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MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
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Richard Lewis, M.D. Hill Physicians provider since 1993. Uses Hill inSite, Hill EHR and RelayHealth for eClaims processing, electronic health records, practice management and secure online communications with patients.
Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.
Your health. It’s our mission.
Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.
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PRESIDENT’S MESSAGE Hang up and Dial 911
The Revolution in Substance Abuse Treatment
Stephen F. Melcher, MD
Board Member Profile Lee T. Snook, Jr., MD
David Pating, MD, and David E. Smith, MD
Meaningful Use of an EHR System: Final Federal Rule
Vitamin D — a Wellness Hormone?
Ann Gerhardt, MD
CONVERSATIONS Faith Fitzgerald, MD: Beyond the Algorithm
IN MEMORIAM Jerome A. Lackner, MD, JD
Wide Eyes in the Developing World
P. Quincy Moore, MS II
Jerome Cared for Patients Outside the Safety Net
Bayanihan, a UC Davis Student-Run Clinic
Katie Camilleri, MS II
David Gunn, MS IV
Voices of Medicine
Del Meyer, MD
Physician Expertise Can Improve our Health Care
Ami Bera, MD
Why We Need a Physician in the State Legislature
Richard Pan, MD, MPH
Wanted: Neurosurgery team to remove this lady’s brain tumor
Nathan Hitzeman, 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. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.
SSV Medicine is online at www.ssvms.org/magazine.asp This is another in a series of cover images by pathologist Dr. Gordon Love. Amid a scattering of red blood cells are two purplish myeloblasts, in which one pink, needle-like structure known as an Auer rod can be seen. Auer rods are named for John Auer, an American physician who discovered the structures in leukocytes from a patient on Dr. William Osler’s ward at Johns Hopkins Medical School in 1902. Auer rods appear in the cytoplasm of myeloblasts and promyelocytes in acute myelogenous, promyelocytic, or myelomonocytic leukemia. They help differentiate myelogenous from lymphocytic cell lines.
Volume 61/Number 5 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
Acid phosphatase, perioxidase, and esterase have been found in Auer rods, suggesting they are formed from coalesced cytoplasmic granules.
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.
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Hang up and Dial 911 …or go to your nearest emergency room.
By Stephen F. Melcher, MD At a recent SSVMS Emergency Care Committee meeting, I got to hear first hand from all of the medical hospital systems about how the mental health cuts are impacting their EDs. And they heard from an inpatient psychiatrist how the same cuts are affecting psychiatric hospitals. Emotions run very high around this issue. There was no blood exchanged, but I knew I was in excellent hands if it came to that. I also began to ask myself what we can do collectively to minimize the impact of these cuts on overstrained EDs — and what the healthcare system can do as the county tries to solve its budget problems.
Educating Patients on Alternatives A good first step would be to try to prevent patients with non-emergent medical/psychiatric issues from going to the ED in the first place. We can educate them about all the services available — and to not just dial 911 or go to the nearest ED. We can start this process in our offices and continue it in the ED. Bill Sandberg has what I think is an excellent idea. He would place identical kiosks in all the EDs to inform patients who come there about alternative avenues for non-emergency medical/psychiatric care. He believes this can be done so as not to violate EMTALA, and he has spoken to some EMTALA experts who think it could work. But, as with any good idea, the devil is in the details. The SSVMS Emergency Care Committee, which has representation from all of the medical hospital systems, would work with the county
to make sure up to date medical and psychiatric information is available to print out. The kiosks would ideally have a phone for the patient or prospective patient to contact the various crisis or advice lines available — for individuals with or without insurance. Individuals with non-emergent issues could be directed to the appropriate level of care, with some staying in the ED, and others going to urgent care clinics, county clinics, etc. Many people return to the ED for nonemergent care because they are unaware of other services in the community. Raising their awareness of these services will hopefully prevent future unnecessary ED visits. It could also reduce wait times in the EDs by reducing the volume of patients. The increased use of EDs by mental health patients is not just a local issue. It is happening across the United States.1 Yet most EDs are not well-equipped to handle this population.
A Therapeutic Space in EDs The EDs can help the mental health patients by creating a more therapeutic space for evaluating, stabilizing and treating mental health patients who are awaiting transfer to a psychiatric hospital, crisis residential facility or discharge from the ED. In my opinion, the current environment of the ED prevents most psychiatric patients from stabilizing as rapidly as they could. A more therapeutic environment would most likely lead to more discharges from the ED and reduce the number of patients requiring psychiatric hospitalization. An ED is a great place to rapidly evaluate a patient after an overdose, or to treat a self
The patients are not going to stop coming. Something has to change.
inflicted injury from a suicide attempt or selfmutilation, or to contain and rapidly stabilize a psychotic aggressive patient. After that, an ED becomes a very non-therapeutic environment — and in many cases a dangerous environment — for the patient and staff. Twenty-three hour crisis stabilization units can be free–standing, associated with a psychiatric hospital, or created within an ED. I know there is a certain level of fear about this — i.e., “if you build it, they will come” — but the EDs can’t keep doing what they are doing and expect a different outcome. (Thinking that way is Albert Einstein’s famous definition of insanity.) I can almost guarantee there will be more mental health cuts this year as the county tries to balance its budget by shifting care and responsibility of uninsured mental patients onto the private healthcare system. The patients are not going to stop coming. Something has to change. I am also concerned that keeping psychiatric patients in the current ED environment has the potential to harm medical patients in a way that isn’t so obvious. When psychiatric patients are brought to the ED on a 5150 (an involuntary hold of those who are a danger to themselves, a danger to others, or are gravely disabled), they have to be observed in a secure space. They can’t be placed in the waiting room — they have been brought to the ED against their will and would leave the waiting room and likely harm themselves or others. They may occupy a space in the ED for hours or days (yes, “days,” you read correctly) after evaluation and are awaiting transfer. When medical patients come to the ED, they receive a rapid medical screening and are then placed in the waiting room until they can be fully assessed and treated according to the priority of their suspected symptoms. A psychiatric patient awaiting transfer is occupying space in the ED that would otherwise be used to eval-
Sierra Sacramento Valley Medicine
uate and treat medical patients — who are now sitting in the waiting room. In looking at the volumes of patients being treated in the EDs, it is just a matter of time before someone in the waiting room goes bad. Medical and psychiatric patients are of equal value. It is important for all of them to get appropriate treatment, but lack of psychiatric services in the community has a domino effect, straining an already overstretched system. A few minutes extra waiting in the ED will likely not cause a psychiatric patient a lot of damage. But for those with a heart attack, stroke or trauma, a few minutes can mean the difference between life, death or serious morbidity. We also need greater dialogue with the three psychiatric hospitals in town. Scott Seamons, regional vice president of the Hospital Council of Northern and Central California, and I hope to facilitate this. It was very clear to me during the mental health redesign meetings and the Emergency Care Committee meeting that there are a lot of misperceptions of what types of patients psychiatric hospitals can treat under their licensure, and which patients they choose to treat with their exclusionary criteria. There is also a lot of misunderstanding over how the three psychiatric hospitals have chosen to respond to this community crisis, and their varying levels of response and participation in the crisis itself as well as the dialogue towards a solution. The county will continue to cut its budget for mental health. We need everyone at the table to help manage this situation and work towards a solution. firstname.lastname@example.org 1 www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf
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
Board Member Statement and Profile Lee T. Snook, Jr., MD University of Nevada School of Medicine Anesthesiology, Pain Medicine CMA Trustee, Solo & Small Group Practice Forum Please contact me by email at: email@example.com
I was born at the Nimitz Naval Hospital in Guam in 1953, after the Korean War, while my dad was still in the Navy. My mom had traveled by boat, pregnant with me, with preeclampsia no less, seasick the whole way in a cabin with three other women who smoked the whole trip. The six months I spent in Guam hold no memory for me, but probably explain a lot of what would follow. I had allergies as a kid and had to drink goatâ€™s milk on the island. Today, I still have allergies to everything, and you can bet that the guy sniffing and sneezing in a meeting will most likely be me. My parents attended Methodist church because you could smoke, swear and drink and still be OK with God, as I recall. My parents came out of the depression, being born in 1931 and 1933, and they worked hard all their lives. They are still pretty tight with a dollar. They are and were the role models that I have held close to my heart throughout my life. I was raised to work for a living and taught that no one owed me anything. It was expected that I contribute to society and do my part, be a member of the community and pay my taxes, serve others and take care of myself last. I owe a great deal to my parents, and I hope I can live up to their expectations as I conduct myself as a physician, father, husband, and son. I have been active in organized medicine since I was a medical student. In Reno, where I did most of my undergraduate work and medical school, the medical community expected you to be a member of the county, state and national medical organization. It was considered a failing and irresponsible to duck this obligation. I have pretty much held true to that dictate over the years. Although in the 1970s, Reno could be considered a bit red neck â€” not that there is anything wrong with that â€” there was also some of the most forward medical thinking around at the time. For many years, all I did was pay dues. Then Bill Sandberg asked me to be on the Board of Directors
of the Sacramento El-Dorado Medical Society in 1990 or so, and later I was Secretary of the Executive Committee. I was hospital-based at the time, working at Mercy San Juan Hospital in the anesthesiology department. I was active in medical staff politics, which I thought was important to our profession. I never went on to be president but ended up going into private practice in pain medicine in 1992, which completely consumed me. There was no pain medicine then and most of what we do today was not well conceived at the time, so I had to learn on the job. Bill also encouraged me to be active in CMA. I will never forget the first CMA House of Delegates that I attended, tears in my eyes, at the singing of the national anthem and the very real democratic debate that went on. People argued, agreed, disagreed and came together to fight again in the future. It was beautiful. I have been involved in CMA ever since. I became active in the Forum called the Solo and Small Group Mode of Practice in 1996. Over the last 14 or so years, I steadily increased my involvement in organized medicine, though I thought Bill wanted to put me out to pasture. I see it as my duty and obligation as long as I can contribute. I jokingly refer to myself as an unpaid CMA staff member, but I do relatively nothing compared to what the real CMA staffers do. I know that we often complain about the wrong end of a stick we have been handed, but it is not true. We have been complaining about the same stuff since I started practice and when I was a medical student. The truth is that I get to take care of people who trust me with their health and their life. This is a sacred relationship that few in life ever get the opportunity to experience. I plan on continuing that relationship as long as I can. After all, it has taken me this long to get this far, and I am learning everyday. Perhaps that is why they call it the practice of medicine.
