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Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2010


Independent But Not Alone.

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Sierra Sacramento Valley

MEDICINE 3

PRESIDENT’S MESSAGE Working Our Way Out of the Mental Health Crisis

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Stephen F. Melcher, MD

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Annual Meeting Invitation

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ELetters

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EDITOR’S MESSAGE Reformations in Health Care

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Striving for Optimal Wellness and Equality in Healthcare

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John Loofbourow, MD

Jose Alberto Arevalo, MD

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A Posit on Health Reform

Etta Lund MD, Willows Pioneer Country Doctor

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CONVERSATIONS Faith Fitzgerald: Know the Science, Know Your Patient

By Irma West, MD 9

David Gunn, MS IV 32

What’s New at CMA?

33

SSVMS Election Results

34

Board Briefs

Land of a Thousand Hills

35

New Applicants

Steven Gelber, MD, MPH, et al

36

Classified ads

Chronic Pain — The Right to Bear Vicodin?

Nathan Hitzeman, MD 15

Toward Fixing the SGR

Gerald N. Rogan, MD

Richard N. Gray, Jr., MD 11

Voices of Medicine

Del Meyer, 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 image, from a slide of adenocarcinoma, is the last in a series of covers by pathologist Dr. Gordon Love.

Volume 61/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

November/December 2010

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Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 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 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 Rajan Merchant, MD Gerald Upcraft, MD Vacant Vacant

CMA Trustees 11th District Vacant Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, MD Very Large Group Forum Paul Phinney, MD

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AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor Robert Forster, MD George Meyer, MD David Gunn, MS IV John Ostrich, MD Nate Hitzman, MD Robert LaPerriere, MD Gerald Rogan, MD F. James Rybka, MD Gordon Love, MD Gilbert Wright, MD John McCarthy, MD Lydia Wytrzes, MD Del Meyer, MD Managing Editor Webmaster Graphic Design

Ted Fourkas Melissa Darling Planet Kelly

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2006 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

Sierra Sacramento Valley Medicine


PRESIDENT’S MESSAGE

Working Our Way Out of the Mental Health Crisis By Stephen F. Melcher, MD IF ANY GOOD HAS COME from our county’s mental health crisis, it is greater awareness of the multiple problems and shortcomings of our county’s mental health and chemical dependency systems of care — even before the most recent budget cuts. It has brought people to the table to try to manage this situation. A few weeks ago, Scott Seamons, of the Hospital Council of Northern and Central California, and I met with the CEOs of the three psychiatric hospitals in Sacramento at the SSVMS Emergency Care Committee meeting. This is the first time I’m aware of that all three psychiatric hospitals were at the table with the county ED chiefs/directors to discuss how to collaborate on this issue and work together more effectively. The emergency room directors and psychiatric hospital CEOs educated each other about the problems they each face in this crisis. At this meeting, the psychiatric hospitals agreed to try to standardize their medical workup as much as possible, so that labs/tests done in any ED will be the same labs/tests requested at any of the three psychiatric hospitals when a patient is presented for admission. Hopefully, this process will fix the current system in which one psychiatrist at one hospital wants labs ABC and another psychiatrist at a second hospital wants labs ABC and D. The request for additional labs adds extra time in the ED for the patient and staff. These requests for labs should be as evidence-based as possible. At upcoming meetings, I hope the psychiatric hospitals will also look at exclusionary criteria for admissions and try to standardize them as much as possible. In 1998, we lost about 100

psychiatric beds with the closure of two psychiatric hospitals. Before we lost those beds, the psychiatric hospitals would take patients with multiple minor medical problems. Today, with the changing market forces and the ability to fill beds more readily, most psychiatric hospitals exclude patients with minor medical problems. Many of these patients now need to be admitted to a medical hospital bed to get psychiatric care. Keep in mind, if it weren’t for their psychiatric needs, these patients would be sent home. There is something wrong with the system when we have to admit these patients to a medical bed, and all of the associated costs to get psychiatric care, because we can’t get them admitted to a psychiatric hospital bed. There are lots of medical needs that can’t be safely taken care of in a general psychiatric hospital (e.g., IVs, feeding tubes). These patients need to go to a med-psych unit licensed differently from a general psychiatric hospital (such as Woodland’s Med-psych Unit). But it seems a minor medical problem like obesity or pregnancy should not keep a person out of a psychiatric hospital, as it does in some hospitals in this state. There are some true safety concerns treating such patients in a psychiatric hospital, but a good nursing staff should be able to address these concerns. There is something wrong with the system when I can admit a peritoneal dialysis patient to a crisis residential facility for psychiatric care, but I can’t get this patient admitted to any of our psychiatric facilities. There is something wrong when I can get a pregnant patient or an obese patient admitted

November/December 2010

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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to a crisis residential unit, but not to some of the psychiatric hospitals in this state. It seems discriminatory. It seems to violate the ADA law. Let’s hope the local psychiatric

hospitals see this the same way. stephen.melcher@gmail.com

Board Member Statement and Profile Our Medical Society is among the largest in California. The Board of Directors includes the officers of the society, and representatives from each SSVMS membership district and the CMA and AMA. All are elected by the membership, so that information and access is vital to a well-run and representative organization. For a complete listing of names and addresses of board members please log on to www.ssvms.org.

John Belko, MD Medical school: SUNY – Health Science Center at Brooklyn 1995 Pediatrics, Pediatric Infectious Disease SSVMS Representative for District #5 – Permanente Medical Group

Why do I serve on the Board? To find ways to help all members of our community get access to quality healthcare. Please contact me by email at: john.belko@kp.org

I was born and raised in New York City, the son of immigrant parents from Eastern Europe. As one might expect, my parents encouraged my brother and I to pursue careers in either medicine or law, but they also stressed that we remember ”where we came from.” They taught us to treat others as we would wish to be treated. To be quick to help, non-judgmental, and supportive. My parents worked two jobs each to help put my brother and me through school, and they made every effort to have us participate in the community to help those that were less fortunate than we. It was these very qualities that helped me persevere and get into medical school and, ultimately, into the field of infectious disease.

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So, how did I get to California? Well, while a fellow in Boston, I met and fell in love with a wonderful clinician. After we got married, we looked for a place where she could continue her training and I could develop and grow my practice. A colleague of mine working at Kaiser South Sacramento suggested that I interview with his group and the rest is history. Since then, I’ve had the opportunity to enjoy wine tasting in the foothills, hiking along the coast, writing science fiction, and gardening. The opportunity to join the SSVMS Board has rekindled a long held interest in helping others, and the opportunity to discuss health care inequities with colleagues from different groups and different locations has proven to be illuminating. As physicians, we all strive to offer outstanding care and service to our patients — we just don’t all agree on how to do it, be it locally or nationally. It is within the auspices of regional medical boards that the future seeds of health care will be planted and nurtured to grow, and I can’t think of a more exciting and challenging time to be a clinician.


ELetters Surgery on a Brain Tumor I am happy to report that shortly after submitting my Sept/Oct article on Maria, an uninsured Hispanic woman with a large pituitary tumor followed at a local volunteer clinic, UC Davis Medical Center came to bat and accepted her on a charity care basis. Neurosurgeon Dr. James Boggan and otolaryngologist Dr. Brad Strong specifically are to be commended. The patient underwent surgery on November 12, only required a two-day postoperative stay, and is recovering well. She is extremely grateful

for this definitive care as are we — the volunteer primary care docs and students who have been following this patient. I also want to acknowledge two doctors who responded to this article offering pro bono services: Sutter neurosurgeon Dr. Samuel Ciricillo and Mercy General anesthesiologist Dr. Bob Sanborn. Here’s one less patient I will lose sleep over! — Nathan Hitzeman, MD hitzemn@sutterhealth.org

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Striving for Optimal Wellness and Equality in Healthcare By Jose Alberto Arevalo, MD This past decade marked the transition of California as the most ethnically and culturally diverse state in our nation. In addition to addressing the chronic problems within our communities of health access, health literacy, health disparities, and health quality, NEPO — the Network of Ethnic Physician Organizations — is committed to act as the collective voice of our physician partners where it matters. Now in our 9th year, NEPO continues to strive for ensuring optimal wellness and equality in healthcare for all Californians. We believe that by developing strategies that focus on strengthening healthcare for California’s most vulnerable populations, healthcare for all Californians will improve. I am honored to be able to work closely in

the coming year with Carol Lee, CEO of the CMA Foundation, Elissa Maas, Vice President of Programs, and a dedicated and skilled NEPO staff. We have much work to do to ensure that our ethnic physician organizations have the latest information and tools to help them navigate the new health care reform changes. We are also working diligently with our community partners to provide the latest and most concise information on Health Information Technology. Please visit www.ethnicphysicians.org for more information about how you can become involved with the work of NEPO. And feel free to contact me at arevalj@sutter health.org Dr. Arevalo is incoming Chair, Network of Ethnic Physician Organizations (NEPO) .

November/December 2010

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Etta Lund MD, Willows Pioneer Country Doctor By Irma West, MD, MPH

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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WHEN DR. ETTA LUND ARRIVED at Willows, California, on September 6, 1906, the thermometer read 114 degrees. She would have preferred to take the train back to her home town, San Francisco, but her husband, Charles Lund, MD, was establishing their practice here and was at the depot to meet her. Thus began 54 years doctoring in and about Willows. Dr. Etta was born in 1879 in San Francisco as Henrietta Cleophea Barbara Steinegger. Her father, Henry Steinegger, was a skilled lithographer whose works were displayed at the de Young Museum in San Francisco, and the Bancroft Library in Berkeley. At age 14, he had come from Switzerland to Philadelphia, where he trained as a lithographer. Dr. Etta’s mother, Henrietta Widmer, an accomplished pianist and linguist, was of also of Swiss descent. Dr. Etta studied music and language abroad before majoring in Latin, physics and chemistry at San Francisco’s Polytechnic High School. She passed the medical school entrance exam and enrolled in Cooper Medical College (soon to be Stanford) in 1899 before finishing high school. After graduating in 1903, she interned at Children’s Hospital in San Francisco and married a classmate, Charles Lund, MD, in 1904. On April 18, 1906, Dr. Etta was shopping in San Francisco and stayed overnight to catch the morning train. She survived the earthquake and joined other doctors, many from an American Medical Association convention, setting up improvised hospitals. She served two weeks in one of them. Her parents and family suffered losses but survived. At Willows the young couple settled into an

