy. The Board recognized Dr. Ostrich for
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. — Michael Lucien, MD, Secretary Bynum, Jason P., MD, Child Psychiatry, George Washington University 2001, The Permanente Medical Group/Sierra Vista Hospital, 8001 Bruceville Rd, Sacramento 95823 (916) 897-7838 Chan, Matthew S., Radiology/Neuroradiology, UC Davis 2004, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-3068 De Ybarra, Jessica NM, Public Health/General Preventive Medicine, UC Davis 1997, California Dept. of Public Health, Div of Communicable Disease Control, MS 7300 PO Box 997377, Sacramento 95899-7377 (916) 650-6875
Minnerop, Marta M., Radiology/Body Imaging, SUNY Downstate 1990, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-3068
Sultan, Sultan A., Internal Medicine, Khyber Medical College, Pakistan 1978, Care Medical Clinic, 6500 Coyle Ave #5, Carmichael 95608 (916) 967-2273
Pitman, Dorothy L., Family Medicine, Ohio State University 1991, Sutter Medical Group, 1201 Alhambra Blvd., #230, Sacramento 95816 (916) 731-7770
Torres, Nancy P., Pediatrics, UC San Francisco 1982, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 474-7744
Roberts, David K., III, Cardiology, University of Miami 1985, Sutter Medical Group, 5301 F St #117, Sacramento 95819 (916) 733-1788
Board Briefs continued from previous page his 26 years of service (13 terms) as a Delegate to the California Medical Association. Adopted a resolution amending the Society’s Employee Money Purchase Pension Fund as required by the Internal Revenue Service. Reviewed a letter to the Sacramento County Board of Supervisors encouraging the Board to (1) place priority on preserving funding which prevents, treats and tracks communicable disease; and (2) provide maximum flexibility to the public health officer to determine how to allocate and prioritize the limited resources to protect public health. Approved a letter to William Vetter, MD, in recognition and appreciation of his 14 years of service on the Board of Directors of NORCAL Mutual Insurance Company. Approved a letter of congratulations to Stephen Hiuga, MD, who was recently elected President of the NORCAP Council. Approved the Membership Report: For Retired Membership — James A. Joye, MD; Dennis L. Ostrem, MD.
“Learning from Lawsuits: Strategies and Resources for Reducing Risk” A risk management CME presentation jointly sponsored by NORCAL Mutual Insurance Company and Sierra Sacramento Valley Medical Society November 18, 2010, 6:30 pm, Dinner served. Active practice physicians are invited to this exciting risk management CME presentation that will review real closed claims scenarios, and present risk management advice. Featured Speakers Scott L. Gassaway, Partner Wilke, Fleury, Hoffelt, Gould & Birney, LLP Medical Malpractice Defense Lisa Buscho, RN, BSN Risk Management Specialist NORCAL Mutual Insurance Co. Attendance Limited RSVP to Le Pham at 916-452-2671
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Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning
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
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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 Technology Products
KLAS / HIT Consumer Satisfaction 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
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Sierra Sacramento Valley Medicine
Dr. George Meyer took this photo at the National Airport in Buenos Aires in January 2010. It is unclear what happens when the button is pushed.
Mutualinterest Your reputation matters. Period.
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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 Jul 14, 2010
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...