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Vitamin D — a Wellness Hormone? By Ann Gerhardt, MD This article originally appeared in DrG’s MediSense Newsletter, intended for a lay audience. It has been adapted for physician readers, and references appear in the online version of Sacramento Medicine. Dr. Gerhardt’s newsletters can be viewed at www. healthychoicesformindandbody.org. Vitamin D used to be a vitamin. Now it’s a hormone, but people still call it a vitamin. Previously relegated to the bone and calcium category, we now know it benefits all the tissues of the body. It helps to prevent cancer, boost the immune system without letting it run amok, and keep the pancreas making insulin, the thyroid making thyroid and the muscles flexing when you need them. It does all this and more by regulating cell maturation, differentiation and cell growth. It also promotes apoptosis, death of senescent cells. The definition of a vitamin is an “organic substance present in minute amounts in natural foodstuffs, which is essential to normal metabolism, and the lack of which in the diet causes deficiency disease.” Vitamin D satisfies requirements of being organic, present in small amounts in the diet (the only natural food sources are fatty fish, egg yolk and liver) and essential to metabolism. It doesn’t satisfy the requirement that we must get it from food, however. We make vitamin D when sunlight converts a steroid in the skin to cholecalciferol (vitamin D3). It also differs from most vitamins in how it works. Most vitamins act as an essential cog in an engine in which enzymes make things happen — things like metabolism, tissue
building, infection fighting and organ function. Vitamin D doesn’t work with enzymes, functioning instead to regulate DNA. Vitamin D requires conversion in the liver to the form that we measure in blood and is stored in fat and liver, called 25-OH-vitamin D. The kidney converts that form to active vitamin D (1,25-diOH-vitamin D). Active vitamin D made in the kidney travels in the blood to act on distant cells, like bone and intestine, to regulate their growth and function. Substances made in one part of the body but acting at distant locations are called hormones. We now call active vitamin D a hormone. We previously believed that only the kidney made active vitamin D, but now we know that many cell types do. Unlike the kidney, however, other tissues keep their active vitamin D local. Animals and humans without functioning kidneys have no circulating active vitamin D, which causes calcium and bone problems, but with an adequate vitamin D supply, their other tissues continue to make active vitamin D. Calcium levels:, Vitamin D stimulates intestinal calcium absorption. When calcium levels are low, we make more 1,25-diOH vitamin D to augment intestinal absorption. Active vitamin D also regulates how much calcium we deposit in bone. Without it, children grow up with rickets, and adult bone grows weak with osteomalacia, a condition of plenty of bone protein matrix, but too little attached calcium. Because 1,25-diOH vitamin D rises and falls in response to calcium status, its levels are an inverse measure of calcium adequacy. They should not be measured to determine D nutriture. For that we measure 25-OH vitamin D,
the storage form. See the end of the article for recommendations about doing blood levels. Rickets: In the 1800s, as families moved to urban areas, sunlight-deprived children experienced an epidemic of rickets’ soft, deformed bone. In the early 1900s, scientists figured out that sunlight cures rickets. Irradiated food also did the trick. When vitamin D was isolated, food manufacturers fortified everything from hot dogs and peanut butter to soda and beer. When unregulated fortification led to vitamin D intoxication in young children, the fortification boom calmed down. The U.S. settled on cereal and milk fortification at safer levels. Osteoporosis: Vitamin D does not cure osteoporosis. Bone consists of a protein matrix, to which calcium is attached. In osteoporosis we lose protein matrix and big holes appear, like Swiss cheese. There is nothing to which calcium can attach. We need vitamin D to calcify bone, but to cure osteoporosis, we need to build matrix and calcify it. Cancer: This is big. With high levels of vitamin D, you are less likely to get colon, pancreas, breast and prostate cancers. In 1941, a scientist noted that people in northern states like Vermont suffered more cancer deaths than did people living in the deep South. This was in spite of more skin cancer in southerners. In 1980, Frank Garland reiterated the finding and linked higher northern colon and breast cancer rates to vitamin D deficiency. Cells start out as immature stem cells, which must differentiate to mature into functional cells. Active vitamin D signals cells to differentiate — to be all they can be as mature cells. Without differentiation, organs contain more immature cells with cancer potential. Active vitamin D promotes defective cell death, preempting their conversion to cancer cells. It also augments molecular defenses against oxidative stress. By promoting healthy cell maturation and differentiation, bolstering the anti-oxidant enzyme system and weeding out the “downers,” active vitamin D prevents cancer. Can vitamin D cure cancer? Some zealots say yes, but controlled trials are lacking and
With high levels of vitamin D, you are less likely to get colon, pancreas, breast and prostate cancers.
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there are severe limitations. In a test tube, active vitamin D tames leukemic cells into normal white blood cells, but failed miserably in leukemic patients to cure their cancer, inducing coma from severely high calcium levels instead. Women consuming more vitamin D-fortified foods or exposed to more sunlight have less breast cancer. Active vitamin D enables breast cell maturation, controls cell growth and enables damaged cells to die. It is non-discriminatory in these effects, exerting population control on both estrogen-responsive and non-responsive cells. Animals lacking either the vitamin D receptor or the 1-hydroxylase activating enzyme develop abnormal breast architecture and more aggressive cancers. The one cancer type that increases with higher vitamin D levels is skin cancer. The same sunlight that makes vitamin D in our skin causes radiation damage, leading to cancer. Sun worshipers may have a nice tan and high levels of vitamin D, but that vitamin D doesn’t protect against radiation damage. Using sun screen to prevent skin cancer reduces vitamin D levels, increasing risk of other cancers. The alternative is to use sun screen and eat fatty fish and fortified foods. Heart disease: Vitamin D (but not calcium) seems to protect against high blood pressure and possibly heart disease. Blood pressure rises when the vitamin D level falls below 15 ng/ ml or when someone lacks the enzymes that convert vitamin D to its active form. Active vitamin D blocks renin, a hormone the kidney releases to boost blood pressure. The data about preventing heart disease are less convincing and lack a plausible mechanism, but study results lean in the direction of benefit. Some people think that the fact that acute heart attacks peak in winter, when sunlight and vitamin D levels are low, points to a protective effect. People with chronic kidney disease treated with a vitamin D-like drug have heart muscle hypertrophy. The small number of studies and unresolved issues about the optimal dose of vitamin D pose obstacles to drawing firm conclusions.
Concerning heart attacks, we know that heart disease deaths have fallen off over the last decade, most likely due to statin use and better medical treatment. Could vitamin D supplements that people increasingly take to preserve their bones also be contributing? Some believe so, but optimal vitamin D levels probably can only go so far to overcome lousy diets and couch potato lifestyles. Diabetes: The data about vitamin D and diabetes are inconclusive at best. So far, adequate vitamin D levels seem to improve insulin sensitivity, enable insulin secretion and are associated with reduced diabetes risk. Weight: Vitamin D helps those who restrict calories to slim down. People with better vitamin D status lose more of their waistline than others with similar weight loss. It may also preserve muscle mass as people lose weight, without an effect on muscle strength. These associations do not make it a weight loss drug. Infection: It’s well known that people catch fewer colds in the summer, when people emerge into the sun-light to make more vitamin D. People with higher year-round blood vitamin D levels also have fewer infections all year. For years patients with tuberculosis were sent to sanitariums in which they lay in beds out in the sun for their cure. Doctors presumed that sun exposure killed tubercle bacilli, but scientists now know that the extra sun-induced vitamin D boosted the immune system to fight off the infection. The race is on to fully elucidate vitamin D’s role in the immune system. Autoimmune disease: Vitamin D may boost the immune system to fight an infection, but it squelches attacks on the body’s own tissue. Vitamin D deficiency predisposes someone to autoimmune diseases like rheumatoid arthritis and lupus. Vitamin D selectively turns on growth of certain cells, called regulatory T lymphocytes. This cell type is responsible for immune tolerance, which is lost in autoimmune disease. Optimal vitamin D levels may help to prevent autoimmune disease, but there is no evidence that it cures an established condition. Psoriasis: Active vitamin D converts out-ofcontrol skin cells, that would otherwise prolifer-
ate into psoriatic patches, into normal skin cells. Dermatologists now routinely use a number of vitamin D analogues to treat psoriasis. Using high dose vitamin D itself causes too many sideeffects related to hypercalcemia. How much is enough: Living in the U.S.’s temperate climate, we just don’t get enough direct UV radiation to make all the vitamin D we need. We used to think levels of 20 mg/ ml were adequate, but now we know that is nowhere enough. To maximally suppress PTH and optimize bone calcium we need 35 ng/ml, and for cancer prevention prevailing opinion recommends levels >50 ng/ml. To get to 50 ng/ ml, you would need to be a Hawaiian beach bum 365 days a year. In Sacramento, sun-bathing naked every day for the four hours of the day in which the sun is most overhead might get you close. North of the equator the sun’s rays are just not direct enough to stimulate much vitamin D synthesis. Forget even trying in the winter. Some people have low vitamin D levels no matter how much sun they get. Naturally dark skin blocks UV radiation, reducing vitamin D synthesis. A prevalent idea in the vitamin D science community is that this is why AfricanAmericans have more severe high blood pressure and heart disease. Some individuals naturally have an excess amount of CYP24A1, a protein that chews up vitamin D, depleting levels. People with malabsorption or celiac disease have trouble absorbing vitamin D from food. These people often need mammoth vitamin D supplement doses. The recommended daily allowance depends on age, from 200 IU (5 mcg) in children to 600 IU in the elderly. Older people are resistant to active vitamin D’s action on the gut. Even with good levels and conversion to the active form, calcium absorption may be inadequate. Some propose a dose of 4000 IU per day for lactating women because of a recent increase in childhood rickets, but that dose has not been uniformly adopted. The RDAs were established to prevent rickets, not promote wellness. With plenty of sun and vitamin D in the diet, one may be able to get to a desirable vitamin D level with the
In Sacramento, sun-bathing naked every day for the four hours of the day in which the sun is most overhead might get you close.
Ergocalciferol is called vitamin D2, but it is not vitamin D and is not bioequivalent.