Sierra Sacramento Valley Medicine

apartment with no indoor plumbing and limited electricity. There were no screened windows or doors anywhere. Patients laughed when Dr. Etta tried to convince them that insects carry disease, one of the many public health issues she took on to educate the community. Transportation was primitive and precarious. The hilly dirt roads were slippery when wet and dusty when dry. At first Dr. Etta traveled by bicycle, then by a horse that loved to gallop, rattling the medicine bottles in her saddlebags, and sometimes breaking them. In 1906, she and Dr. Charles acquired one of the first cars in town, a one cylinder Cadillac for $600. Gas was 7 cents a gallon. Doors, windshield, and top were absent. Dr. Etta was driving the Cadillac up a hill in the rain when a cow appeared at the top sliding toward her. It righted itself just before hitting her. Her next car was an electric Studebaker which she charged at a PG&E station every 25 to 30 miles. Then came a Ford sedan with headlights that shone brighter as speed increased. Dr. Etta was returning from delivering a baby about midnight when the Ford’s headlights failed. She had only a box of matches. She lit one and walked ahead, memorizing the road, then returning and driving as she remembered She repeated the process for miles before reaching a camp where she saw a light in a tent. As she approached a man emerged and said “Thank God you are here, my wife is very ill. We have been trying to reach you”. On a stormy night, while her husband was using their car, Dr. Etta received an urgent call from an outlying ranch. She hired a driver. They became mired in the mud about a quarter


mile from their destination. She walked, falling deeper in the mud, as she spotted a tent where five men were living, two of them suffering from respiratory infections. She took care of the sick and visited, laughing about her muddy appearance, until the rancher and his horses extricated the car. Her good humor made a strong impression on one of these men. Drs. Etta and Charles were appointed County Physicians in 1909. The Glenn County Hospital, built in 1897, was used as a home for indigents. The Lunds acquired a room there to care for accident victims from the farms. However, their first case was a young man who had placed himself on the railroad tracks before an oncoming train. Surviving but with both legs mangled he was carried to the hospital about 3 a.m. An old dining room table was pressed into service. As the clothing embedded in his legs was peeled off, Dr. Etta gave the anesthetic with one hand and held the instruments with the other, as Dr. Charles amputated both legs. The patient recovered without infection. All deliveries were made at home. The charge was $25. Equipment the doctors carried included a sterilizer designed by Dr. Charles. It was a wash boiler with a spigot. Items to be sterilized were placed on a mesh frame above the water line. After adding water and tying the lid, the sterilizer would be heated on a wood stove. Other items carried were chloroform, ether, instruments, gowns and sheets (gloves were not mentioned). Surgery was most often performed at home on the kitchen table. Once a milk shed was selected, because it was the cleanest place to remove a ruptured appendix and treat a liver abscess in a child. Dr. Purkett, another pioneer women doctor, gave the anesthetic while the Drs. Charles and Etta operated. The child survived. Sometimes family members had to help. A few of them fainted and had to be left on the floor until the surgery was completed. The Sacramento Valley Irrigation Company came to Willows in 1909, and Drs. Etta and Charles became its contract doctors. For each of several hundred employees they received $1 a month — for which they provided medical

care, medicines and a place for sick patients to stay. They rented a room in a residence for the laborers and took the clerical workers into their home, now a large house with upstairs bedrooms fitted for patients. A most serious problem, particularly for outdoor workers near northern California rivers, was malaria. Quinine was prescribed, often as an inunction to be rubbed into the skin of the elbow and groin. Drs. Etta and Charles decided to go their separate ways. Just before the 1918 influenza epidemic struck, Dr. Etta opened a 12-bed hospital, the Willows Sanitarium. The Red Cross took over and increased its capacity as patients overwhelmed it. Dozens of beds were set up in hotels and other locations. Dr. Etta stayed without pay, not removing her clothes or going to bed for 14 days. A young mother came to the hospital in childbirth with influenza pneumonia. As she lay dying, Dr. Etta delivered a 4-pound baby girl. The father begged Dr. Etta to keep the baby. She asked how he had selected her as worthy of adopting his child. He asked her to recall the night she came to a tent, all muddy, to care for sick men. He was one of them and he was very impressed with her ability and kindness. Thanks to expert medical care by Dr. Etta, the infant survived to become her daughter, Rosalie. She provided the doctor with three grandchildren. Dr. Etta closed her hospital in 1926 because too many patients failed to pay their bills. She retired from her office in the late 50’s but continued for a few years as City Health Officer and Medical Consultant to the Public Assistance Program. She died in 1972 at 93 years. I wish to thank Robert Steinegger, Dr. Etta Lund’s nephew, for providing me with personal information and these articles:

For each of several hundred employees they received $1 a month — for which they provided medical care, medicines and a place for sick patients to stay.

imariewest@aol.com References: Lund, Etta. Saddle Bags to Station Wagon. Parts 1 and 11. Wagon Wheels, Colusa County Historical Society, 1958

November/December 2010

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Open Wide...

With ConďŹ dence!

It’s Open Enrollment time for the Sierra Sacramento Valley Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower beneďŹ ts. Following are many valuable beneďŹ ts that can save you money: U Annual BeneďŹ ts of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

U Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). U Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on January 1, 2011. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAfďŹ nity.com/cmadownload.html to download an enrollment kit.

U During Open Enrollment only, members may join as an individual or as a group with your employees. Sponsored by:

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Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the ďŹ nal arbiter of coverage.

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What’s New at CMA? A brief report on the 2010 CMA House of Delegates.

By Richard N. Gray, Jr., MD, Vice Chair, 11th District Delegation, California Medical Association LAST YEAR, I STARTED BY TELLING YOU what an amazingly democratic and consensus-making body the House of Delegates (HOD) is. I would be remiss in not mentioning that again: The manner in which this body allows hundreds of physicians to come to an understanding and speak with one voice is truly remarkable. We will do it next year in Anaheim, but the following year we’ll be back in Sacramento. If you have never seen the HOD in action, come and see it in 2012 — it’s worth the visit! SSVMS was well represented, with seasoned delegates and alternates to our delegation, as well as Jerry Rogan to the administrative forum, Ruth Haskins to the specialty delegation, Lee Snook to the solo and small group forum, etc. Your representatives have an impact in many ways, not the least of which is Paul Phinney, who is currently running unopposed as the next CMA President-Elect. His leadership of the executive committee will help shape CMA’s agenda for the next several years. This year’s resolutions dealt with numerous topics, ranging from what CMA’s policy should be on legalized marijuana, how to promote vaccinations, transparency and independence in drug and device trials, as well as our yearly foray into the ethics of physician-assisted suicide (it’s still unethical). Additionally, there was education and action on items you need to know about. For example: What are ACOs? Accountable Care Organizations are a product of the Affordable Healthcare Act. Regardless of your position on it (Democrat who loves it, Republican who wants to repeal it), this legislation is the law of the land and will stay that way for the next several years; even with a Republican majority

in Congress, the President will veto any changes he sees as disrupting what he has put in place. So, you need to know how to position yourself with your ACO. Basically this is a broader definition of your “medical home.” Instead of the primary care physician and office, it is the primary care physician and office, and the network he or she belongs to for lab, imaging, specialty consultation, physical therapy, hospitalization, etc. Though the administration describes how these need to be physician-led, there are hospital systems already establishing ACOs through their 1206(l) foundation status. CMA’s policy on future legislation is that these ACOs must be physician-led to ensure that patients’ interests are the highest priority, and they must not be allowed to circumvent the California corporate bar. Additionally, CMA has been tasked with assisting the county medical societies in educating their physicians about this and helping them to develop ACOs that are sustainable, equitable, and fair. Science and Public Health. Although the House is safety minded — for example, encouraging use of seat belts and motorcycle helmets — we voted against mandating helmets for skiers and snowboarders. However, we did take a stand on educating the public about the health consequences of high-fructose corn syrup and other artificial sweeteners. Government Health Programs and Health Reform. We supported our osteopathic colleagues by supporting recognition and payment for osteopathic manipulative treatment by Medi-Cal and all payors. We made new CMA policy regarding Adult Day Care Centers: a patient’s primary care physician shall retain responsibility for the patient’s medical care,

November/December 2010

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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as opposed to relinquishing it to a care center medical director. Membership, Finance and Governance. Again this year, we did not raise CMA dues! We supported the development of a mentoring program with retired physicians for new, younger physicians. Insurance and Reimbursement. We supported the right of physicians to contract directly with their patients for health care services. We supported a standardized and expedited credentialing and re-credentialing process, and encouraged all private and public payors to use a single, online credentialing process. Quality, Ethics and Medical Practice Issues. We struggled with the issue of reimbursing women for “donating� oocytes for research purposes. We supported hospitalized patients in designating individuals who would have visita-

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Sierra Sacramento Valley Medicine

tion privileges no more restrictive than those given to immediate family members. Health Professions and Facilities. We voted to build a coalition to develop a comprehensive strategy for achieving a more equitable distribution of physicians practicing in primary care specialties. However, we also voted to take appropriate action to limit naturopathic practitioners from practicing beyond their scope of practice. These and many more issues were debated while we hammered out policies between noon Friday and noon the following Monday. It was time well spent, and California patients and physicians are better served because CMA is looking out for their interests. rgraymd@comcast.net


CONVERSATIONS

Chronic Pain — The Right to Bear Vicodin? By Nathan Hitzeman, MD I CONFESS that on particularly challenging days, when it feels like I am arm wrestling with patients over controlled medications, I imagine a chronic pain doll. Yanking a string on its back would spit out these familiar epithets (imagine your favorite patient’s intonations here): “My pain is still 11 out of 10, doc.” “Someone stole my pills. Not the blood pressure ones, just the vicodin.” “The other pills don’t work. Only the vicodin works!” “You need to extend my disability.” “The pharmacy shorted me my pain meds.” “There were 31 days last month, so I ran out of pills.” “I’m going on vacation, and I need my refill early.” “My previous doctor didn’t have a problem prescribing these for me.” “Don’t you care about my pain?” As a nation, we seem to have decided that the right to bear vicodin is as American as the right to bear handguns, and the cost is no less deadly. Recent CDC data show that visits to the Emergency Department due to the “nonmedical use” of opioid analgesics increased 111 percent during 2004–2008 (from 144,600 to 305,900 visits).1 Estimated ED visits due to the nonmedical use of benzodiazepines increased 89 percent during that same time (from 143,500 to 271,700 visits). But for some reason, a deadly epidemic caused by human behavior doesn’t create the same public health outcry as something like H1N1. Perhaps this is because there is no pill to solve taking too many pills! Don’t get me wrong. I’ve been through chronic back pain myself and have seen family

members nearly transformed by chronic pain, and it is no laughing matter. But when you step back and look at our society as a whole, you have to ask, just what in the world is going on here? I mean, hydrocodone has become the #1 prescribed medication in the country, and I am pretty sure that was not a Healthy People 2010 goal.2 My mailbox is choking with chronic pain monographs and articles. They describe how pain is undertreated, but then are quick to warn doctors to be “vigilant” in preventing opioid misuse. Indeed, we should invoke a “multidisciplinary approach.” That does little to help me as a clinician when there are few outpatient multidisciplinary chronic pain teams around, and fewer still that accept Medi-Cal patients. Referring to a psychiatrist or addiction specialist is also problematic due to insurance rules and mental health shortages. Furthermore, such articles do not address the tough physician-patient interactions that need to take place to taper off meds on someone who has been on chronic opioids, or how to reconcile saying “no” in an era of patient satisfaction scores and threatened litigation. It seems like half of my patients have some kind of chronic pain these days, and, unless you are a pediatrician, I bet your practice is not much different. Nationwide estimates show that 50 million Americans (about 1 out of 6) have chronic nonmalignant pain.3 While some doctors just evade the issue by not prescribing any opioids, I think that is a cop out. In this article, I will give some practical advice for the management of chronic pain.

November/December 2010

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If disability is the ultimate benchmark, we are losing ground — not gaining.