RDA. Often it takes much more, on the order of 1000–2000 IU vitamin D3 per day. This is the dose that most vitamin D and bone experts recommend as being safe and effective without confirmatory blood levels. Natural vitamin D in humans and other animals is cholecalciferol (vitamin D3). Dietary sources of vitamin D3 are cod liver oil, fatty fish (which can deliver the recommended allowance in one serving), egg yolk, liver, and fortified food — milk, orange juice, ready-to-eat cereal, margarine and yogurt. Ergocalciferol is called vitamin D2, but it is not vitamin D and is not bio-equivalent. It is made from irradiating sterols in foods, primarily fungi. One IU of vitamin D3 from cod liver oil is as good as four IU from irradiated foods. Some stores sell irradiated mushrooms as sources of vitamin D. It is available as 50,000 IU capsules by prescription. Vitamin D2 is less efficiently converted by the liver to circulating vitamin D, binds less well to the protein that carries it to cells and is degraded more easily than vita-
min D3. Though many physicians prescribe it, experts do not, and it has a greater chance of inducing toxicity if taken wrong. Vitamin D toxicity: Too much vitamin D dangerously elevates serum calcium levels, leading to kidney stones and altered mental status. People most at risk are those with an unsuspected parathyroid adenoma and those who take high dose supplements. Vitamin D levels are expensive: (The following comments are my opinion). Should everyone have a 25-OH-vitamin D level? That would cost a huge amount of money, and there are not prospective trials to prove that the expense would be offset by reduced cost of prevented disease. We don’t need to do a blood test to know that most non-supplement users in Sacramento have levels below 35 ng/ml. We could empirically supplement everyone with 1000 to 2000 IU per day, but how would we identify toxicity? You could just wait for the patient to get loopy. Or do a serum calcium level and urinalysis to look for blood or crystals, which are inexpensive, functional surrogates. If abnormal, one could check a 25-OH-vitamin D level then. People debate the prudent upper end of healthy levels, putting it somewhere between 60 and 100 ng/ml. Some people, including those with osteoporosis, malnutrition, celiac disease and malabsorptive disorders, need 25-OH-vitamin D levels as part of their care. They are likely to be deficient and need extraordinary doses to achieve optimal status. Like any other drug with an effective and safe range, we should do levels to assure adequacy and prevent toxicity. Once at an optimal level, check no more than yearly. 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 e.LetterSSVMedicine@gmail.com
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Faith Fitzgerald, MD: Beyond the Algorithm By David Gunn, MS IV Dr. Faith Fitzgerald earned her B.A. in zoology from UCSB in 1965, and her MD from UCSF in 1969 — where she also did her residency, was chief resident, and worked as assistant professor and then as assistant chief of medicine until 1978. She was assistant professor of medicine at the University of Michigan until 1980, when she came to UC Davis as associate professor, dean of students, and eventually was appointed a professor and Chief of the Division of General Medicine. Dr. Fitzgerald has been elected as a regent and master of the American College of Physicians. She has been invited to speak at over 100 different colleges and organizations throughout the world. Faith Fitzgerald: Now, what is the purpose of our conversation? What aims have you, young man? [laughs] David Gunn: My aim is to allow you to share with us some of your perspectives on medicine and culture. How does that sound? FF: Fine! I worked with Dr. Hibbard Williams, who served as the third dean of UC Davis School of Medicine. We worked closely at UCSF, and when he became dean at UCD, he called me in Michigan and asked me to come on home to California. I told him that I was very happy there. I had left the San Francisco of the early 60s and 70s, which was kind of chaotic, for Michigan — where they had families and baseball games — and had gotten more or less used to that in the 2.5 years I had been there. But he told me that he needed me, so I came back as associate dean of students. It was a time of change, where I held several offices, sometimes all at once [laughs], just because...I said yes. So the real reason I’m at UC Davis is because of
Hibbard Williams. Do you know him? DG: Yes, actually. We had a visiting professor give a talk on the Hippocratic Oath, and I was introduced to him by an alumnus. The first thing I wanted to ask him about was his portrait in the School of Medicine where he’s in that beautiful red chair holding a book. He told me that was taken at the artist’s, and is neither his chair nor his book — completely staged [laughs]. FF: It was an interesting time in UC Davis’ history, sort of a middle time. The founding dean, John Tupper, had retired and an intermittent (but really good) guy had held office for a short time. We got Hibbard, who had just been chief of medicine at Cornell. At the time, there was Hibbard Williams; Ernie Gold, executive associate dean; and associate deans Jim Castles, Don Rockwell and Donal Walsh; I was dean of students, and that was it! And a very competent staff, very busy, and it was all at the Davis campus. DG: That sounds nice. FF: It was nice, except after a few years I missed the wards, so I went back to join the department full time. DG: What would you say has changed in the culture of medicine at UCD between now and then? FF: UCD has become very much more disparate than it was. It was a small founding faculty and a great deal of insular identity that made people want to come to Davis. We were the poor cousin of the UC System of medical schools. UCSF and UCLA were, obviously, the headliners. And there was San Diego, which had been designed as a primary care school, as had
We were the poor cousin of the UC System of medical schools.
Faith Fitzgerald, MD
...it can be done with
Irvine and Davis, created by active California legislation under the direction of Dr. Tupper. UC San Diego had defected almost immediately, and became a university hospital as opposed to training generalists. Irvine and Davis have hung on a little longer. When I came it was the family practice school, which seemed a little silly to me because young people can’t really know what their interests or geniuses are until they are exposed to these sorts of things. So, to say you’re going into family practice because you’re here didn’t make sense to me. We loosened that a little earlier than Irvine did, but eventually a school that is designed to train one type of doctor just won’t work. Students have different ambitions and aspirations. DG: So you see that genesis as being organic in nature, as opposed to being directed from the executive staff in order to acquire additional scientific funding? FF: You know, and I know, that the acquisition of funding and grants, and the regalia of success in academic medicine is a powerful force, and remains so. DG: Is that not a product of our leaders? Or is it of the social milieu of the time?
grace or it can be done with venality...
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FF: I think both. It’s not that there was any aspiration that was anti-intellectual, or antiacademic. The problem was that as it grew into the academic model, with multiple specialties and subspecialties, each formed their own more insular group — as opposed to teaching medical students on par with each other. Still, the colleagueship among faculty at UC Davis is far less war-like than it is at many other institutions, where people battle one another. That really still isn’t true with us, although you see things now and again. It is now more like the class of separate kingdoms vying for favor than it used to be, when everyone worked together with the common endpoint being the multi-disciplinary education of the student. That’s probably a product of the family practice movement, where every faculty member here was supposed to be a good clinician and a good teacher and teach his or her part to every student. The legacy of academic medicine, by the way, has to do with the hierarchal structure of 19th century schools in England and Germany. So it’s no surprise that our academic structure is somehow predicated upon ranks of honor. The aristocrats are the Nobel laureates, who don’t necessarily participate in the medical community of teaching. And the commoners are the generalists — who don’t do a lot of research, but who may teach. DG: If we’re all vying in our fiefdoms for accolades from an external source, what, generally, is that source? FF: Largely it is NIH grant funds. DG: The dollar is king. FF: Well, it’s not so much the money, as the acknowledgment that you are held in high regard by those who are seen as, more or less, the demigods of science. It is an affirmation that you are worthy. You may have noticed in your class, as we certainly all have in our lives, this need to be more worthy. Which is a good thing — I mean, you don’t want people who aspire to be adequate, that’s no aspiration at all. But it can be done with grace or it can be done with venality, in the sense as seeing your own advancement as much more important than the general
enterprise. The key is in the balance. And really good places are always aiming for that balance, and I think Davis is trying for that. DG: Earlier you mentioned different specialties of practice. You did your residency in internal medicine which now seems to be more of a generalist’s practice. FF: In a time when GPs still existed, and when family practice was coming up to fill the generalists’ role, in the 1970s, IM still maintained its role as specialty diagnosticians and cognitives (or cognitive thinkers):the brains. It was a very sought after residency. Now, since primary care is defined by people other than us and has largely become everything else but what the specialists or subspecialists do... it’s interesting I just fell into my own trap. Specialty was surgery, pediatrics, medicine. Subspecialty was gastroenterology, hepatology, etc... Now specialists means subspecialists where a generalist internist is primary care. DG: So what role do you see current primary care and family practitioners fulfilling? FF: Well, I can’t speak to FP, they have their own agenda, I’m sure. It would seem to be principally outpatient, and caring for larger groups of people. Internists care for adults, sometimes adolescents, but almost never children. But the internist can be seen as [dealing with] one of two things — the day by day care which includes screening and wellness and preventative medicine, (which is really the algorithm now); and the other is dealing with complex multi-system disease; which is my idea of internal medicine. It’s taking all the bits and pieces and bringing them back to the patient with some cohesive uniform plan; a plan which does not necessarily follow the pointers given by subspecialists: the work up for gastritis, anemia, etc... there’s too many things going on. To put them in the context of the patient’s needs and wants, is a revolution — an evolution — back to the old internist who was supposed to be the coordinator of complex care, to ask for help from subspecialists for procedures, or to ask for help for new frontiers in rarely seen disorders. DG: And that is why you chose internal
medicine? FF: Yeah, I loved the problem solving, putting all these things together; I loved the time that I was allowed to spend with patients. It wasn’t doing things to things, it was getting to know individuals. DG: Can you recall an early memory that demonstrates your love for problem solving? FF: As a child?! DG: Well, or earlier [laughs]. FF: [gasps]. Well I can tell you about internship — is that child enough? DG: [laughs] Sure! FF: Well, I had a woman admitted to my service with abdominal pain and fever of unknown origin, she must have been mid-50s, poor, African-American from Oakland and just charming, just charming. But she had had a classic FUO full workup at the time — with the exception of a laparotomy. [This was] pre-CT scan when the only way to see the inside was to go inside. All of the diagnostic studies had been done, and still no answer. I had been treating her for her fever and malaise, as an intern under supervision, although less supervision than we give now. And off she went to surgery, and they found...nothing. No lymphoma, no occult tuberculosis and then she began to get better. Her fever lysed, she began to regain her strength. It was if the opening of her belly was in itself therapeutic, so I talked to her. ”I’m so glad we didn’t find anything terrible like a tumor or a bad infection.” “I know,” she said. ”What do you think happened?” “They let the devils out.” ”Oh.” Turns out she had a husband who was a philanderer, and she’s telling me all of this after 6 months of work up plus a laparotomy. She had gone after his latest amour, and had said some nasty things about her. Then she said that his latest conquest was a witch-woman, and had leveled a curse upon her: she would be miserable for the rest of her life; at which point she began to feel sick. The question that was always lingering in my mind after that was whether that laparotomy was an exorcism of sorts.
It wasn’t doing things to things, it was getting to know individuals.
DG: Sort of a conversion disorder... FF: Sort of a symbolic ”letting the devils out.” She did fine after that, except for calling me every night to see if she could have an aspirin — she’d never had a doctor before, and she just loved the idea [laughs]. I went over to visit her at her house in Oakland, which was in a very, very bad neighborhood (I was afraid
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of getting mugged while I was there), but her house was immaculate, and she had dressed all up for the lunch and I thought: I really love this kind of work. [smiles] This is neat stuff. It wasn’t a diagnostic triumph, in the sense that I had come up with some bizarre or arcane disease, but what she taught me was that you stick around long enough, and listen hard enough and pay attention and you get rewards you could not imagine. DG: Great story. FF: It was a turning point. DG: Turning point how? FF: For me, when we go into medicine we think it’s about the information, how much you know in the way of the given wisdom. And here was this woman who had undergone the gauntlet of everything we knew and no one had ever asked her why she thought this had happened. How she generated a fever, I don’t know — it was never a high grade fever. The weight loss was easy to explain, she was depressed, and it might have been that she was in isotonic contraction; she just began to flag and fail. Then she underwent this procedure, and I guess she figured that did it: she was now expiated. There are areas where data and information don’t help. You know, Francis Bacon established the scientific method: observation, numeration, testing and validation, and reproduction. But there are certain
phenomena amongst the commonest things that affect humanity that cannot be observed or numerated or isolated or reproduced by another observer — fear, anxiety, depression, fatigue... DG:...Faith... FF: Yes? ...what? DG: No, the quality, not your name [laughs]! FF: Yep, yep, yes, that too. Oh, my name is a mistake. My mother named me after her grandaunt, my grandfather’s sister, but in Russian of course your name is Vera, a very common Russian name. My mother, being a newly arrived American, didn’t want her child growing up being constantly mispronounced as Vierra, so she just translated it into English. It had nothing to do with spirituality, it was just, ”What can I call this kid that honors my father?” Grandauntie Vera was evidently caught after the Bolshevik revolution and was never heard from again, my grandfather lamented her, and though my mother had never met her, she nonetheless wanted to do something to honor her. The alternative was to name me after my grandfather, Georgiana Victoria, thank you very much, no. So she decided Vera, and that was it. DG: So you’re not a spiritual person? FF: No. DG: No semblance of a belief in a higher power? FF: Spirituality is a human construct, clearly, so I have to “believe” in spirituality, but do I believe there is a diety? No. DG: What’s your favorite part about Sacramento? FF: The extraordinary culture. I spent time in San Francisco, where it’s all very experimental and singleton. You’re supposed to be an individual in San Francisco, which is odd, retrospectively, when you look at the 1960s and 70s when everyone looked the same and spoke the same, but they all thought they were individuals. They all thought their job was to be unique and creative and...zoned out in some way. And it was a very, in a sense, self-centered culture. “I’m doing my own thing.” Then I went to the midwest, where it was very much more family oriented, children oriented, mid-western value
oriented. DG: More selfless. FF: In a way, unless you count family as self, which these people did. They had obligations beyond their own indulgence in things that pleased them — it’s not pejorative. I had those two extremes when I came to Sacramento. It seems to have this combination of community sensibility and of family orientation of the midwest (or it did when I came), plus the creativity of California. It’s a bit less nonsensical than San Francisco. San Francisco is an interesting place that I was in for 13 years. I enjoyed it, but in retrospect it’s a very difficult city to live in. Transportation, cost, and great beauty that wasn’t always there because of this perennial fog (I thought I would get rickets [laughs]). After a while it got to be too much trouble to live there: it took you longer to get to a place than you spent there. Sacramento was much easier. I really like Sacramento, except it has no beach! I grew up in Berkeley and Santa Barbara and San Francisco. I really like the beach. I remember as a child standing on the beach thinking I was in continuity with the shores of Japan and the harbors of China — the same body of water. The majesty of it all puts you in your place. And now I’m here in Sacramento and no beach! People say you can drive to the beach. No you can’t! It’s different, you can’t hear the breakers, the smell, and I do miss it. Sometimes I find myself in an evil mind and I’m thinking...earthquake! [laughs large] DG: What do you wear on the beach? FF: Usually shorts and a t-shirt. DG: Black? FF: Of course! That’s another thing people ask me about, it really has no magical implication. DG: We’ll talk about that next time... FF: Yes, let’s talk again.
I really like Sacramento, except it has no beach!
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
Voices of Medicine A review of various local and regional medical journals.
By Del Meyer, MD
The Art(?) of Writing(?)
It really doesn’t matter if the doctorauthor can write or not, because there are many excellent underemployed writers who will write the book for you.
Emily Dalton, MD, discusses writing in “Where Have All the Flowers Gone,” in the May issue of the Bulletin of the Humboldt-Del Norte County Medical Society. Last month I attended a conference entitled: Books, Memoirs and Other Creative Nonfiction at Harvard. It’s a great course, and I highly recommend this method of getting CME credit for writing, having fun, and networking with people in the publishing business. Self-help books, medical texts, and memoirs comprise the 3 main categories of medical nonfiction. The publishing world is very interested in books that will sell lots of copies and make money. I don’t know why I was surprised by this. (We all need to get paid for our work.) Maybe it is because I live in a remote rural area, or that I have my head in the clouds. Naively, I figured the compensation for one’s writing would be roughly commensurate with the quality. I expected the publicists, agents, and editors to be interested in one’s prose, one’s command of the English language, and one’s writing style — but instead I found myself being asked about my TV appearances. Why would a writer want to appear on TV? If I wanted to be on TV, I would be at a conference for actors. I checked my syllabus — I was in the correct place. Of the three main entry points into the world of publishing, the most popular for physicians is the self-help genre. The pathway goes like this: start with a “hot” topic bound to generate immediate interest from a target market. Ideally this would be a topic so engrossing that your intended buyers will be compelled to open their wallets and purchase your book
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right away, instead of going home and seeing if they can download something similar for free. Typical book ideas include using cutting edge knowledge of neurobiology to improve one’s functioning, a new spin on how to lose weight, or how to deal with some common but specific physical/mental disorder.* In order to be legitimate, the physician backing the book must be an “expert” on the topic, but in addition, he/ she must be somewhat of a celebrity (hence the TV appearances). It really doesn’t matter if the doctor-author can write or not, because there are many excellent underemployed writers who will write the book for you. Nevertheless, the best books in this genre are written out of altruistic passion by physicians who have a unique sort of help to offer and see an unfulfilled need for their expertise. They certainly don’t do it for the money. Most of us could make more in a month doing our day jobs than we would earn for a year’s work on a full-length book. Success in publishing is all about having a “platform,” which contrary to common understanding is not a sturdy, flat, wooden structure. A platform is a publishing term for your public persona and your professional reputation and accomplishments. In order to build that platform, you have to do things that most of the rural physicians I know abhor: Give speeches, get on television and radio, and talk to reporters and the press. I don’t know about the rest of you, but I have learned that the press is not usually our friend. They misquote the things we say and get us into trouble with people we did not mean to offend. Besides, most of us in rural areas are so inundated with demands from large numbers of patients, the obligations of running a business,
hospital duties, committee responsibilities, and being on-call that inviting additional (unpaid) professional social contact into our lives is completely unappealing… *During the week of March 28, number three on the New York Times nonfiction list combines all three of those concepts: Change Your Brain, Change Your Body, by Daniel G. Amen is about using the brain-body connection to lose weight and avoid depression. Read Dr. Dalton’s entire “In My Opinion” at www.sonic.net/~medsoc/images/bulletins/MAY%20 2010%20BULLETIN%20EXCERPTS.pdf
Kick the SGR Dr. Bradford A. Anderson discusses Congress and Medicare payments in the August issue of VITAL SIGNS, the journal of the Fresno-Madera and Kern Counties Medical Societies. To my Brethren; It is summertime, which means it is time to play Kick the Can. The game is an urban version of “hide and seek.” A can is used so that neighbors and businesses would be aware to watch out for children hiding at play. The rules of the game are very simple. It takes at least three parties to play. One person is chosen as the Captain. The can is then kicked down the road as far as possible. During that time the Captain chases after the can as the other participants hide. The Captain then brings the can back to the “home base” where the Captain then counts out loud, with eyes closed, to a predetermined number. After reaching that number, the Captain begins to hunt for the other players. When the Captain finds one of the hidden players, their name is called out, and both the hidden player and the Captain race back to the can. If the Captain gets there first, the hiding player becomes captured. Otherwise, the hiding player gets to kick the can and goes free to hide again… This game closely resembles what is going on with the SGR fix initiative in Congress. In 1983, Hsiao and his group derived a relative value for every physician encounter and procedure calculating risk, technical skill, and mental and physical effort. This then became
the basis of Medicare’s fees. In 1997, in order to limit the growth of Medicare expenditures for physician fees, the federal government tied the growth rate of reimbursement to the gross domestic product (GDP). This became known as the sustainable growth rate (SGR). Unfortunately, Hsiao and his group did not account for regional cost differences or that the cost of providing medical services was growing faster than the GDP thereby necessitating a “fix” to the SGR. This is, however, a costly endeavor. The SGR fix is just like the can in Kick the Can. A special item is kicked down the road then brought back to center stage by the most interested party, organized medicine. Just like the “Captain,” organized medicine has to seek out one of the two parties hiding in the streets and either call them out or capture them before they grab the can and make the issue their own. Two months ago, as an example, the deficit hawks, the fiscal conservative block of Democratic and Republican parties, grabbed hold of the can and kicked it down the road until this Fall. Organized medicine will never win this game unless it is able to capture both parties and take control of the SRG fix. We need to make our representatives, patients, and particularly our seniors, aware of the can being kicked down the road. If some form of a permanent solution is not made, then the solution will become more expensive and access to care more difficult. I know, my brethren, that I’m speaking to the choir. However, we must let the other 65 percent of us who are not paying attention or feel that because they are not providers don’t have a dog in the fight, understand that “where Medicare goes, insurers follow for the guidelines in covered services and baseline physician fee schedules for private payers as well as workers’ compensation. So go forth, my brethren, spread the word. Guard the can, capture the hidden, and keep the faith. Amen.
The SGR fix is just like the can in Kick the Can.