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Unfortunately, there are no magic bullets, but I will give some pearls not always mentioned in the watered-down and overly politically correct pain monographs. I hope you will find that while patients with chronic pain do require more than quick 15-minute visits, once you have your system down and values in place, it does get easier — and sometimes even rewarding! First, let’s try to figure out how we got here. While one could argue that the increase in opioid prescriptions reflects better screening and detection of pain, let’s consider a recent article analyzing Medicare disability data.4 These data from millions of Medicare patients show that disability from pulmonary and cardiovascular disease has declined over the past decade — no doubt thanks to antitobacco programs and lifesaving cardiac interventions. However, disability from musculoskeletal injuries, namely back pain, continued to rise (from 20 percent to now 25 percent of permanently disabled workers drawing Social Security benefits). This is despite huge increases in imaging of the spine, epidurals, and back surgeries.4 If disability is the ultimate benchmark, we are losing ground — not gaining. If anything, we are pathologizing what previously may have been considered normal aging. Human beings were quadrupeds not long ago on the evolutionary timeline, and, as a trade off for bigger brains and freed-up hands, yes, we get bad backs at some point in our lives. Yet somehow, generations have managed to live with it, thrive, and reproduce. Now, back pain is considered a disease and is treated as such. Patients, in turn, are quick to assume this “sick role.” In 1997, with the robust L5-S1 of a 22 year old, I climbed the volcano Mt. Merapi in Indonesia with a tour group. Upon my descent, I collapsed on the side of the trail to catch my breath. While pondering why I paid for this experience, I was amazed to see what looked like an 80-year-old native lady lithely trotting down the slope with an ungodly stack of kindling on her back. Her muscles were impressive cords dancing under her tan skin, but her joints looked horribly knobby and arthritic. She

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smiled a toothless grin and left me in the dust. Since then, I have come to appreciate that if you don’t use it, you lose it. I sometimes reflect on this woman and imagine her transplanted into our American culture. Here she would probably be depressed, not know her neighbors, live in fear of crime, hoard lots of unnecessary goods made in China, have chronic pain, be on several pain killers, and have gone through a barrage of marginally useful imaging and treatment procedures. So how do we get out of this mess? Any pain expert will tell you that the goal of pain management is to maximize function, not eliminate pain. That is the one point of this article you should take to heart: FUNCTION. Forget the 0–10 pain scale; it is a carryover of an inpatient tool and has little utility in the clinic setting. Rather, a local pain management friend of mine asks every patient, “What are you able to do with this pain medication that you could not do before?” If there is no discernable increase in function like playing with the kids, tending to the garden, or riding the bike again, then the medication is not working and not worth the side effects or abuse potential. Here are the arguments I use to dissuade patients from opioids and to dissuade myself and the residents I teach from prescribing them. s Hydrocodone has become the #1 prescribed medication in our country and yet more people are becoming disabled (less functional) despite its use.2,4 s According to the CDC, deaths from prescription painkillers have doubled over the past decade. (Prescriptions for them have quadrupled.)5 s Visits to emergency departments for misuse of controlled substances doubled during 2004–2008. Over a half million people go to the ED yearly for misuse of controlled substances.1 s Methadone, oxycodone, and hydrocodone are statistically most likely to result in overdose and death.5 This doesn’t mean they are not effective and useful in many patients. But they come with real risks and require


careful oversight. s According to the National Survey on Drug Use and Health, 5 percent of people over 12-years-old have misused a prescription pain reliever in the past 12 months. More people abuse prescription drugs than abuse cocaine, heroin, hallucinogens, and inhalants combined.6 s Medication abuse cuts across all socioeconomic levels. Brett Favre, Cindy McCain (John McCain’s wife), Robert Downey, Jr., and Rush Limbaugh have all learned this the hard way. However, a CDC study out of Washington State was the first to confirm that opioid overdose is more common in the Medicaid population.5 s A personal or family history of substance abuse of any kind (alcohol, illicit drugs, prescription painkillers) is the most predictive factor of misuse of medications.7 s Side effects of opioids include constipation, nausea and vomiting, sedation, confusion, and respiratory depression. s Short-acting opioids by themselves are not appropriate for around-the-clock chronic pain. Withdrawal or rebound effect makes pain that much worse when they wear off. This rollercoaster effect can reinforce chronic pain pathways. s Opioids typically only decrease pain by 1–2 points on a 10-point pain scale and are often not worth the side effects.8 We have all witnessed the spiral of disability. It’s puzzling why Americans are becoming disabled at such alarming rates. The phenomenon may be due to a combination of factors: people lacking social support, people not being valued for their work in our corporate society, a culture of victimization (assigning liability rather than embracing personal empowerment), deconditioning from sedentary lifestyles and obesity, and — perhaps most disturbingly — because we physicians are not setting proper limits. Are we enabling the whole process by pathologizing and working up pain rather than reassuring and rehabilitating? Would our compassion be bettered tempered by tough love

and personal responsibility? Once a patient is started on opioids or continued on them (at this point, imagine your favorite “inherited” patient), here are some tips I use to guide management. Use hydrocodone with caution. It can be very effective for acute or breakthrough pain, but is being rampantly overprescribed and misused. Although anecdotal, I find codeine and tramadol to be less abused by my patients. One expert report on osteoarthritis management supports using them as first line opioids.9 Be cautious as tramadol lowers the seizure threshold in those at risk. Establish rules with chronic pain patients from the start. Do a background search at https://pmp.doj.ca.gov/pdmp/index.do. Use questionnaires to screen for aberrant behavior (see resources at the Federation of State Medical Boards, www.fsmb.org/PAIN/resource.html). Then, have a signed pain agreement (a sample can be found at www.painmed.org/pdf/controlled_ substances_sample_agrmt.pdf). Treat underlying depression. Many chronic pain patients have it. Pain is a mind-body experience. Antidepressants have been shown to help chronic pain. Allow enough time for your chronic pain visits. Rushed care is sloppy care. Use non-opioid modalities. If a patient does not want to try these and says only opioids work, that is a red flag. Non-opioid therapies include ice/heat, support groups, walking clubs, volunteer activities, yoga, Tai Chi, pool therapy, physical therapy, weight loss, lumbar support devices, topical remedies (Salonpas patches, Tiger Balm, capsaicin), Tylenol, NSAIDs, chiropractics (more useful for acute exacerbations), acupuncture, relaxation, massage, and TENS units. Use opioid conversion charts when switching agents. Start at lower doses when switching agents, especially with the fentanyl patch. Equianalgesic dosing between morphine and the fentanyl patch is not straightforward. Document functional level at each visit in addition to pain severity and side effects. Discuss and document driving precautions when prescribing opioids or chang-

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Are we enabling the whole process by pathologizing and working up pain rather than reassuring and rehabilitating?

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You need to do what is medically right rather than what is best for your patient satisfaction scores.

ing doses. Risk is greatest in the first week after the change. This applies to benzodiazepines and “muscle relaxants,” too. The latter are really just sedatives that do not act directly on muscle tissue. A well-publicized case of a local intoxicated/over-medicated sheriff’s deputy barreling her car into a Starbuck’s establishment really drives home the point.10 Do urine toxicology screens when warranted. They are recommended by consensus guidelines, are not unreasonable, and are standard of care. One study showed that 21 percent of opioid-using patients with no aberrant behavior had urines showing other nonprescribed drugs.11 Alternatively, urine tests can confirm patients are actually taking some of their opioid or benzodiazepine and not just selling it. Have patients bring in pill bottles to each visit. Check how many pills are left, and double check that the bottles are prescribed from you! Know your limits and the ceiling of doses you are willing to prescribe. High doses — that is, exceeding 180 mg of morphine a day (or OxyContin 40 mg tid) — have not been assessed for long-term effectiveness or safety.12 While any dose of opioids can be dangerous, leave the “big boy” doses to the experts and don’t put yourself at risk. Have an exit plan. Taper off or stop opioids when appropriate. Patients may get upset or walk out on you. You need to do what is medically right rather than what is best for your patient satisfaction scores. Ironically, I find that some of my patients end up respecting me more

1-800-901-5830 sYEARSOFMEDICALEXPERIENCE s .ORTHERN#ALIFORNIAPHYSICIANS sWELL TRAINEDPROFESSIONALOPERATORS s3TATEOFTHEARTCOMPUTERTECHNOLOGY s$ISCOUNTEDRATESFORNEW336-3ACCOUNTS s3PANISH #HINESEAND2USSIANSPOKEN

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once limits are set. Get family members involved. They can give you their assessment of the patient’s function, and they sometimes will tell you when the patient is misusing medication. Accept that a certain percentage of your patients will misuse medications. We’ve all been “burned” at some point. There is no 100 percent fool-proof way to avoid misuse and drug diversion, except not to prescribe any controlled substances ever (and many of us would consider that unethical). Take comfort in knowing that you are helping most of your patients. Seek support. Discuss tough cases with colleagues and faculty. Read up on chronic pain consensus guidelines. I didn’t make up this stuff (well, not most of it at least!).7 http://download.journals. elsevier-health.com/pdfs/journals/1526-5900/ PIIS1526590008008316.pdf hitzemn@sutterhealth.org 1 Cai R, Crane E, Poneleit K, et al. Emergency department visits involving nonmedical use of selected prescription drugs — United States, 2004-2008. MMWR. 2010;59(23):705-709. 2 U.S. Prescription Drug Sales Grow Slowly; Hydrocodone Most Prescribed. March 26, 2009. By Marketing Charts. Available from: http://seekingalpha.com/article/128003-u-s-prescription-drugsales-grow-slowly-hydrocodone-most-prescribed 3 Brown RT, Zuelsdorff M, Fleming M. Adverse effects and cognitive function among primary care patients taking opioids for chronic nonmalignant pain. J Opioid Manag 2006;2:137-46 4 Deyo RA, Mirza SK, Turner JA, et al. Over-treating Chronic Back Pain: Time to Back Off? JABFM. 2009;22(1):62-68. 5 Overdose Deaths Involving Prescription Opioids Among Medicaid Enrollees — Washington, 2004-2007. MMWR. 2009;58(42):11721175. 6 Substance Abuse and Mental Health Services Administration Office of Applied Studies. The HSDUH Report: Patterns and Trends in Nonmedical Prescription Pain Reliever Use: 20022005 (April 6, 2007, Rockville, MD [DHSS Publication No SMA 06-4194, NSDUH Series H-30]). US Department of Health and Human Services Web site. www.oas.samhsa.gov/2k7/pain/pain. pdf. 7 Chou R, Fanciullo GJ, Fine PG, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain. 2009;10(2):113-130. 8 Nuesch E, Rutjes AWS, Husni E, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2009;(4):CD003115. 9 Zhang W, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16:137-162. 10 www.kcra.com/news/20760826/detail.html 11 Katz NP. Anesth Analg. 2003. Oct;97(4):1097-102. 12 Ballantyne JC, Mao J. Opioid therapy for chronic pain. NEJM. 2003;349(20):1943-195


Land of a Thousand Hills The challenges of medical care at a hospital in the mountain foothills of Musanze, Rwanda.

By Steven Gelber, MD, MPH; Agnieszka Witkowski, MD; Craig Keenan, MD; Jan Ramer, DVM; Kirsten Gilardi, DVM; Mike Cranfield, DVM; Tonya Fancher, MD, MPH This is the first of two related articles describing a new One Health Initiative collaboration between the UC Davis Department of Internal Medicine and the UC Davis School of Veterinary Medicine. HIGH IN A VOLCANIC MOUNTAIN range in northwestern Rwanda are some of the rarest primates in the world: mountain gorillas. While most of the thousands of people who live in the foothills surrounding the Parc des Volcans will never see the gorillas in person, their presence affects every aspect of their lives. One of these effects is doubtlessly beneficial: the flow of money that foreign tourists pump into a local economy that otherwise depends on subsistence farming and cottage industry. Despite the access of near-universal health care provided by the national government, the rural health clinics and the district-level hospital in Musanze suffer from lack of resources, lack of staffing, and lack of physicians. The goal of the One Health Initiative in Rwanda is to integrate the health of the endangered mountain gorillas, whose medical care is provided by the Mountain Gorilla Veterinary Project1, with the health of the local environment and the local people. Supported by the UC Davis Department of Internal Medicine and School of Veterinary Medicine’s Wildlife Health Center’s One Health program, two internal medicine residents spent one month in Musanze in June 2010. They worked with interns and physicians at Ruhengeri District Hospital and with Comprehensive Community Healthcare Initiatives and Programs (CCHIPs)2, an American NGO that has been coordinating capacity-building in multiple rural health centers in the hospital’s catchment area.