Physician Expertise Can Improve our Health Care By Ami Bera, MD In a rare and perhaps unprecedented development, two physician members of SSVMS are running for office this year — in the 3rd Congressional District and the 5th Assembly District, respectively. We asked both for a statement late in the campaign, and their responses appear on this and the next page. As doctors, service informs every decision we make. As a physician, I’ve found that serving my patients first requires listening to my patients — hearing their concerns, and then having the courage to make informed, critical decisions. While these values of service and leadership are defining qualities of the medical community, they are too often lacking in our political leaders. Our community faces real challenges — providing affordable healthcare, revamping our education system, and most importantly, getting Californians back to work. But when I look to Washington, all I see is broken politics. Too many of our leaders are refusing to listen, and refusing to serve the people they were elected to represent. As physicians, we must take a leadership role in changing our government — and we have a special role to play in improving the tone and substance of our healthcare debate. We have a unique privilege of working each day with patients and their families, and we can
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bring our expertise to reforming our broken healthcare system. While the recent legislation was an imperfect bill, it was an important first step. In the coming months, we must bring our ethic of service and leadership to improving our healthcare. I’m running for Congress because we need to bring these values of service and leadership to all aspects of government — and this message is clearly resonating with the people of northern California. Our campaign has over 2,400 volunteers, which has allowed us to reach out to over 186,000 voters. We are the only challenger campaign to outraise our Republican incumbent five consecutive quarters in a row, relying on contributions from over 2,700 individual donors. This success is starting to catch the attention of the national media — recently the National Journal released their list of the seats most likely to switch, and our opponent is one of only three GOP incumbents on the list. I encourage you to visit our website, www. BeraForCongress.com, to learn more about our campaign, and I urge you to join our campaign by giving a contribution — only by working together can we restore the ethic of service we all value so highly to our broken government. Be well. 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 e.LetterSSVMedicine@gmail.com
Why We Need a Physician in the State Legislature By Richard Pan, MD, MPH I am asking for your support for my candidacy for the State Assembly in the 5th District of Sacramento. I was honored when you elected me SSVMS President in 2004 and more recently as your CMA Trustee. As Chair of the CMA Council on Legislation, I advocated on your behalf at the state Capitol. I was proud to receive the SSVMS Medical Honor Award in 2005 and the Medical Board of California Humanitarian Physician Award in 2010. As SSVMS President, I set out to achieve three goals: (1) to reach an all time high in SSVMS membership; (2) to increase physician engagement in the community; and (3) to make health care coverage available to all low-income children in the region. Together, we reached all of these goals because we had a shared vision and commitment to our society and our community and we established partnerships and coalitions around our shared vision. I believe that’s the type of philosophy and leadership our State Legislature lacks right now. I am running for the State Assembly because my patients and their families suffer from the economy and cuts to essential services, my clinic faced closure because of poor MediCal payment, and our communities are being hurt by the gridlock in state government. As a physician and educator at UC Davis Children’s Hospital, I am committed to working on the problems afflicting our state. We need elected officials who will come together to solve the problems facing California. I have demonstrated that capability. There are currently no physicians in our State Legislature, but the Legislature will decide
numerous issues concerning medical liability, including MICRA, scope of practice, and coverage and payments for MediCal, Healthy Families, and other health programs. We need representation by a practicing physician who understands the impact of state laws on patients and medical practice. With implementation of federal health reform in our state, now more than ever, we need a doctor legislator who can speak personally to issues and about the importance of the doctor-patient relationship. I’m counting on your support as a physician to: • vote for me, if you live in the 5th District; • talk to your family, friends, colleagues, and staff about why electing a physician is important to your and your patients; • support the campaign at www.panfor assembly.com. You’ve permitted me to represent you at SSVMS and CMA. I ask your support again as I seek to take on issues in our State Capitol. Please be free to contact me or Pat Dennis at 805-708-5499. 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
Wanted: Neurosurgery team to remove this lady’s brain tumor By Nathan Hitzeman, MD Maria is a 43-year-old undocumented Spanish-speaking woman who came to the United States six years ago and works as a housecleaner. She has lived happily with her sister and her sister’s family until last year, when she started having unusual headaches and changes in her vision. She was seen at a local free clinic and referred to an ophthalmologist in the area (the cost covered by the free clinic). After two visits, she was thought to have a brain tumor. The free clinic ordered a brain MRI at a discounted rate from a local medical imaging company, and a 4 cm pituitary tumor was revealed. Several months later, Maria’s options for surgery remain uncertain. N: Maria, why did you come to the United States? M: I came to forget my ex-husband. We lived in a small town — it’s different there. You know how small towns can be. It was hard to leave, though. I still call my family there, but I haven’t been back. I haven’t told my mother about my diagnosis because I know she won’t sleep. She knows I have problems with my vision. She says, “Daughter, daughter of my life, tell me what is wrong.” I tell her it is nothing. N: It sounds like you miss your mother? M: Yes. My mother ended up alone. My older brother died in a car accident. My mother didn’t have a partner so she raised us by ironing for people.
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She sacrificed so much. N: What would your mother do if she found out your diagnosis? M: She would want what every mother wants, to have her children close. But I do not think I could go back to Mexico. It would be better if she doesn’t know. N: How has your life been in the United States? M: At the beginning, I didn’t like it so much. Over time, I got to like it more. I live with my sister and her family, and that is nice. I help take care of their kids. I also like my job, although I haven’t been able to work these last few weeks because of the dizziness. I turned around too fast while I was cleaning a bathtub and hit my face against the wall. My nose bled and hurt very badly. I didn’t want to tell anyone, but I realized it wasn’t safe to work anymore. N: How did your symptoms of the tumor first start? M: It is hard to say because I used to have migraines in general, so I just attributed the headaches to my migraines. However, my eyes started to get irritated, especially my left eye. I went to the free clinic, and a doctor told me my eye looked very red, so he referred me to an eye doctor. I went to the eye doctor in August [of last year] and they looked at my eye but didn’t tell me much. I went back in March, and they put me in a machine and told me to press buttons when I saw lights. The
doctor then told me that I had something behind my eye that would push my eyes out — more so on the left. I asked him if it was something really bad, and he said yes. N: How did you react to the news? M: I had hoped that the doctor was wrong, but deep down, I knew something was really bad. After I had the scan, I cried with my sisters. They tried to convince me everything would be alright. [Maria cries at this point in the interview.] I was hopeful when the young doctors at the clinic said they would look for a surgeon to take out the tumor, but a lot of time has passed, and I don’t know if I will get the procedure. Upon the free clinic’s advice, Maria tried going to a local emergency department. However, it was felt that her vision was not bad enough for urgent intervention. She was told to follow up with a neurosurgeon. Through the volunteer clinic, she was able to see a local neurosurgeon for a free consult. The tumor was thought to be
resectable and the surgeon was willing to waive his professional fees. However, to be admitted to the hospital, Maria would have to qualify for charity care and possibly make a personal financial contribution. As a next step, Maria was told she would have to formally apply for Medi-Cal, get rejected (as an undocumented immigrant, this is almost certain), and then come back with that documentation to qualify for charity care. She has spent the last two months trying to obtain this denial letter. N: Do you think about going back to Mexico to get treatment? M: Sometimes there aren’t good resources there, either. And if I got worse, I wouldn’t want to be a burden on my mother. I try to help her as best I can. I have been sending her money over the years. N: How have your symptoms progressed? M: The pain is worse, and I sometimes vomit. When I ride on the metro, I get lightheaded like I
might fall. The feeling is not exactly lightheaded. I don’t know how to describe it. I wake up with the headaches. I try to make myself strong and little by little, they get better throughout the day. Sometimes I look in the mirror and my face looks different to me — like a stranger. It feels swollen. My eyes are always irritated. I feel more clumsy. I can’t do things too fast. I sometimes hit myself against walls and furniture. N: Do you have hope? M: I try to stay strong, but I don’t know what will happen. I cry a lot. My manager told me I could go back to my job after I got the procedure.
Each time I drive past a billboard advertising one of our local healthcare systems, it pains me to think that the rental cost of this billboard would probably more than cover her surgery.
As of this year, the United States spends 17 percent of its GDP on healthcare — far more than any other industrialized country which has universal healthcare — but still does not insure 1 out of 6 of its occupants. About 12 million people (20 percent of the total uninsured) are estimated to be in the United States illegally.1 They tend to be younger and healthier than American citizens, and, having no benefits, avoid seeking medical attention unless there is a crisis. One analysis estimated that although undocumented immigrants account for 3.2 percent of the population, they account for only 1.5 percent of healthcare costs in the U.S.2 Still, in the absence of comprehensive preventative care, the cost of emergency care is taking its toll. In California, emergency MediCal spending for uninsured immigrants neared $1 billion in 2007.1 Most of this spending was for childbirth, complications of pregnancy, and major injuries. Uninsured immigrants account for 10 percent of emergency department patients in California and may account for 10 percent of the annual cost of uncompensated care in California hospitals. A UCLA study in 2007 estimated that 1 million of the state’s nearly 5 million uninsured residents are undocumented adults and 136,000 undocumented children.3 Data from UCLA for 2009 have shown a worsening in the healthcare crisis.4 Uninsured rates statewide now average 24.3 percent. Almost 29 percent (2.7 million) of Los Angeles County residents were without insurance at some point in 2009. Four coun-
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ties in California had uninsured rates over 30 percent: Shasta, Merced, Madera, and Imperial. Although anti-immigrant sentiment continues to run high in parts of the country, it is interesting to note that experts estimate that uninsured immigrants contribute more to the economy in taxes and labor than they receive in public benefits.5 On a personal note, I would bet that anyone — Republican, Democrat, or Human Being NOS (Not Otherwise Specified) — who would sit down with Maria and talk with her would want her to have timely care. But for now, as her physicians, we wait helplessly while a tumor grows slowly inside Maria’s head. When her vision completely fails, or she starts convulsing, she may receive more aggressive care in an emergency department. On a desk somewhere sits her application for MediCal, awaiting denial. A sea of doctors and hospitals surround Maria. Each time I drive past a billboard advertising one of our local healthcare systems, it pains me to think that the rental cost of this billboard would probably more than cover her surgery. I want to rent one and place a picture of her on it. “Wanted: Neurosurgery team to remove this lady’s tumor.” However, I cannot afford that so I write this article to you, dear Reader. firstname.lastname@example.org The author thanks medical student Denise Gutierrez and Dr. Cecilia Romo for their translation of Maria’s comments. 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 1 Okie, S. Immigrants and health care - at the intersection of two broken systems. NEJM 2007;357(6):525-529. 2 Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff (Millwood) 2006;25:1700-11. 3 Brown ER, Pourat N, Wallace SP. Undocumented residents make up small share of California’s uninsured population. Los Angeles: UCLA Center for Health Policy Research, March 2007. 4 Lavarreda SA, Chia YJ, Cabezas L, Roby D. California’s uninsured by county. California Health Interview Survey. UCLA Center for Health Policy Research. August 2010. 5 Mohanty SA, Woolhandler S, Himmelstein DU, Pati S, Carrascquillo O, Bor DH. Health care expenditures of immigrants in the United States: a nationally representative analysis. Am J Public Health 2005;95:1431-8.
The Revolution in Substance Abuse Treatment By David Pating, MD, and David E. Smith, MD Reprinted from the June 2010 issue of San Francisco Medicine. There is a coming revolution in substance abuse and mental health treatment, and it’s called health care reform. Building on two decades of brain research, we’ve reached a policy epiphany: The best evidence-based treatment does little good if people cannot access treatment. Health care reform might change all that. In the new paradigm, 31 million new patients nationally (3.7 million in California alone) will be newly insured, giving them access to effective substance abuse treatment. It’s been called a new “culture of coverage,” and physicians must be prepared. Here are just a few reasons: • Nationally, up to 40% of hospital admissions are drug- or alcohol-related. Yet fewer than 20% of physicians routinely ask about alcohol and drug abuse. Many do not know how to refer patients once a problem is detected, and, worse, there is a shortage of programs to treat drug addiction and alcoholism. • Pushed by patient demands for instant cures, many physicians prescribe large volumes of opioids for transient pain conditions and as sedatives for anxiety, creating the most rapidly growing drug epidemic: prescription drug abuse. OxyContin is everywhere. • Unaware of the developmental risks of substance abuse, many physicians treat adolescents as “small adults,” missing years of opportunity to prevent, delay, defer, or detect emerging drug, alcohol, or mental health illnesses. Meanwhile, through well-intentioned “zerotolerance” policies, marijuana-abusing students
are expelled from school, again missing key prevention moments while solidifying their academic and social failure. • As a community, we continue to treat addiction as a moral disorder punishable by jail time, foster care, or stigmatization rather than seeking opportunities to promote recovery, resilience, and community health. But that was before the revolution. As health care reform unfolds, opportunities will arise to bring the science of substance abuse treatment to mainstream medicine, with significant economic and public health benefits. We know what works in managing the social problem of substance abuse; we just need the political will. Fortunately, the Accessible Health Care Act of 2010 declares mental health and substance abuse treatment an “essential” benefit. As clinicians who have dedicated their careers to improving access to comprehensively integrated evidence-based treatment for substance abuse within HMOs (DP) and free health clinics (DS), we have seen firsthand the achievable improvements in health care and quality of life and the reduction in total health care costs when addicts and alcoholics are properly treated. At Northern California’s Kaiser Permanente, we have demonstrated that medical savings associated with integrated substance abuse treatment pays for the cost of treatment within six months by reducing hospitalization and emergency room and medical office visits. More significantly, simple screening for substance abuse in high-risk conditions, such as pregnancy, reduces the odds of preterm delivery by 2:1, placental abruption by 7:1, and intrauterine fetaldemise by 16:1. And we suspect that if indi-
The best evidencebased treatment does little good if people cannot access treatment. Health care reform might change all that.
viduals with addiction are properly treated, not only will their health costs decrease but so will the health costs for their families. In the public sector, for every 1,000 Californians who are uninsured or receiving Medicaid, 118 will have an alcohol abuse (or dependence) disorder, 57 will abuse drugs, and 12 will abuse pain medications, totaling 152 persons having any addiction-related disorder. Annually, this costs the state $1.29 billion in health care costs for the approximate 20% of Californians who are uninsured. If only 10% of this cohort were treated, the estimated health savings would be $400 million alone, with additional reductions in psychiatric problems (greater than 40%), family and social problems (50–60%), other medical problems (15–20%), and employment problems (15–20%) — all stemming from proper substance abuse intervention.
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Treatment works! We just need to make it accessible to a larger population. That’s the beauty of heath care reform. Treatment coverage will expand, costs will come down, capacity will grow. We need physicians willing to lead this revolution! David Pating, MD, is chief of addiction medicine at Kaiser Medical Center, San Francisco, and assistant clinical professor in the Department of Psychiatry at UCSF. Currently, Pating serves as an appointed Commissioner on California’s Mental Health Services Oversight and Accountability Commission (Proposition 63), where he chairs the Services Committee. David E. Smith, MD, is the Chair of Addiction Medicine at Newport Academy and serves as the medical director of Center Point. He was the founder of the Haight Ashbury Free Medical Clinic. He is also an adjunct professor at UCSF. A full list of references is available online at www.sfms.org.
Meaningful Use of an EHR System: Final Federal Rule A summary for physicians prepared by the CMA.
In order to qualify for federal electronic health record (EHR) incentive payments, a physician must demonstrate “meaningful use” (MU) of a certified EHR system. Achieving MU requires meeting criteria established in federal regulations. The final rule for Stage 1 of MU in the Medicare program was released by the Centers for Medicare & Medicaid Services (CMS) on July 13, 2010. The State of California will define MU for Medi-Cal. Generally, non-hospital-based Medicare providers will qualify for up to $44,000 and non-hospital-based Medi-Cal providers can qualify for up to $63,750. The final rule only defines Stage 1 of MU. A subsequent federal rulemaking will define Stage 2, which will take effect in 2013. CMS has not defined the expectation after 2014. Physicians can begin demonstrating MU on January 1, 2011. In the first year a physician must demonstrate MU for 90-days within the calendar year. A physician is allowed but not required to assign their incentive payment to a third party, however, a physician practicing in multiple sites must designate only one site to receive their incentive.
Medicare Incentive Program. Overall, a physician will have to report on 15 objectives in order to achieve meaningful use. One of the objectives, reporting on clinical quality measures, will require reporting on six quality measures. Therefore, a physician will have to report on 20 measures total. Within the clinical quality measure objective, three will be “core” or “alternate core” measures on which all physicians will have
to report. In addition, physicians will select three clinical quality measures from a list of 41 options. Physicians who believe that a core objective or core quality measure is inapplicable to their specialty will be allowed to report that to CMS and will not be held responsible for that objective. In addition, physicians will not be held accountable where health information technology infrastructure may not be developed enough to allow for completion of an objective.
Medi-Cal Incentive Program. While the final determination of meaningful use for the Medi-Cal program will be left to the state, the rule limits the ability of states to deviate from the Medicare meaningful use definition. Unlike in the Medicare program, Medi-Cal incentives are based on cost. In any given year, the maximum incentive for a Medi-Cal physician will be 85 percent of the “net allowable average cost.” In the Medi-Cal incentive program physicians must have a practice of 30 percent MediCal patients (20 percent for pediatricians). In a clinic or medical group setting, physicians are allowed to use a practice-level determination. That is, if more than 30 percent of a clinic’s patient volume or a capitated medical group’s patient panel is Medi-Cal, every physician in the clinic or group can qualify under the program. For a more detailed summary of MU, please go to CMA’s HIT resource page www.cmanet.org/HIT
Jerome A. Lackner, MD, JD 1927–2010
I met Dr. Lackner some years ago in the early stages of my pain practice, sometime near 1990 or so. I had begun interventional procedures, as an anesthesiologist, and started medication management from my experience as an internist. Because my practice developed into an opiate analgesic practice, I found myself at the other end of Jerry’s philosophy in regards to prescribing. We developed a friendship, and he taught me about addiction and I shared my experience with the positive aspects of opiate analgesic therapy. I had little knowledge about what a giant of a physician I was privileged to work with. When I became involved in the recovery community, I met Jerry again at a 12 step meeting based at Sutter General Hospital. He was the guru of that meeting. Some years later he founded the Silkworth Foundation to provide services to people suffering from the disease of addiction without regard for payment. I attended a fund raiser and found people from all walks of life whom he had helped to become sober and experience the joys of life without drugs and alcohol. Few people were willing to do this then and now. He knew what was right and under-
stood his singleness of purpose as a physician. I knew that he was Governor Jerry Brown’s head of the California Department of Health Services and that he had provided aid and comfort to the farm workers of California, a group of hardworking people who often were without health care and without a physician. He founded the United Farm Workers Union clinic in Salinas, and became a tireless advocate for the farm worker’s rights. I did not realize he was known to Dr. Marin Luther King during the civil rights march in Selma, Alabama, in 1965. He also fought against what he felt was the “dehumanizing effects of managed care” and famously dropped out of the insurance industry and Jerome A. Lackner, MD, JD decided to go it alone for the benefit of the underserved. Jerry Lackner was and is a role model for what we physicians should all aspire to be: selfless in the pursuit of social justice. When he saw the outrages of his time, he did something about them. Godspeed to you, Dr. Lackner. — Lee T. Snook, Jr., MD
Nominations Are Being Accepted for the SSVMS Annual Awards The Golden Stethoscope: Candidates must be members for at least 15 years and have demonstrated a career clearly oriented to their practice and the care of their individual patients in an environment of unselfishness, compassion and empathy. Medical Honor: Candidate must be a member for 5 years, practicing or retired, whose high achievement has allowed a contribution of great significance to El DoradoSacramento-Yolo medicine or community health. Medical Community Service Award: Presented
to a non-physician community member or leader of a community organization in the El Dorado-SacramentoYolo area who has made a significant contribution to a medical or public health problem. Send letters of nomination to the Medical Society office c/o Byron Demorest, MD, Chair, Scholarship & Awards Committee, or contact Chris Stincelli at (916) 456-2018. Deadline: November 1, 2010. We encourage you to discuss your nomination with us in advance to be certain award qualifications are met.
Wide Eyes in the Developing World By Quincy Moore, MS II
...even those who cannot afford a new pair of shoes can receive quality care at a community clinic.
As a first-year medical student, I was filled with ambivalence when offered an opportunity to spend four weeks in the hospitals and clinics of Leon, Nicaragua. I never wanted to be “that person” who travels to impoverished countries to enjoy their natural beauty and culture at a bargain price — only to return home to my air-conditioning and hot showers — while leaving little behind. As the second poorest country in the western hemisphere, Nicaragua has a gross national income per capita of just $1,080 (per the World Bank). I figured the value of my plane ticket could have had a greater impact on the Nicaraguan people than my mental arsenal of biochemistry, anatomy, and basic physiology. But during my month-long stay with seven classmates, three undergraduate interpreters, and three physician preceptors, the value of our mission became clear. The MEDICOS Nicaragua program at the UC Davis School of Medicine has existed for eight years as a student-driven exchange between U.S. and Nicaraguan medical students. Our focus is to learn how medicine is practiced in a resourcepoor country and to build relationships with Nicaraguan students — some of whom travel to Sacramento each winter. UC Davis students bring basic medical supplies to donate to public hospitals and clinics. Such supplies are appreciated in a place where premies are raced down two flights of stairs because there is no portable ultrasound to bring to the NICU, or where blood is dripped from a needle into an open tube because there are no vacutainers. During our visit, I tried to learn from the strengths of Nicaraguan health care rather than
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dwell on the limitations of Leon’s public hospitals and clinics. I was humbled by the universal health care; even those who cannot afford a new pair of shoes can receive quality care at a community clinic. Even this poor nation has surpassed the U.S. in deciding that health care is a fundamental right instead of privilege. I admired the government’s effort to prevent disease before it becomes costly and difficult to treat. We accompanied a health worker in El Sauce, a small rural town, on his daily mosquito abatement assignment. We strolled through smothering heat, knocking on brightly colored doors and calling over fences to women washing clothes on the first non-rainy day that week. Each family welcomed us into their yard. Most households kept barrels and tubs of reserve water for washing, since plumbing supplied fresh water for only a few hours each day. We inspected stagnant water for pupae and larvae, dumped contaminated water, and deposited chemical insecticides. When we found larvae, we took samples to bring back to the lab to test for dengue. If the lab technicians find evidence of dengue, they send a team to fumigate the entire block surrounding the affected house. With few resources, Nicaraguan health officials are careful to maximize the impact of each dollar spent. “Nica” medical students also impressed me with their clinical acumen. Medical training is practical and fast-tracked with undergraduate and medical studies combined into six years followed by internship and two years of public service. Astronomical student loans are unknown, and the public service component reflects a social responsibility I have not seen in the States.