The Ruhengeri District Hospital is an acute care facility with departments of surgery, internal medicine, pediatrics, and obstetrics. For internal medicine, mornings begin at ”7 a.m. sharp,” when the overnight intern presents patients admitted to the hospital since yesterday’s rounds. There are three interns here, and during the course of the week, they take turns staying overnight for admissions. They provide most of the care to the patients. Graduates of the single Rwandan medical school become general practitioners after completing a one-year internship rotating through internal medicine, surgery, obstetrics and gynecology, and pediatrics at one of five teaching hospitals in Rwanda. In this country of 9.3 million, there is one doctor per 18,000 citizens and one nurse for every 1,700.3 Although the hospital’s Internal Medicine department has a 100-bed capacity, the acuity of illness warranting hospitalization is much lower than what we see in the U.S. Over 90 percent of Rwandans are covered by the national health insurance plan, Mutuelles de Santé, that costs $2.00 per year.4 To receive care in the district hospital, the patient must be referred from a rural health center. A patient with cough and fever may have to walk many miles to reach the clinic. Once there, the patient may remain briefly in the clinic’s 3–6 bed inpatient ward, or be referred to the district hospital for more treatment. If there is no family member to provide nursing care and meals, patients are expected to do this on their own, and will have to walk to town to purchase food. Therefore, the beds are often filled with patients sick enough to be hospitalized but well

November/December 2010

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Ruhengeri District Hospital

The large volume of patients and significant staff and resource constraints result in nearly identical medical care for the critically ill and the walking sick.

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enough to get themselves to the hospital. Medications supplied to the hospital from foreign donors are included in the national health insurance plan, but the supply can be erratic; a patient might receive two days of intravenous antibiotics and have to purchase the remainder of the course from an outside pharmacy. At the same time, like anywhere in the world, there are plenty of very sick patients in the district hospital. On one particular morning, rounds included a young adult with possible bacterial meningitis, a handful of severely anemic malaria patients, and several tachycardic, hypotensive patients with suspected typhoid fever. Interns present the overnight cases inside a small room — which also serves as the utilities room because it has a functional sink — surrounded by the doctors and nurses who staff the hospital wards. As is done in medical education around the world, there is some gentle pimping (questioning) by the attending staff, and then the teams set out for bedside rounds to see all 80 patients on the wards. This census, we are told, is relatively light. Rounds are conducted in English, even though the patients and nurses speak only Kinyarwanda (and sometimes French) and the interns themselves only began to learn English when they started medical school. Here in Musanze, there are also several Cuban physicians who see patients and supervise rounds,

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so Spanish has been added to the language fray. The bedside presentations begin in slow and carefully articulated English, but it is not long before the medical debate that follows quickly picks up in a fast, colorful mixture of Kinyarwanda, French, English and Spanish. Many familiar elements on rounds cross the language barriers and continents. The doctors sometimes speak gruffly, remove patients from their bed to expose their naked bodies or various deformities for everyone to see, and do not explain diagnoses or treatments because they are in a hurry. The patients stare blankly ahead, make no eye contact, and are absolutely gracious about the care they receive. Procedures like lumbar punctures and thoracenteses are done at bedside, quickly and without explanation or anesthetic. The large volume of patients and significant staff and resource constraints result in nearly identical medical care for the critically ill and the walking sick. Labs are often checked once at the time of admission; results take a day or two to come back. Vital signs, if necessary, are monitored once or twice daily. There is an x-ray machine on site, but it has not worked for several weeks, so patients who need an x-ray must pay for transportation to a different town to have it taken and then return for treatment. The EKG machine ran out of paper a few months ago, and replacement paper is no longer available — if it ever was — in Rwanda. Despite the many differences between our medical systems, the overall culture and practice of medicine is surprisingly similar. Interns struggle through rounds and whisper answers to each other, attendings capitalize on teaching moments, and patients often serve as a mere background for medical education. Yet, as soon as rounds end, patients become the focus again, and one can see the concern in their doctors’ faces, as they sadly discuss a dying patient or make frustrated references to the financial constraints that prevent them from providing their patients with the tests or medications they need. While participating in rounds, we American outsiders struggle to grasp limited wisps of


patient histories, marvel at physical exam findings rarely seen back home, and find our knowledge and skills of limited use. We realize how reliant we are on technology and tests. We often find ourselves frustrated by the lack of history and diagnostic tests, which leads to the empirical treatments that our team implements out of necessity to do the best that they can with the information they have. Sometimes, we pass by beds, now again occupied, where last week’s patients had died without known cause. It takes effort to find a sense of purpose and to realize just how much we are learning every day. On one particular day on rounds, we diagnose a spinal tumor by history and exam alone, examine a child with hematuria and likely schistosomiasis, and — almost — find ourselves bored by “another clear case” of malaria before the blood smear is even done. There are opportunities for learning here that cannot be substituted by books or “experienced” attendings lecturing on the yesteryears of residency, when they ran their own gram stains. More importantly, despite our prestigious roles as “western doctors,” with more formal schooling than that of some of the attendings who lead our rounds, there is a deep humility to learn here. We have not just become dependent on expensive tools for making even a simple diagnosis, we have lost our comfort with the ambiguity that — though glaringly blatant in a resource-limited place like Rwanda — remains present in every clinical encounter. In the face of these challenges, the nurses and physicians, often overworked and as frustrated as we were with the resource limitations, performed their duties with great humility and courage. In the hospital, we saw several young patients recover from bouts of presumed typhoid fever and severe malaria with timely treatment with antibiotics and Coartem (artemether/lumefantrine) provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria. In the rural clinics, we saw first-hand the beneficial effects of investments in the clinic infrastructure and the improvements in clinic management through training and capacitybuilding facilitated by the CCHIPs team. The

pride and cohesion among the clinic staff was clearly leading to beneficial outcomes for the community’s public health, with community health workers improving immunization access for children and many more women making use of the clinic’s birthing rooms for childbirth instead of attempting less safe home births. As a resident training in the resource-rich hospitals of Sacramento, the stark differences in health care in rural northwestern Rwanda were immediately apparent. However, as we spent more time with our Rwandan colleagues, the similarities in our training became more evident. History-taking, physical exam skills, and the treatment of asthma attacks, hypertensive urgencies, and heart failure exacerbations were more similar than different from our practices here in California. One of the most rewarding opportunities we had was in developing teaching sessions for the nurses in the CCHIPs clinics and more informal teaching with interns in the hospital. These exchanges convinced us that, with increased investment in medical education, Rwandan health care has the potential for great improvement. We hope that more residents and faculty from UC Davis will have the chance to return to Musanze for the kind of bilateral education that we experienced in Rwandan hospitals and clinics, and that these relationships will be beneficial to Rwandans as well as to the health of the mountain gorilla community. Tonya.Fancher@ucdmc.ucdavis.edu

We have not just become dependent on expensive tools for making even a simple diagnosis, we have lost our comfort with the ambiguity that — though glaringly blatant in a resourcelimited place like Rwanda

We would like to thank the citizens of Rwanda and the patients, staff and faculty of the Ruhengeri District Hospital for their patience and grace for welcoming us into their lives. We would also like to thank Drs. Nathalie Nsengiyumva, Mark Henderson and Timothy Albertson for their support, as well as Bill and Ro Wyman and the excellent CCHIPs and MGVP teams for making this possible. 1 2 3 4

— remains present in every clinical encounter.

http://gorilladoctors.org http://wwhps.org http://www.moh.gov.rw www.nytimes.com/2010/06/15/health/policy

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Voices of Medicine After 18 years: Au Revoir

By Del Meyer, MD Editor’s Note: This is a review of Dr. Del Meyer’s 18 years with our medical society publication. He has been a regular contributor to SSVMedicine (formerly Sacramento Medicine) since 1993. Several years ago, he began two online publications, the MedicalTuesday Newsletter and HealthPlanUSA. They have grown exponentially, so that he now must devote most of his efforts there. While his Voices of Medicine feature will no longer appear here, it can be found in MedicalTuesday. I want to express to you, Del, my personal thanks and that of the Editorial Committee for your fine and enduring contribution to our publication; you will be missed. — John Loofbourow, MD

The Beginning — 1993

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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I volunteered for the editorial board of the then Sacramento Medicine in 1992. Upon appointment in 1993, I wrote a series of articles on Basic Health Care, Self Care, and Physician Care. At that time there was a push to put more routine care into health plans, even vitamins and fitness centers were suggested, or anything thought to be health related. I pointed out that this approach would jeopardize all health plans and make them unsustainable. Europe was eliminating costly items of their socialized government plans. This has been borne out by our experience in the United States. Part of that series dealt with a cost analysis of the process of dying as more people felt that hospitals were the only environment in which to say goodbye to loved ones. As Intensive Care Units were becoming more sophisticated and relatives could hardly get close to their loved ones with all the tubes and monitors, more Americans chose to die at home.

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This can be observed in the daily obituary columns that frequently announce that Mr. JB, born in 1918, died at home surrounded by his loving family. A byproduct of this research also revealed that the people who died in their ninth and tenth decade of life, frequently worked into their eight and ninth decades of life. It is now commonly recognized that early retirement significantly shortens life. I then wrote a series of OpEd articles treating the issues of the day such as: Managed Care — Friend or Foe; HealthCare Insurance — An Oxymoron? Government Medicine — a Fait Accompli. An article on Military Physician Travelogue detailed my two years of global military travel, courtesy of the United States Air Force. In 1993, the editor, Dr. Richard Johnson, gave me permission to begin a monthly column that I called Hippocrates & His Kin. In 1994 he announced his retirement after 15 years, and I was asked to be editor.

The Editorship: 1994–1997 During the next four years, I was responsible for the monthly Editorial in the eleven issues per year, and continued to write the monthly Hippocrates Column (HHK) until early 2001, when I began a similar column called Hippocrates’ Modern Colleagues published on my professional site, DelMeyer.net. In June 2005, the Hippocrates Column was resuscitated and incorporated into the MedicalTuesday Newsletter, where it continues to the present day. In October 1994, I began the monthly Physician/Patient Bookshelf column to review books written by our colleagues on any subject


or by any author on medical care and practice. These book reviews can be read topically at the HealthCareCommunication.network. I had the good fortune of becoming acquainted and working with Jim Coyle, MD, an internist of long standing in our community. In fact, my office was located on Coyle Avenue, named after his father, also a physician. About that time I noted that many of the county medical societies around the state were sending copies of their journals and bulletins to our society. As these were discarded, I requested that they be tossed my way. Since they contained more useful information than I could possibly use in my “Hippocrates and His Kin” commentary, I asked Jim if he would like to help peruse them and consider writing a column based on these “Other Voices” from around the various medical societies throughout the state. Jim’s column, which ran from April 95 through May 98, developed a richly deserved loyal readership. He became a valuable contributor to the editorial board of this journal — his writings were inspiring and insightful. I continued to write the Editorials, Hippocrates, and Bookshelf columns every month until the end of my term as editor in December 1997.

The Editorial Board: 1998–2010 After Jim’s untimely death on April 15, 1998, I resumed the perusal of these journals from other medical societies, and realized that they contained a wealth of material. Thus in memory of Jim and as a tribute to his fine work, I continued the column, bringing the opinions of other physicians around the state to our readership. Perhaps nothing new — but in a different voice to pique your interest. I continued on the editorial board for the next 13 years, writing the Voices of Medicine column and occasional book reviews. Since 2002, I’ve written an enlarged VOM, adding it to my electronic newsletter, available throughout our country and internationally. At this time, I have thousands of colleagues who request my newsletters and more than a

hundred thousand who visit my electronic journal sites each month. I now plan to be more involved with this enlarged format and audience that we reach through our MedicalTuesday Newsletter. I see many opportunities to engage our profession globally. There is a lot of work to be done if we wish to save a personalized health care system from the intrusions of a government bureaucracy, where patient care has to compete with every other budget item from the freeways to prisons. During any recession, our patients would suffer from lack of or inferior care.