Nica students are thrust into the clinical setting starting with their second year and learn quickly to master the physical exam. The “pops” of their percussions announced internal organs, their eyes were a library of pathology, and they exhibited confidence and control when seeing patients on their own. “Nicaragua is a poor country,” one of them told me. “We cannot use the technology you have in your country to diagnose our patients. We have only this,” he said, holding up a stethoscope. Careful observation and examination had to suffice, and it proved surprisingly accurate. Despite the clinical acuity of their physicians, I often felt sorry for Nicaraguan patients. I was shaken by the prevalence of patients presenting with “diabetic foot” or malnutrition, as well as the repeated failure of the X-ray machine during an endoscopic retrograde cholangiopancreatography. But in an impoverished country, I expected to see this advanced pathology and lack of resources. Universal healthcare did not always mean timely and adequate healthcare. I was more troubled by something that felt easily changeable. Medical professionals demonstrated great commitment and clinical knowledge, but rarely took measures to ease the mental and physical discomfort of their patients. Nicaragua is full of humble people with generous hearts. The doctors were no exception, but their interactions with patients often lacked the communication and tenderness I had come to expect from good physicians back home. In labor and delivery, soon-to-be mothers writhed in pain while doctors, nurses, and medical students intervened only to facilitate delivery or chide mothers against screaming. Women endured the hardship of labor in a communal room with total lack of privacy and minimal draping. Students filed through to do cervical checks, often without a word of acknowledgment to the patient. Doctors conferred on a patient’s condition in the midst of the scene, talking as if they were alone. HIPAA was nowhere to be found down here! With no family members allowed in the birthing room, the indifference of the medical staff seemed to leave women feeling isolated and unsupported. Perpetually toeing the line between assisting
and interfering, my colleagues and I made an effort to comfort patients when we could. We held patients’ hands, asked them permission before a procedure, explained what we were doing and why, complimented someone’s courage in a time of difficulty, or simply smiled. I never asked why the Nicaraguan doctors seemed less concerned with their patients’ comfort. Perhaps physicians felt that government-funded healthcare, for which every patient was unfailingly grateful, did not include this luxury. Perhaps I was blind to some cultural understanding between patient and doctor. Perhaps the Nicaraguan medical education system stands where its U.S. counterpart did 40 years ago — imparting a paternalistic bedside manner similar to that which my mother witnessed in nursing school. Whatever the case, I left with an appreciation of the patient-centered education I receive in medical school and the compassionate doctors whom I have worked with early on in my medical career. Some see MEDICOS as an exciting opportunity to observe unique pathology, witness extreme poverty, and bring resources to a country in need. But I now know that there is a much richer experience to be had. I learned from doctors there the richness of the physical exam and the subtleties of practicing medicine where resources are scarce. I sat next to patients in need of companionship. I traded philosophies with medical students who walked a different path than mine. I saw how much one can do with so very little, and left inspired to bring some of Nicaragua back to my country. We have much to be proud of in the U.S., but any “American” who travels with open eyes and a caring heart can learn as much from the developing world as I did.
I learned from doctors there the richness of the physical exam and the subtleties of practicing medicine where resources are scarce.
QPMoore@UCDavis.edu For more information about MEDICOS Nicaragua, see the September 2009 issue of Sierra Sacramento Medicine. Email the author to make a donation or get involved with the program. 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 September/October 2010
Are You Receiving the Benefit of Your Membership Savings? Eligible members save 5% on their workers’ compensation premiums (15% depending upon your small group medical policy). The Sierra Sacramento Valley Medical Society and EMPLOYERS®, through Seabury & Smith Insurance Program Management (Marsh), have teamed up to offer the workers’ compensation insurance coverage and service they need at a discount. These discounts can be accessed by contacting Marsh, the SSVMS sponsored broker and administrator. In addition to the upfront savings you may receive as a SSVMS member, you may also benefit from long-term savings with an EMPLOYERS workers’ compensation policy. Here’s how: • Payment Flexibility — EMPLOYERS’ policies start at just $500, and payment plans are available. • Helping Keep Your Employees Safe — Loss Control field staff and online tools, such as Loss Control ConnectionSM, make it easier to help your employees follow safe work practices, reducing the chance that they will be injured. • Helping Keep Your Practice Safe from Fraud —
Since 2003, EMPLOYERS’ rigorous fraud detection efforts have resulted in over $35 million in savings. • Financial Strength — EMPLOYERS is rated A(Excellent) by the A.M. Best Company. And, should your practice have a workers’ compensation claim, the experienced professionals at EMPLOYERS will work to deliver prompt, efficient service to resolve your claim quickly and fairly while helping to ensure your employees get appropriate healthcare and return to work as soon as medically possible. This sponsored workers’ compensation program provides an affordable insurance policy and includes tools, resources, and expertise that will help you control future costs. To find out more, call a Marsh Client Service Representative at 800-842-3761. CA Ins. Lic. #0633005 · AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management 46755 (9/10) ©Seabury & Smith Insurance Program Management 2010 In California, workers’ compensation insurance and related services are offered through Employers Compensation Insurance Company.
Your care makes all the difference.
Trevor Austin Kott — Oct '06 - Apr '07. Still inspiring people to give hope to patients in need.
There are those who give blood and there are those who stand ready to give marrow should a match be found. To the medical professionals who care for every man, woman and child who receives these precious gifts, www.bloodsource.org
not-for-profit since 1948
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thank you for your support of every patient in need.
Jerome Cared for Patients Outside the Safety Net Jerome Lackner, the iconic physicianactivist with the giant handlebar moustache who convinced Sacramento News and Review to publish his 1997 diatribe against managed care, has finally said farewell to medicine. He never retired, asserting he was “forced out” of his primary care practice by a managed care system that “made no provision for the type of medical care” he gave. In his letter to patients and community, the former state health director under Governor Jerry Brown quipped that he was “trying to break into prison to escape managed care.” He denied burnout. He just didn’t want a “prefrontal lobotomy to achieve financial success as a doctor under managed care.” In spite of what seemed like a farewell letter, he remained devoted to each and every patient. At age 70, with the help and encouragement of Nancy Otterness and other friends, Jerome founded the Silkworth Memorial Fund and Clinic. (We always called him Jerry, but Nancy says he preferred Jerome, so I’ll honor that preference in this tribute. His patients just called him “Doc”). The non-profit venue allowed him to escape managed care but continue to devote his life to saving people from their addict-selves. The “clinic,” operating out of his Davis home, provided completely free, round-the-clock medical care for patients suffering from drug and alcohol addiction. He cared for anyone who needed him, from physicians to parolees. The clinic perpetuated Jerome’s life of giving. Since administering medical care to civil-rights workers pummeled during 1965 marches in Alabama, he had always been a crusader. He worked with Cesar Chavez to provide health care to farm labor workers. He welcomed the
disenfranchised into his practice. Jerome worked 24 hours per day, 365 days a year. He couldn’t understand why doctors could see patients during the day when they were well enough to walk into the office, but leave them to fend for themselves with on-call physicians when they were really sick in the middle of the night. He committed himself to their care — whenever they needed him. Michael Parr remembers many evenings spent with Jerome doing interventions for “impaired” physicians as part of their work on Sutter’s Physician WellBeing committee. Nancy calls it an old-school brand of dedication that hasn’t been seen since country docs went out of style. He gave of himself to community and family, as well as his patients. People have taken issue with his style, but he filled a community void by taking care of those outside the safety net. According to Michael, Jerome could treat addicts with courtesy and respect because he knew addiction is a disease, not a moral issue. Far from resenting their father’s “addiction” to medicine, his children adored and respected him. At his memorial service they lovingly recalled participating in his medical life and spending summer vacations as a family doing volunteer medical care in farm labor camps. This son, brother, uncle and father of physicians felt “blessed to have difficult patients with easy diseases.” His joy came from fostering true health, not just escape from disease, by coupling “judicious use of medical means” to lifestyle change. Jerome didn’t pick patients who needed a pill and a pat on the knee, he chose a “flock” of difficult addicts and alcoholics. He would start office visits by asking what was going on in their lives, because he knew the physical symptoms followed the emotional. His September/October 2010
This son, brother, uncle and father of physicians felt “blessed to have difficult patients with easy diseases.”
ever-present dog named Special was the office psychiatrist. Jerome gave patients the time they needed, sometimes with two-hour visits, which probably contributed to his managed care, but not patient, downfall. He held out under managed “care” as long as he could. His personal savings paid office staff to satisfy the HMOs’ “rampant paperwork addiction” until his money was gone. That was when his friends tried to compensate for his disabled business acumen by setting up the Silkworth clinic as a venue for his special brand of care. Even then, though neither he nor his wife (the CEO of the clinic) took a salary, the clinic suffered from poor funding because he refused government grants — he would not violate his patients’ confidentiality to satisfy grant documentation requirements. Jerome could be stubborn. He believed he would have been “better balanced and better
Being unchangeable and unique led to a solitary treatment style.
To learn more, call 866-534-3403 or visit healthcare.goarmy.com/k827.
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behaved” if he had been more heedful of the rabbinic scholars on his mother’s side of the family. As Michael puts it, “Dogmatic is an understatement.” That approach at times brought him up against hospital review committees, on one of which I served. I seem to remember that we felt his detox treatment was certainly unconventional but the patient did fine and we were no match for his expertise in the field. His stubbornness extended to his patients, but hardly anyone minded because they knew it originated from an endless well of devotion to their care. A new patient-addict was told to quit at the first visit. Otherwise he/she could leave and come back when ready — he would always be available. If willing to quit, his next line was, “Come to a meeting tonight — I’ll go with you.” Jerome figured he had remedied more than 1,000 addicts over the years. As an alcoholic clean and sober since the 1970s, he long ago started his own 12 step fellowship group at Sutter General Hospital. He attended and directed all the meetings, which, according to Nancy, were unlike any other. Being unchangeable and unique led to a solitary treatment style. The late psychiatrist Larry Otterness, MD, came closest to being a true collaborator. He and Jerome shared patients and lectured frequently about addiction and treatment. Jerome said he wanted to die practicing medicine. He achieved that goal, in spite of having slowed considerably. According to Michael, “There will never be another man or doctor like him. Jerry was remarkably kind and tireless in the fight against addiction on behalf of his patients.” — Ann Gerhardt, MD, with help from his friends, Michael Parr, MD, and Nancy Otterness, PhD, and Jerome’s own printed words.
Board Briefs July 12, 2010 The Board: Unanimously voted to support Dr. Paul Phinney’s candidacy for CMA President-Elect in 2011 and to approve his use of the Society’s name on his announcement card. Nominated Dr. Demetrios Simopoulos to the CALPAC Board of Directors representing Senate District 1. Approved the following CMA Delegation changes: (1) Dr. Robert Kahle appointed to the new Delegate Office #18; (2) Dr. Reinhardt Hilzinger moved from Alternate-Delegate At-Large Office 10 to Alternate-Delegate Office #1 to fill the vacancy created by Dr. Kahle’s appointment to Delegate; (3) Dr. Russell Jacoby appointed to Alternate-Delegate at-Large Office #18. Approved the Membership Report For Active Membership — Nancy P. Torres, MD For Reinstatement to Active Membership — Derek J. Wong, MD For a Return to Active Membership from Retired Membership — Gerald N. Rogan, MD For Resignation — Robert J. Rhodes, MD (moved to Colorado).
September 13, 2010 The Board: Received an update from Dr. Stephen Hiuga, President of the Northern California Physicians Council (NORCAP). The council was founded in 1975 to assure that physicians had affordable and reliable medical malpractice insurance. Approved the 2010 Second Quarter Financial Statements and Investment Recommendations and Reports. Authorized the Executive Director to sign
the contract between SSVMS and Sacramento County for the SPIRIT Project volunteers to provide services in county clinics. Approved grants from the William E. Dochterman Medical Student Scholarship Fund to the following individuals for 2010: Kellen T. Galster, Kiyumi V. Heard, Andrea L. Nos and Kelly Quinley. Approved the Membership Report: For Active Membership — Mohammad K.S. Al-Souqi, MD; Brad H. Auwinger, DO; Sundeep S. Bains, MD; Jamil H. Bitar, MD; Jason P. Bynum, MD; Keith W. Chan, MD; Matthew S. Chan, MD; Phillip A. Cole, MD; Erin M.S. Deane, MD; Shuchita Gupta, MD; William B. Hatten, DO; Candace J. Jones, MD; Mohammad J. Kabbesh, MD; Joanne B.S. Lim, MD; KieuLoan Luc, DO; Amin Matin, MD; Marta M. Minnerop, MD; Loay A. Muftah, MD; Tuan A. Nguyen, MD; Robert P. Norris, MD; Anandray B. Patel, DO; Michael A. Patmas, MD; Dorothy L. Pitman, MD; Jacob Reznik, MD; Gurnasib S. Sandhu, MD; Jaskaram V.S. Sandhu, MD; David R. Soto, MD; Amber M. Stevenson, MD; Sultan A. Sultan, MD; Tien H. Tran, DO; Kevin T.I. Whang, MD. For Government Membership — Jessica M. N. de-Ybarra, MD For Resident Membership — Alexis F. Lieser, MD For Reinstatement to Resident Membership — Andrew H. Huang, MD For Reinstatement to Active Membership — Aaron C. Cook, MD Dropped for Nonpayment of Dues — Kevin A. Vu, MD For Resignation — John J. Geraghty, MD (transferred to Placer-Nevada); Erin B. Marcin, MD
Bayanihan, a UC Davis Student-Run Clinic By Katie Camilleri, MS II Bayanihan (Buy-uh-nee-han) Clinic: a mouthful of a name, which in Tagalog means “a collective group of people working together towards a common goal.” For volunteer physicians, this goal is to help teach and guide future doctors while providing care to the underserved and uninsured. For UC Davis medical students, this goal is to gain clinical experience with hands-on patient care and leadership in a free clinic. For UC Davis undergraduate volunteers, the goal is to provide substantial outreach to the Filipino community and Filipino World War II veterans. As a whole, this goal is to thrive as people, providing quality free health care to patients from the Sacramento area every Saturday, while simultaneously enriching themselves and others through learning and teaching. Pre-clinical medical students particularly value the bed-side teaching and clinical perspective that volunteer physicians offer. Samuel Tate, a second year medical student, appreciates how preceptors “evoke thought processes and allow medical students to engage in the care of their patient from intake to discharge.” Medical students have an opportunity to collect patient histories, perform physical exams, present to physicians, collectively assess the patient and determine a treatment plan. The experience can be equally valuable for preceptors. As volunteer preceptor Dr. Lorenzo Rossaro said, “The learning experience is a two way road and I feel the medical students complete my understanding of how medicine should always and universally be aimed to the suffering… they remind me why I became a doctor in the first place.”
Sierra Sacramento Valley Medicine
Bayanahan Clinic’s History In February of 2002, four UC Davis undergraduates recognized the need for a free clinic serving the Filipino community, specifically Filipino World War II veterans. Richard Ikeda, executive director of Health for All, became the group’s sponsor, and supported development of this primary care project. A name was chosen, and a mission statement drafted. A major fundraising golf tournament (now an annual event) was organized by Dr. Aloysius Llaguno. Dr. Ikeda opened the doors of Health For All to the Bayanihan clinic on Saturdays. In October 2002, the group recruited undergraduate clinic volunteers, specifically Filipino pre-health students, to encourage them to pursue a career in medicine. In 2007, Bayanihan Clinic officially became a student-run clinic affiliated with the UC Davis School of Medicine. Dr. Luz Guerrero, medical director of Bayanihan Clinic, five medical student directors, and a board of undergraduates manage the clinic. Physicians from the community, UCDMC, Kaiser, and Mercy, UC Davis medical students, and UC Davis undergraduate students ensure Bayanihan Clinic’s ability to offer free health care. Additionally, Bayanihan Clinic volunteers organize and hold medical outreach events to veterans and the Filipino community around the Sacramento area, including mini-medical missions in Yuba City, Vallejo, Mare Island, South Sacramento, and at the American Legion. Last July, Bayanihan Clinic even sent a medical mission to the Philippines. Bayanihan Clinic always needs more physician volunteers. If you would like to precept continued on next page
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 Al Souqi, Mohammad KS., Internal Medicine, Khyber Medical College, Pakistan 2001, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000
Gupta, Shuchita, Internal Medicine, Maulana Azad Medical College, India 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6097
Patel, Anandray B., Pulmonary/Sleep Medicine, Univ Health Sciences College of Osteopathic 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5764
Auwinger, Brad H., Family Medicine, Western University of Health Science 2007, Sutter Medical Group, 5765 Greenback Ln, Sacramento 95841 (916) 865-1040
Hatten, William B., Family Medicine, Univ North Texas/College of Osteopathic Medicine 2007, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777
Patmas, Michael A., Internal Medicine, University of Nevada 1981, Woodland Clinic Medical Group, 1325 Cottonwood St, Woodland 95695 (530) 669-5357
Bains, Sundeep S., Family Practice, UC Davis 2006, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-7070
Jones, Candace J., Pediatrics, UC Los Angeles 2007, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060
Biring, Inderpal K., Internal Medicine, Touro University 2007, Sutter Medical Group, 2800 L St, Sacramento 95816 (916) 454-6640
Kabbesh, Mohammad J., Infectious Diseases/ Geriatrics/Internal Medicine, University of Damascus, Syria 1997, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2605
Bitar, Jamil H., Emergency Medicine, Harvard Medical School 2005, The Permanente Medical Group, 2025 Morse Av, Sacramento 95825 (916) 973-6061 Boyd, W. Douglas, Cardiothoracic Surgery, University of Ottawa, Canada 1984, UCDMC, 2221 Stockton Blvd., #2112, Sacramento 95817 (916) 734-7255
Rahimi, Sholeh, Internal Medicine, Albert-Ludwigs University of Freiburg, Germany 1994, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5225
Lieser, Alexis F., Emergency Medicine, UC Irvine 2007, American College of Emergency PhysiciansSacramento (Research Fellow-Health Policy)-Resident Member Lim, Joanne B., Radiology/Interventional Radiology, Wake Forest University 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6518
Chan, Keith W., Orthopedic Surgery/Sports Medicine, Stanford University 2004, Sutter Medical Group, 2725 Capitol Ave #302, Sacramento 95816 (916) 731-7800
Luc, Kieu-Loan, Family Medicine, Touro University 2007, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2605
Cole, Phillip A., Infectious Diseases, UC San Francisco 2003, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040
Matin, Amin, Radiology/Musculoskeletal Radiology, Harvard Medical School 2004, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400
Deane, Erin M., Family Medicine, UC San Diego 2007, Sutter Medical Group, 568 N. Sunrise Ave #250, Roseville 95661 (916) 865-1140
Muftah, Loay A., Pediatric Radiology, Cairo University, Egypt 1989, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400
Eder, Shelley J., Family Medicine, UC Davis 2007, Sutter Medical Group, 1201 Alhambra Blvd., #300, Sacramento 95816 (916) 451-4400
Nguyen, Tuan A., Radiology/Neuroradiology, UC San Diego 2002, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400
Reznik, Jacob, Ophthalmology, UC Irvine 2004, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 746-4538 Sandhu, Gurnasib S., Internal Medicine, Government Medical College, India 2003, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000 Sandhu, Jaskaram V.S., Internal Medicine, Rajendra Medical College, India 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6097 Soto, David R., Radiology/Interventional Radiology, SUNY-Downstate 2003, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400 Stevenson, Amber M., Dermatology, Chicago Medical School 2006, Sutter Medical Group, 8170 Laguna Blvd., #200, Elk Grove 95758 (916) 478-6570 Tran, Tien H., DO, Radiology/MRI, Touro University College of Osteopathic Medicine 2004, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400 Whang, Kevin T., Radiology/Vascular Interventional Radiology, Georgetown University 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6518
Norris, Robert P., Emergency Medicine, University of Pittsburgh 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6061
Bayanihan continued from previous page medical students or be on our list of on-call specialists, please contact Amy Jouan at (916) 734-4106 or email@example.com. For more information see www.bayanihanclinic.com or firstname.lastname@example.org.
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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Position Available M.D. / D.O. wanted as part of a holistic antiaging team of practitioners. Independent contractor position with rooms for rent / % split. Currently we have Pilates, Massage and Chiropractic and would like to add a Nurse practitioner, and Acupuncturist as well. Low overhead. Beautiful decor and prime space. Located Howe and Hurley. Huge marketability potential. Contact: drkit@nepheshonline. com or call 916-925-2007.
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.
Membership Has Its Benefits!
Free and Discounted Programs for Medical Society/CMA Members Auto/Homeowners Insurance
Mercury Insurance Group 1-888-637-2431 www.mercuryinsurance.com
Avis: 1-800-331-1212 (ID#A895200) Hertz: 1-800-654-2200 (ID#16618)
Clinical Reference Guides-PDA
EPocrates 1-800-230-2150 / www.epocrates.com
Conference Room Rentals
Medical Society (916) 452-2671
MBNA 1-866-438-6262 / Priority Code: MPF2
Corporate Express /Brandon Kavrell (916) 419-7813 / firstname.lastname@example.org
Practice Management Supplies
Histacount 1-888-987-9338 Member Code:11831 www.histacount.com
Infinedi – Electronic Clearinghouse 1-800-688-8087 / www.infinedi.net
Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911 Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...
Marsh Affinity Group Services 1-800-842-3761 CMACounty.Insurance@marsh.com
HIPAA Compliance Toolkit
PrivaPlan 1-877-218-7707 / www.privaplan.com
Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com
Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma
Security Prescription Pads
Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php
UCG Decision Health 1-877-602-3835 / www.decisionhealth.com
Travel Accident Insurance/Free
All Members $100,000 Automatic Policy
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 (email@example.com) if interested.
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Since 1973 • Max Uden, Owner • (916) 455-5880
Sierra Sacramento Valley Medicine
Out of this world design. www.PlanetKelly.com
Dr. Gordon Love’s article in the last issue about the Loa loa worm reminded Kaiser ophthalmologist Dr. Sukhjit Johl of an old case. “As an oculofacial plastics fellow at a busy level I trauma center, I spent a lot of time in the emergency department. One night, while making an ED ‘sweep’ before going home, one of the ED residents asked me to take a look at a patient [a recent immigrant from Nigeria]. I was able to remove the worm at the slit lamp and held it up like the Vince Lombardi trophy to the cheers of the ED staff gathered around.” These are his photos of the affected eye, and of the worm itself, measured in centimeters.
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Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...
Published on Sep 14, 2010
Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...