The Voices of Medicine Ten years ago, when I entered “Voices of Medicine” in the search engines, I would see the links of my column reported from Sacramento Medicine. Now when I enter “Voices of Medicine” I see thousands of articles on the Voices of … the various medical schools: Voices of PENN Medicine, Voices of VA Medicine, Voices of Military Medicine, New Voices of Medicine, Voices of Genetic Medicine, Voices of Family Medicine, Voices of Traditional Herbal Medicine, Conflicting Voices of Medicine, Voices from the Heart of Medicine, Books for Voices of Medicine, Voice of Medicine Vaccines, Voices of Personalized Medicine, Voices on Diversity in Academic Medicine, Voices of Integrative Medicine and others. The Google search now gives millions of related articles. This is the highest form of praise. I will miss the voices of my colleagues in the various California county medical societies whose opinions I’ve come to know and respect. I leave the highlighting of their VOICES for someone else. Meanwhile, I invite you to read and subscribe to the MedicalTuesday newsletter on Medical Practice issues and the HealthPlanUSA newsletter on HealthPlan issues in our country and globally. You may also keep in touch by subscribing to the Blog on either journal. Au Revoir!

Now when I enter “Voices of Medicine” I see thousands of articles on the Voices of …

DelMeyer@DelMeyer.net DelMeyer@MedicalTuesday.net DelMeyer@HealthPlanUSA.net

November/December 2010

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An Invitation to All SSVMS Members, Alliance Members & Guests The Sierra Sacramento Valley Medical Society and Alliance Invite You to Attend the 2011 Annual Awards, Installation and Dinner Friday, January 21, 2011 Hyatt Regency Hotel, Sacramento 6:00 pm Social / 6:45 pm Dinner / 7:30 pm Program

Installation Alicia M. Abels, MD, President 2011 2011 Officers and SSVMS Board of Directors

Award Presentations Golden Stethoscope - William J. Au, MD Medical Honor - Faith T. Fitzgerald, MD Medical Community Service - Helen Thomson, Supervisor, Yolo County Dorothy Dozier Helping Hands - Jerilyn Marr CMA-A Dedicated County Member - Margery Scott Marshall

Music by, Gardenia Azul Gardenia Azul will fill the evening with tropical music for your listening or dancing pleasure. The trio of musicians have performed and recorded around Sacramento for many years with songs popular in the 1950’s and 60’s, and rich in the heritage of Mexican and Cuban music. Please mark January 21 on your calendar now and watch the mail for your formal invitation. All members are asked to please consider hosting a medical student or resident. Sponsored by NORCAL Mutual Insurance Company


EDITOR’S MESSAGE

Reformations1 in Health Care We can no longer rigidly apply the old principle that ”Every life is sacred, and beyond price,” though it has been basic to the politics, and the ethics, of medicine for more than half a century.

By John Loofbourow, MD I HAVE BEEN A PART OF the medical profession since moonlighting in small ERs as a U of Minnesota junior med student in 1953. Medicine has been a grand ride where the ongoing clash between past and future has marked every day of that journey; so our national debate on health care today is not surprising. Events, not design, thrust each reformulation of medicine on us. Yet the current national debate is broader than ever, because it involves all medical professionals, a sophisticated medical technocracy, the various medical industries, government, and most significantly, a public with ever greater interest in, and access to, information about personal and national health. No Hippocratic, scientific, or political priesthood seems able to set the agenda or determine the future of the nation’s health. Who will? A president, a governor, an Alaskan housewife, a plumber? I have no idea. Most physicians, knowing the territory, wouldn’t want that responsibility, even if it were offered — which is not the case. We are physicians, not shapers of national policy. But some medical Martin Luther will nail the tenets for reformation on the waiting room door. And after all the shouting and theatrics that follow, those who determine the ultimate outcome of our current national debate will be the citizens of our nation. There are many difficulties, of course. Among them is that too many national report cards look like the one in the next column. Nonetheless, the vast majority of our citizenry is actively debating the issues in terms of technologies and scale unimagined a few

decades ago. For the first time, we are forced to include in our thinking the terms of large animal veterinary medicine2: herd medicine, which requires consideration of cost vs. return, so that every investment in prevention, diagnosis, or treatment must be effective enough to pay for. With due reverence for many religious distinctions between man and animals, the general principles of herd medicine must apply to universal health; to both sheep and the rapacious human mammal.3 We can no longer rigidly apply the old principle that ”Every life is sacred, and beyond price,” though it has been basic to the politics, and the ethics, of medicine for more than half a century. A reformation is as overdue as a one-year, unpaid mortgage. And similarly, it’s no one’s ”fault”; blame is a waste of emotion and time. Some things seem clear: (1) U.S. health has improved dramatically over the past century.

November/December 2010

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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(2) Despite that, we cannot afford to go on doing what we now do, the way we do it. To reform U.S. medicine will not be fast or easy, and unintended consequences will happen. (3) Technology offers more and more options, and more and wider access to health related information; that makes personal decisions about health care increasingly subjective and decisions about public policy increasingly objective. You may claim a right to a medical intervention while society may claim the right not to decide to pay for it. (4) Physicians, whose chief obligation was once to the patient, now cannot avoid a sometimes conflicting obligation to a nation determined that health care is a public, or collective responsibility. (5) Health care, sickness care and preventive care will be reformed, on the one hand by society as a whole, and on the other by individuals voluntarily assuming more control of and responsibility for their own health.

(6) The cacophony of political and public yammering is a vital part of this current reformation. Though physicians will find our work even more difficult at times, we should remember that we are privileged, accomplished, and respected members of society. In my old age, I delight in being preceptor to medical students and idealistic, intense premeds. They make it clear that medicine has a bright future, even if we old timers can’t yet read the fine print. john@loofbourow.com 1 Change is a tired pitiful term that means absolutely nothing. A little better is Reformation. 2 Small animal vets, as opposed to large animal types, now seem to be physicians in sheep’s clothing, often chiefly devoted to lucrative diagnosis and treatment of disease or dubious preventive interventions. 3 Granted that the bottom line for large animals is a profitable sale, while the bottom line for patients is a long productive, healthy life, in universal health care, the principle is the same in both cases.

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A Posit on Health Reform “The ‘Patient Protection and Affordable Care Act’ is so ill-conceived, ill-timed and hastily drafted that it should be repealed immediately.”

Among 129 responses, 77 (60 percent) disagreed. Though a posit does not constitute a valid poll, the results of this posit coincide very closely with the most recent CMA survey on the same topic, as noted in Dr. Paul Phinney’s comment at the end of this page. Forty-nine very slightly edited comments follow. AS LONG AS WE HAVE A SYSTEM that has a mandate for care (ER service), we need a mandate to insure. In addition, many of the other provisions of the bill (extension of benefits to older children, pre-existing condition policy, national minimum coverages, health insurance exchange) do a great job in diversifying the risk pool and broadening coverage. If one measures health care efficiency in terms of outcomes versus dollars spent, the for-profit/fee-for-service system we have in place, with high-risk/high-cost patients covered by Medicare and lower-risk/healthier/low-cost patients the domain of the private sector, is both terribly inefficient and insufficient. The PPACA is a great step in the right direction. — Srihari Namperumal, MS III During the debate over the health care bill, I recall Nancy Pelosi saying, “We need to pass this bill so that we can see what is in it,” a profoundly revealing statement from the leader of the House that shows how lazy our elected representatives can be about doing their jobs. The bill is poorly conceived, without enough thoughtful deliberation about unintended future consequences and costs of its provisions. Repeal it and start over, with a much more limited role of the federal government in our health care system. — Terry Williams, MD It was high time that the public subsidy of the health insurance industry profits was at

least limited, even if the measure did not go far enough. It is only fair to ask them to insure all of us if they want to be in the business of insuring any of us. If it is too hot in the kitchen, then they shouldn’t be cooking. — Daniel Egerter, MD A noble idea morphed into a terrible plan by a corrupt, partisan legislative process. The citizens of the United States deserve far better than this bureaucratic monstrosity. — David Linstadt, MD It should not be repealed — it should be amended. It is beneath us as a wealthy and humane society to fail in providing universal coverage. The PPACA is a significant step in remedying that failure. However, the PPACA itself is fatally flawed (in the fullest sense of the term) in failing to explicitly include protection for human life and conscience as stated in the Hyde and Weldon Amendments. In refusing to include such protective language in the Act, the Obama team may have lost critical support that will bring down the whole of it. — Stephen McCurdy, MD One thing I have learned about our health care system is that change is inevitable and constant. We are at the beginning of the biggest changes since Medicare and Medicaid arrived in the mid 1960s. According to SSVMS and CMA opinion polls, half of our members are ready for and support these changes and the other half are firmly against them. Be assured that what we see in these reforms is not what we will get. The Affordable Health Care Act and all of its components are a work in progress that will be never ending, just like the Winchester Mystery House, another door here and another there. — Bill Sandberg According to the most recent poll of CMA

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The Affordable Health Care Act and all of its components are a work in progress that will be never ending, just like the Winchester Mystery House...

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The results are statistically valid within a couple of percentage points, and show a shift in sentiment of CMA members towards favoring the legislation as compared to a year earlier when equal percentages were in favor as were opposed.

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members, more than half (59 percent) would disagree. This professionally run, telephone interview poll was carried out on a sample of CMA physicians closely reflecting the demographics of the association as a whole. The results are statistically valid within a couple of percentage points, and show a shift in sentiment of CMA members towards favoring the legislation as compared to a year earlier when equal percentages were in favor as were opposed. The two polls were conducted by a reputable firm with experience running polls for Republican candidates, and, as such, is unlikely to have a bias in favor of liberal ideology. — Paul Phinney, MD Reform is necessary because of the fiscal crisis facing our health care delivery system. PPACA primarily afforded access at a great cost to the taxpaying public without any unit cost or utilization cost reform save Medicare Advantage. Many states are under water currently and cannot fiscally respond to the mandates in the bill no matter how worthy the goal is to have all Americans insured for health care. We appear to be heading towards “social equality ideology” that is neither our choice nor can we afford the cost currently. Reconsideration of a true safety net insurance product should be considered, delivered by the private insurers. However, no matter how much money we spend on medical insurance for healthcare delivery, Americans will remain unhealthy until our cultural behaviors improve, e.g., obesity, smoking, ETOH, etc. The delivery system is principally treating the ill (save pediatrics). — Robert Forster, MD I look forward to its full implementation. — Sam Applebaum, MD The ACT contains many provisions that a compassionate, responsible society should have been doing years ago. It expands coverage for children and many who would otherwise be unable to get insurance. It goes after fraud. It ends despicable insurance company practices like canceling existing insurance for sick people or refusing to insure in the first place. It provides incentives for 20,000 new primary care doctors. Many of its components emphasize preventive

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care. It is not perfect, but not because it was hastily written. The faults arose when people who live by the motto of, “I’ve got mine, screw you,” started to gut key components. OK, that led to it garnering enough votes to pass. But it needs to be reformed, to un-gut it. As it is currently written, without a public option to compete with Big Insurance, it is a corporate give-away. It will require reform to keep insurance companies from jacking up rates so high that everyone pays the fine rather than acquire insurance. And it will require close monitoring to keep the people who find ways to subvert well-intentioned laws from doing so. — Ann Gerhardt, MD I don’t understand it all so it must be those bad things you listed! — Byron Demorest MD It’s probably the best we can get for now. — Mark Levy, MD Most, if not all, of the bill’s provisions are appropriate. The problem is, as expected, it may not go far enough to control fraud, abuse, and waste in fee-for-service care. But those provisions will follow when the payments become unaffordable. The key now will be the creation and implementation of regulation. California has already started to implement its piece. The new law requires Medicaid to implement correct coding initiative edits but California Medi-Cal implements new CPT codes 9 months late. California Medi-Cal claims processing will require new methodology to control fraud and abuse. — Jerry Rogan, MD It does nothing for actual health care. And it does nothing for malpractice reform. It seems to just squeeze reimbursements to providers, did not actively seek the input and advice of patients, and has loaded care for 30 million new patients without making any additions to primary care capacities in our community! —Pankaj Patel, MD The PPACA is a costly, overly-complicated hodgepodge. I favor making the health plan that our federal legislators and government workers have being made available to all Americans. It would be ungodly expensive but higher co-pays


and deductibles than we are used to would help. Health care is at least as important as defense. We can do this. The greatest nation on earth should have no less. — Lawrence Bass, MD [Disagreeing] Please read A “Broader Regulatory Scheme” — The Constitutionality of Health Care Reform, from NEJM, in defense of my position. It includes a great legal overview of the importance of reform to health insurance. — Jessica Nuñez de Ybarra, MD It is a good start. It still needs a lot of work, but that can be said for anything the government creates. — Anthony Russell, MD I write from both the physician’s and patient’s point of view. The AMA and AARP sold out their respective memberships with physicians accepting their new roles as compliant rationers of medical care and the elderly as victims who no longer can trust “their” doctors for independent judgment. Most physicians don’t know the mesh of regulations that will direct their judgment assisted by their Medical Directors who will counsel them. Obamacare will require thousands of new IRS agents to govern compliance. Pragmatically speaking, “quality” is Compliance. The Hippocratic Oath is dead! The public must be told that “Primacy of the Patient” no longer governs the service of doctor to patient. So should the trial lawyers. There are at least two constitutional challenges doctors should back. Finally, whatever bill emerges from repeal, the sick and those with preexisting conditions must be insurable and there must be major tort reform which the AMA backed away from when Obama declined to grant. — Cleve Baker, MD It definitely needs some help, but I would not start over. — Thomas Curran, MD Most of this repeal chorus is a partisan political smokescreen to subvert the current administration and win the next presidential election. — Mark Zlotlow MD In contrast to Nancy Pelosi’s statement, we need to “read what is in the bill BEFORE we sign on to it”. — Harold Rennolet, MD More pluses than minuses and certainly not hastily drafted! — Jonathan Breslau, MD

The worst piece of legislation ever produced by Congress. Large employers have already projected the effects and costs are going up for employees. Small business cannot afford to add new employees. The number one component that should have been in this legislation is missing...tort reform. — Reinhardt Hilzinger MD The private sector has had years to get medical costs under control. Instead, we now spend 17 percent of our national GDP on healthcare and still fall far short of insuring everyone. In this age of fear of big government regulation, the PPACA was probably as close as we could come to real reform without completely dismantling the current system. Some of the reforms no doubt will appeal to liberals and conservatives alike: dealing with the Medicare Part D doughnut hole, barring health plans from excluding children due to pre-existing conditions (and at a later date, applying that to everyone), allowing dependents to stay on health plans until age 26, and raising Medicaid reimbursement. The more contentious items seem to be the promotion of accountable care organizations and what that means exactly. And lastly, the issue of health insurance exchanges managed by the individual states. We know how good California has been managing its finances! Should be interesting to see how it plays out. — Nate Hitzeman, MD While this bill was not financial reform it is a start; everyone in this country deserves decent health care and, while awkward in its approach, this will move towards that goal. — Thom Atkins, MD It should have included a public option provision. — Gerald Swafford, MD They need to have tort reform in order to decrease the cost of medical care. — Richard Wakamiya, MD The bill hardly addresses the problems of our healthcare system and, in fact, puts more money in the hands of the insurance companies; however, it does insure millions of new people and it is at least a step in the right direction. — Jana Chtchetinin, MS II

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The worst piece of legislation ever produced by Congress.

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If it is “ill-timed” it is because it is way overdue. If there is an “illconceived” model, it is our current fragmented, overpriced, wasteful system of irrational rationing.

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Everyone should be able to purchase health insurance, so the “preexisiting” ban is a very positive aspect of Health Care Reform. Also being able to keep children on the parents’ plan until age 26 is good. — Debra Johnson, MD This is just the first, but very important step, towards an affordable healthcare system with universal coverage for the USA. — Ralph Koldinger, MD According to those who really know the specifics of the bill, it’s worse than we can imagine. — Greg Nulton, MD When I was in school 20 years ago, Canadians and even Brits were coming to the US to get care not available, or not available for months to years in their home country. Where will we go if the U.S. goes “nationalized”? — Brian Wipperman, MD This is the first step to improve our totally broken system. It is totally wrong to repeal this. Let us improve it. If repealed, nothing will happen for another several decades. We cannot afford that. — Jane O’Green Koenig, MD Some of its provisions should be changed; specifically, there should be more restrictions placed on the control insurance companies have on delivery of health care to Americans. —Sebastian Conti, MD Does absolutely nothing to reduce costs and waste. We need evidence-based medicine in combination with tort reform so that we don’t waste billions of dollars in unnecessary tests performed solely for “defensive” medicine. — Steven Polansky, MD This bill is intended to ultimately result in the federal government controlling your person through health care. Pelosi was right in saying it needed to be passed to learn what it contains — and what we are finding is UGLY, for instance the 1099 requirement which is probably a first step of a value added tax. — Donald Macko, MD Although far from perfect, it is an improvement over our current system. One only need look at the EDs to see the results of poor healthcare asset allocation. Patients wait hours for care, often for non-emergent issues often exacerbated by time delays due to lack of access, and

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inability to purchase or qualify for insurance. Lack of communication between providers adds to the costly stew and leads to unnecessary and/ or repetitive testing. It is inexcusable that the U.S. spends more than any other nation, yet ranks nowhere near the top in most measures of healthcare delivery. — Kimette Marta, MD Reform will always be considered ill-timed and “hastily drafted,” not to mention illconceived, to those who oppose it. Like a pregnancy, there is never a “convenient” time for reform. The Patient Protection and Affordable Care Act is complex and imperfect... but it’s a start. If it is “ill-timed” it is because it is way overdue. If there is an “ill-conceived” model, it is our current fragmented, overpriced, wasteful system of irrational rationing. Let’s put our energies into moving forward; let’s build on a decent start. Let’s not stagnate in a system that has become sadly laughable to developed nations worldwide, and has proven over and over that it does not work equitably, rationally, or compassionately. — Jody Gordon, MD It may not be the ultimate ideal in health plans, it is definitely going in the right direction. For a change, a plan has been proposed that is for the rights of the patient. — Shereen Zakauddin, MD Too broad a statement. Some parts of the Act should be repealed. — Kuldip Sandhu, MD It gives more coverage to more people but does not really address the problem of cost control. If you can truly keep cost under control, there will be affordable care. The current Act or Bill, all it does is shift the cost of care probably through higher taxes in the future. — Vong Lee, MD We cannot throw the baby out with the bath water. It could certainly use some amendments. — Olivia Kasirye, MD Too many extraneous things in the bill, such as businesses filling out 1099s every time $600 is spent, and the 182 committees and commissions. Let’s start over and get it right this time and allow congressmen and senators time to actually read the bill. — Sidney Yassinger, MD


The “Patient Protection and Affordable Care Act” is neither ill-conceived, ill-timed or hastily drafted. It was the product of many months of careful consideration by intelligent specialists, in consultation with many important interest groups. In contrast, our current, disordered health care “system” is both illogical and inhumane. We should proceed with the legislated changes, then build from there. — Steven Orkand, MD It is the worst piece of legislation in history and should be repealed. It should then be replaced with many separate bills that are thoroughly debated and passed in the usual honest fashion. — Donald Hause, MD Not only hastily drafted, but most members of Congress never read the act. — Norman Label, MD It’s a start! We need health care insurance reform to make this work — caps, incentives for preventive care, etc. — Barbara M. Livermore, MD This legislation is a small step toward a system of medical care that will bring us into the civilized world. — Saul Schaefer, MD While it is not perfect, there are parts of it that cannot be argued against. The objectors say it should be entirely repealed, some stating that we have the best system in place already, ignoring the fact that the current system is melting down. They are driven solely by partisanship and they have not presented viable alternatives. — Clifford C. Marr, MD The suggestion to repeal the entire PPACA represents pure political posturing, good for sound bites, but devoid of any thoughtful evaluation. In fact, one should say that the notion of total repeal is “ill-conceived, ill-timed, and hastily drafted.” Many of the provisions in the act will be good for patients, some will be good for the economy, and some will even be good for physicians and others who provide health care. In

fact, many Republican leaders will admit, but only in private and off the record, that some of the PPACA policies, particularly regarding health care cost reduction, are well-aligned with their stated goals. That said, there is no doubt that this law, like most of the ideas that emerge from the Congress, could and should be improved — through careful study and revision of key sections, but not through wholesale repeal. — Alfredo Czerwinski, MD I don’t know how many of us have the background and knowledge to answer this question. I like CMA’s position that we want to retain the good and correct the bad parts of the legislation. However, I have heard others say that the plan is “so ill-conceived and hastily drafted” that it is irreparable, needs to be scrapped and started again based on proven principles of public health. — Richard Gray, Jr., MD

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Faith Fitzgerald: Know the Science, Know Your Patient This continues an interview with Dr. Faith T. Fitzgerald, Associate Dean of Humanities and Bioethics at UC Davis. Part I ran in the last issue.

By David Gunn, MS IV

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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David Gunn: I’ve often thought about the quality of “genius,” and what we choose to label as genius. Is it knowledge, far surpassing what we thought we knew? Is it insight that is obvious that previously went unnoticed? Is it connecting disparate dots? Is it creativity? Do you feel genius is more reliant upon creativity or upon a strong memory [that allows us to connect the dots]? Faith Fitzgerald: Both are necessary. There are speculations based on fMRI and other neuroimaging that creativity depends upon a predicate background of information and data. It could be objective data, or sensory input from one’s own visual, olfactory or auditory senses. Then you need the ability to relate that data to other things. The thought is that the neo-cortex is largely a matter of information — a computer — but how you rank and relate that data, the value of that information is highly dependent on the ability to integrate it with deeper, older structures, the frontotemporal lobes, the paralimbic system — emotional, judgment centers of the brain. Those complex relationships, the ability to see things in many different ways (particularly in our time, when “information” is readily available, whether it be true or pertinent or not), has not generated great creativity, save for the people who know how to use it well. And I suspect they do it well because that’s the way their brains are constructed. Genius is really a matter of accomplishment — if you think back over the history of genius — as opposed to people who score high on modern IQ tests. Creative people left a legacy of Sierra Sacramento Valley Medicine

something new, something different. So really, in assessing genius over the millennia of human accomplishment, it largely has to do with, ”Oh, that’s a new way of doing things, that’s a new way of seeing things.” And not because the information wasn’t there, because it obviously was, but the way one thought of it, constructed it and applied it. Einstein, the genius of the 20th century, said ”I’m not particularly smart, but I am very, very curious.” He was clearly very smart in the sense of having all the data, but having all the data can sometimes be impedimentary. One can be satisfied with knowing what everybody else knows. He was able to look at constructs as they were and say there must be something different. Most scientific genius has been this gift of not accepting everybody’s opinion of what’s going on: Galileo, Einstein. Looking at the known facts in a different way — that’s genius. DG: One of the stories I’ve heard is, “Stump Faith.” Where and how? FF: American College of Physicians, and most visiting professorships. DG: Do you remember one of the first times this game was played on you? FF: Actually, it happened at an ACP meeting in Washington, D.C., in the mid 70s. Off I went — I think I was an assistant professor of medicine at UCSF at the time — and they said we’re trying this new thing, and I thought what have I got to lose? They presented me clinical cases, all of which were strange and unknown to me, and I got them all! This was in front of a large audience


of people, an exercise in diagnostic reasoning. My gift was not in knowing so much, but that I tended to be theatrical in my presentation and was evidently entertaining. They kept asking me back, and pretty soon I got a reputation. I’ve missed many cases since, but people don’t seem to remember the misses. I find it fun and challenging. And I suppose the advantage I had was that I always considered the audience an ally, and never an enemy. It wasn’t scary for me — and it is for many; they hate being wrong, but I don’t care, there’s not life at stake here, it’s a game. DG: That is such a great message — when you feel connected to the people around you it belies everything about how you interact with them and how you carry yourself. FF: It does establish a comfortableness, ”these are my family,” in a sense. They all have these challenges to meet, and they don’t expect anything more than the best effort you’ve got. There’s no shame in being wrong. DG: The same quality that drives many medical students to succeed also makes them competitive, and in that competition, there is an adversarial relationship that separates them from others. FF: And that’s a shame. That is something not part of the original construct of teaching at Davis, because the colleagueship used to be much more ”helpful” oriented. It’s a thing that I mourn in its loss, although it’s not as great a problem at Davis as it is at other institutions. DG: I wanted to ask you about theater; I know you have an interest in opera, because one of your colleagues wanted to know why you like Cosi fan Tutte so much? FF: Because I’ve always loved Mozart — he’s so melodic. It’s the music actually, not the story. With Verdi it’s often the story. With Mussorgsky it’s the cultural thing, because I grew up in an orthodox Russian household, and the sounds of the music are the sounds I heard in a Russian Orthodox Church — I can almost smell the incense when I watch one of these ornate Russian operas. Each opera has its own quality. I didn’t care for opera much until I was 43, I’m 67 now. I watched on public television, Placido Domingo. God, that’s a good looking

guy! [laughs] And a wonderful voice, and a good actor. So, that’s what got me interested. Then he went off to go help the survivors of the great Mexican earthquake, so I thought okay, I’ll follow this good guy, and that got me into opera. DG: Which performance did you hear him give first? FF: La Traviata. It’s a hard one not to like, plus it’s got a little medical history in there, tuberculosis. DG: Changing gears for a second — what is the most important part of the Hippocratic Oath? FF: [sigh, pauses] “Into whosoever’s house I enter I do so for the benefit of the sick.” DG: Because it places an emphasis on the patient? Or because it draws attention to the familial relationship between the care provider and the patient? FF: It’s about the fiduciary relationship — no matter what the other pressures. Sick is interesting: Susan Sontag, the kind of crazy American philosopher, said, after her own breast cancer, that all humanity can be divided into the kingdom of the well and the kingdom of the sick: a much more fundamental allegiance than any other single thing. DG: So what do you think about students who are about to graduate deciding the oath they will take, as opposed to taking the oath that was designed by those who have come before them? FF: As long as the core principle remains that of the fiduciary relationship, I don’t care. If a man or woman is going to take an oath, he or she should be pretty sure they are going to be able to keep it, which means you may have to change words back and forth. Once that oath is taken, to renege upon it suggests that you can’t be trusted, and being a good physician is entirely dependent upon trust. When the Hippocratic oath was around, everyone was so wed to it by tradition that they left in things like, “I will not cut for stone.” Well, that left the urologists out. Or, “I will not give a woman a pessary”; well, that’s fine for me but there are some gynecologists who still use them. And there was the part about, “I will not do abortion,” which evidently meant that most

November/December 2010

It’s about the fiduciary relationship — no matter what the other pressures.

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I’m particularly disquieted by algorithmic thinking, by pathways that are turned into dogmatic requirements.

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physicians in the Hippocratian cult were not competent at it and wouldn’t do it due to incompetency [as opposed to moral objection], but nonetheless from the 1960s and 70s on it was controversial as to whether people should swear to that. Of course you can take any oath as long as you don’t say, don’t pledge, to the parts you don’t agree with. Which is why the perfect oath thing doesn’t make sense. We’re a heterogeneous people — just as sick people are — so to say that everyone has to swear to the [same oath] doesn’t make sense. But to have that core: to care for the sick, and that of the fiduciary relationship is the important part. DG: What do you think is the difference between the physician as humanitarian and the physician as investigative scientist? FF: There is no difference. Investigative science must be done humanely, to work in partnership with patients. The particular difficulty is that the risk-benefit ratio, within which we normally work, doesn’t fully exist in clinical trials — you’re doing the trial to establish the risks and benefits — so you can’t give as much information. What you can do is set up safeguards with which the patient concurs, and to go ahead and give it a trial. There is little risk to you outside of your reputation, but the risk to patients is great... it requires scrupulous honesty to them. DG: But do you see one as more important than the other? FF: I think they’re both so tied together as to be inseparable. Someone once described bedside medicine as the clinician going to their laboratory — each patient has an individual problem, but the doctor must take a bunch of different data and try to make sense [of them] with science in this unique case. The patient I told you about earlier [see the previous issue of Sierra Sacramento Valley Medicine], with the FUO and laparotomy, it might have been that she could attribute her symptoms to devils, which is not scientific until you understand the pathophysiology of fear and chronic anxiety. It’s flawed humanity to use bad science. Science is a way of thinking and a way of asking questions — it’s not the information you get, for

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that can be tainted in many ways. We know that from the initial rejection by experts of the great discovery of Warren and Marshall [H.pylori, Nobel Prize winners, 2005]. We know that from our own experience of the paroxysmal and almost seismic overturning of ”absolute truths”: everyone should take statins — nope, wait; all post-menopausal women should take hormones — no, wrong. Our task as scientists at the bedside is to craft known science data to this single patient. That’s the important difference from the bench of clinical medicine: it’s not what you know of information, it’s how you apply it. I’ve used the analogy that to treat patients with ”good” science, but without knowing them, is like plating bacteria on an unknown medium — you don’t know what’s going to grow. To just apply cohort data is not sufficient. I’m particularly disquieted by algorithmic thinking, by pathways that are turned into dogmatic requirements. How can anyone know what to do without knowing who the patient is and what they need? And algorithms don’t. The data are for “the diabetic”, and other data for “the patient with congestive heart failure,” or “the cirrhotic” — but there is no such person. DG: Do you feel like Osler would have agreed with that? FF: Yeah, oh, for sure! The problem is our tools are so much stronger now. The risk is greater, CT scans and MRIs being the most recent example. It’s a wonderful technology that allows you to see inside, sort of physical diagnosis in the dark. Good radiologists are superb physical diagnosticians, it’s just the physique they are diagnosing is isolated from how the patient presents in whole; they don’t know their stories very well. DG: I know you place an emphasis in your writing on bedside physical diagnosis, but that’s not something that students are exposed significantly to. FF: Yeah, it’s a pity. A pity for two reasons. One is the sustaining influence of technology may crumble over time as the economics become harder and harder. And two is the recognition that this application of “virtual” patients is not extant in a large part of the world that


actually needs doctors. So you cannot export those things to sub-Saharan Africa nor to the teeming streets in rural India — you just can’t. I’m not sure that medical students understand that the most enduring therapeutic instrument in all of medicine is the doctor him or herself. This is demonstrated by the effect of quacks — who can make people feel better absent science, and who may use even false technology to do so. And that attentiveness to themselves as individuals is what many patients use to adjudicate whether the doctor is any good or not. It’s not doing things to things, it’s working through, as partners in a sense, with each patient that makes them feel better. But I’m not despairing about young doctors, because they’ll learn that experientially. DG: And that patient we discussed earlier with the FUO, is that when you first learned that? FF: Yeah, I think she taught me that very quickly. It was in the first months of my internship: if we’d talked a little longer... DG: And not that you would have done the laparotomy any earlier to release the spirits... FF: Right, the surgeons would have done the laparotomy anyway because the spirits would have been second in line to a lymphoma. There was then no better way of making the diagnosis. But the fact that her conviction that she’d been hexed was a possible cause of her fevers was nothing that any of us had considered because we had not asked her, “What do you think is going on?” DG: Right, to just say, “What do you think the problem is?” FF: One of the things that’s happening is patients are going on the internet, and they may not have an idea of what the cause of their problem is, but they’ve matched it with something [they’ve read]. “Could I have angioimmunoblasticlymphadenopathy? Because it sounds just like what I’ve got!” That was the problem with computer diagnostics: there was no individualization. At an ACP meeting in the late 70s they put me up against a new computer program. The computer was run by a poor guy who spent the whole previous night programming in the clini-

cal data, and I was getting the case de novo and trying to come up with differential diagnoses. The computer was very good with data, listing every differential diagnosis that appertained to the overt symptoms and signs. What it could not do was to eliminate those that were so unlikely as to be highly improbable. It was another fever case, and this computer was listing things like Tsutsugamushi fever, in a patient that had never left Philadelphia. That’s very unlikely, and something we would throw out immediately. It could not craft the data to the patient, it had no sense of ranking, and it was only programmed for the United States, so if someone came in with fever from China it would have no idea what was going on. DG: A fancy computer for the late 70s. FF: It was! It was in vogue at the time to think that all you needed was enough data and you could solve the problem. I think that’s been shown not to be true. DG: So how do you approach patients who come to you with a handful of computer printouts? FF: I ask them to try and tell me their actual story without getting it confused with what they read. I’ll have patients coming in with hundreds of pages of previous tests, articles, and doctors’ opinions and they’ll plop it down in front of me. I push it aside, and they’ll say, “Aren’t you even going to read it?” And I’ll say, “No, because if the answer were in here, you wouldn’t be here. So tell me the story as much as you can.” ”I got this headache, so my doctor said...” “No, tell me about the headache, not what the doctor said, not about the MRI test...” It’s becoming increasingly difficult for people to own their own histories. It’s usually two minutes of their own history followed by unsuccessful diagnostic studies performed by others — which don’t help. What the FUO patient taught me was the story can help — not in substitution for the other data — but you should go back to the story when the data doesn’t work. And that’s the case in these complex chronic illnesses.

It’s not doing things to things, it’s working through, as partners in a sense, with each patient that makes them feel better.

dgunn11235@gmail.com November/December 2010

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Toward Fixing the SGR By Gerald N. Rogan, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

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DURING THE 2010 LAME DUCK SESSION of Congress, physicians lobbied Congress to fix the sustainable growth rate (SGR) calculation to stop the looming 21 percent reduction in Medicare fees. Congress calls this the “doc fix.” Congress may “kick the can down the road” by postponing the looming reduction. This SGR problem is like a bad penny, always turning up. Congress’ rationale for the SGR is that docs largely control the volume of medical services provided. If the collective volume of services per patient is too high, collectively the docs are responsible and should be paid less for each service. The problem with this logic lies with the tragedy of the commons. (If you do not know the story, “google” it.) The docs’ response to proposed SGR reductions is always the same: increase our fees or we walk! They refuse to negotiate with CMS to develop a win-win solution. Docs see themselves as victims of Medicare’s fixed fee authority, not as partners with our government to help patients. The fixed fees that docs must accept may constitute a covenant. For this benefit, the doc can see the patient and be paid less than most commercial plans pay. But, because of their age, Medicare patients require much more time for the same level of E&M service. Commercial plan patients are younger and the plans usually pay better than Medicare. In fact, the Medicare covenant is one sided, so really it is not a covenant, is it? It is more like slavery. What do the docs get for agreeing to Medicare’s price fixing? In my view, we get nothing. Considering this, I have proposed to CMS and to the CMA an alternative strategy to fix the SGR. I am sharing it with you in hopes some of these ideas will resonate with you and lead to a better way to fix the SGR than hours of

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complaining, begging, and threats. Idea #1: Stop fraud and abuse which adds to the SGR problem. Require providers post a performance bond to qualify for Medicare enrollment and re-enrollment. The performance bond would insure the Trust Fund against fraud and certain cases of abuse. Your medical liability carrier could issue the bond. Your medical liability insurer also could vet you for enrollment as a Medicare provider much faster than your local Medicare Administrative Contractor’s (MAC) Provider enrollment staff, more accurately, and with better customer service. The MAC’s job will be to finish the enrollment vetted by your insurer. Imagine signing up for Medicare as quickly as for medical liability insurance, plus enjoying hassle free changes if you relocate or add another doc! Idea #2. Tort Reform. To offset the cost of a performance bond, physicians who enroll in Medicare should be granted the right to refer all medical malpractice litigation claims filed on behalf of a Medicare beneficiary to federal court and/or a dispute resolution process established by the federal government similar to the method used when a government physician employee is sued for negligence. Medicare beneficiaries could opt out of this process and revert to litigation under state law, but by doing so waive their right to not be balanced billed for charges in excess of the Medicare limited charge. This would be a real quid pro quo — limiting charges in exchange for tort reform — a real covenant, not slavery. Idea #3. Change the Claims Processing System. Medicare should change its claims processing system to one that operates like credit card transactions, so that fraud and abuse can be detected and stopped on the first, second,


or third transaction, not after the 3,000th transaction (called “pay and chase”). Physicians will benefit because the cost to submit a credit card charge is much less than the cost to send a bill to Medicare. Docs can be paid as quickly as pharmacists. The Medicare patient should have a bank issued photo ID Medicare card with a PIN number. The card would be used to conduct the financial transaction. Claims submissions can be analyzed in real time sorted by both the doc and the patient and across a robust claims history of potentially duplicative services. If you find any of these ideas helpful, or have other ideas, I encourage you to write to your CMA representative so the CMA can develop a new strategy to fix the SGR and present it to CMS for a discussion towards a win-win solution, instead of “kicking the can down the road” endlessly. jerryroganmd@sbcglobal.net Dr. Rogan is the former Medicare B Medical Director for California.

SSVMS Election Results 2011 BOARD OF DIRECTORS President: Alicia Abels, MD President-Elect: David Herbert, MD Immediate Past President: Stephen F. Melcher, MD District 1, North: Robert Kahle, MD District 2, Central: Jose Arevalo, MD, Steven Chen, MD, Michael Flaningam, MD, District 3, South: Bhaskara Reddy, MD District 4, El Dorado County: Demetrios Simopoulos, MD District 5, Permanente Medical Group: John Belko, MD, David Herbert, MD, David Naliboff, MD, Robert Madrigal, MD, Anthony Russell, MD. District 6, Yolo County: J. Dale Smith, MD 2011 CMA DELEGATION District 1, North: Jon Finkler, MD, Delegate; Reinhardt Hilzinger, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Margaret Parsons, MD, Alternate District 3, South: Barbara Arnold, MD, Delegate; Katherine Gillogley, MD, Alternate District 4, El Dorado County: Ronald Foltz, MD, Delegate; Demetrios Simopoulos, MD, Alternate District 5, Permanente Medical Group: Elisabeth Mathew, MD, Delegate; Anthony Russell, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office #7: David Herbert, MD, Delegate; , MD, Stephen Melcher, MD, Alternate At-Large Office #8: Alicia Abels, MD, Delegate; Gerald Upcraft, MD, Alternate At-Large Office #9: Norman Label, MD, Delegate; Robert Forster, MD, Alternate At-Large Office #10: Satya Chatterjee, MD, Delegate; Maynard Johnston, MD, Alternate At-Large Office #11: Boone Seto, MD, Delegate; Alternate (Vacant) At-Large Office #12: Kuldip Sandhu, MD, Delegate; Rajan Merchant, MD, Alternate At-Large Office #13: Earl Washburn, MD, Delegate; Ulrich Hacker, MD, Alternate At-Large Office #14: Charles McDonnell, MD, Delegate; Robert Madrigal, MD, Alternate At-Large Office #15: Richard Jones, MD, Delegate; Alternate (Vacant) At-Large Office #16: Richard Gray, MD, Delegate; Alternate (Vacant) At-Large Office #17: Janet O’Brien, MD, Delegate; Alternate (Vacant) At-Large Office #18: Robert Kahle, MD, Delegate; Russell Jacoby, MD, Alternate

November/December 2010

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Board Briefs November 8, 2010 The Board: Approved the 2011 Operating Budgets for the Sierra Sacramento Valley Medical Society (SSVMS), the Community Service, Education and Research Fund (CSERF) and the 2010 Third Quarter Financial Statements. Approved the amendments to the SSVMS Alliance Bylaws. Approved the following recommendations from the Scholarship and Awards Committee for the 2010 SSVMS awards: Golden Stethoscope Award, William J. Au, MD; Medical Honor Award, Faith T. Fitzgerald, MD; Medical Community Service Award, Helen Thomson, Supervisor,

To learn more, call 866-534-3403 or visit healthcare.goarmy.com/k827.

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Yolo County. The awards will be presented at the SSVMS and Alliance Annual Dinner scheduled for Friday, January 21, 2011 at the Hyatt Regency Hotel. Approved the Membership Report For Active Membership — Megan L. Anderson, MD; Parimal T. Bharucha, MD; Inderpal K. Biring, DO; W. Douglas Boyd, MD; Shelley J. Eder, MD; Wiley L. Fowler, MD; Azad Ghassemi, MD; Richard C. Graves, MD; Megan F. Gross, MD; Anne Igbokwe, MD; James C. Kaw, MD; Yevgeniy A. Lepler, MD; Vilasinee Morkjaroenpong, MD; Bilal Naseer, MD; Minh T. Nguyen, MD; Raymundo J. Ortega, MD; Andrew M. Park, MD; William L. Phillips, MD; Erin R. Prince, DO; Sarah F. Schutzengel, MD; William E. Teague, MD; Shaw-Ta Yeh, MD; Cindy Q. Yu, MD; Stan Zipser, MD. For Reinstatement to Active Membership — Raquel C. Cripe, MD; Hong-Wen “Wendy” Xue, MD. For 65–20 Active Membership — Michael A. Cerruti, MD; Prabhas Tung, MD. For Retired Membership — Philip K. Dirksen, MD; Donald M. Hopkins, MD; H. Setsuo Masaki, MD; John S. Rice, MD; John B. Williams, MD. For Resignation — Laura C. Miller, MD; Michelle P. Rhodes, MD (moved to Colorado); Barbara L. Rounds, MD; Scott W. Siegner, MD (moved to Illinois); C. Heidi Zhou, MD. Serving as the BloodSource Member Board of Directors, the Board approved the following: (1) 2011 Slate of Board of Trustees Officers and Trustees: Keith McBride, Esq., President; Harry H. Lawrence, DDS, Vice-President; Paul Rosenberg, MD, Secretary/Treasurer; George Chiu, MD, Past President; Esther Aw, Trustee; Chris Ann Bachtel, Trustee; Brenda Crum, Trustee; Angelo M. de Mattos, MD, Trustee; Donald Delach, Trustee; Diana Dooley, Trustee; Sherri Kirk, Esq., Trustee; Anthony Nasr, MD, Trustee; Mervin B. O’Neil, MD, Trustee; Margaret Parsons, MD, Trustee; Larry Salinas, Trustee; Gerald Simon, MD, Trustee. (2) Ratified the approval of the amendments to the BloodSource Bylaws.


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 Anderson, Megan L., Emergency Medicine, UC San Diego 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Bharucha, Parimal T., Pulmonary & Critical Care Medicine, Govt Medial College, India 1999, Pulmonary Medicine Associates, 6660 Coyle Ave #350, Carmichael 95608 (916) 482-7621 Cho, Sandy S., Internal Medicine, Tufts University 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Cripe, Raquel C., Family Medicine, UC Davis 1998, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055 Fowler, Wiley L., Gynecologic Oncology, University of Tennessee 2003, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Ghassemi, Azad, Radiology/Neuroradiology, University of Texas, San Antonio 2002, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400 Gross, Megan F., Radiology, UC San Francisco 2002, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400 Graves, Richard C., OB-GYN, Baylor College of Medicine 1988, UCDMC, 2521 Stockton Blvd., #4200, Sacramento 95817 (916) 734-0471 Igbokwe, Anne, Pathology/Molecular Genetic Pathology, University of Ibadan, Nigeria 1995, BloodSource, 10536 Peter A. McCuen Blvd., Mather 95655 (916) 453-3714 Kao, James C., Gastroenterology, Duke University 2003, Woodland Clinic Medical Group, 1321 Cottonwood St #203, Woodland 95695 (530) 668-2600

Kumata, Dennis S., Anesthesiology, University of Southern California 1985, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6468

Rittenbach, Jonathan S., Anesthesiology, Loma Linda University 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Lepler, Yevgeniy A., Psychiatry, Donetsk State Medical Institute, Ukraine 1985, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95825 (916) 688-2000

Santos, Amadeu F., Nuclear Medicine/Radiology, University of Washington 2000, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4400

Morkjaroenpong, Vilasinee, Pulmonary Disease, Mahidol University, Thailand 1991, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040

Schutzengel, Sarah F., Pediatrics, UC Davis 1989, The Permanente Medical Group, 1840 Sierra Gardens Ave, Roseville 95661 (916) 787-6535

Naseer, Bilal, Critical Care Medicine/Infectious Diseases, University of Punjabi, Pakistan 2001, Pulmonary Medicine Associates, 6660 Coyle Ave #350, Carmichael 95608 (916) 482-7621 Nguyen, Minh T., Radiology/Body Imaging, New York University 2000, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4401 Ortega, Raymundo J., Family Medicine, UC Davis 2007, Sutter Medical Group, 2210 Del Paso Rd #A, Sacramento 95834 (916) 285-8100 Park, Andrew M., Family Medicine, Loma Linda University 2007, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6635 Phillips, William L., Cardiology, UC San Diego 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4406 Prince, Erin R., DO, Emergency Medicine, Kansas City University 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

Sweidan, Suzanne R., Internal Medicine, UC San Francisco 2003, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 Teague, William E., Emergency Medicine, UC Davis 2006, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 973-6800 Xue, Hong-Wen, Family Medicine, Shanghai Second Med University, China 1985, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040 Yeh, Shao-Ta, Emergency Medicine, Drexel University 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Yu, Cindy Q., Pathology, Beijing Second Medical College, China 1986, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7266 Zipser, Stan, Radiology/Interventional Radiology, Chicago Medical School 1997, Sutter Medical Group, 2800 L St #610, Sacramento 95816 (916) 733-4401

TheAlliancewouldliketoremindSSVMSmembersthatthepopularandveryusefulCommunityRe sourcesforOlderAdultsdirectorywasrecentlyupdatedandcopiesareavailableattheSSVMSof fice.This12pagebooklethasseveralhundredlistingsofagencies,seniorservices,advocates,nursing homesandotherprogramsservingtheseniorpopulation.Itincludesstateandnationalorganizations andagenciesaswellasthoseinSacramento,Yolo,andElDoradocounties.Someofthemanycatego riescoveredinclude:Advocacy/IssuesonAging,ConsumerAffairs,FinancialAssistance,Safety,Trans portation,andVolunteerism.  Copiesaredistributedtoawidevarietyofcommunityresourcesincludingallofthelibrarybranches, manycity,county,andstateagencies,hospitalsandotherhealthrelatedfacilities,seniorcentersand agencies,medicaloffices,andindividuals.Thedirectoryisalsoavailabletodownloadatwww.ssvms.org undertheResourceSection.BulkquantitiesareavailabletopickupbyfirstcallingtheSSVMSofficeat (916)4522671.WeencourageSSVMSmemberstoobtaincopiesofthisveryhelpfulbooklettoshare withtheirseniorpatients.

November/December 2010

35


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2010-Nov/Dec - SSV Medicine  

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

2010-Nov/Dec - SSV Medicine  

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