2011-Mar/Apr - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2011

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Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE “What’s Next? Drugs and Rock-n-Roll?”

Alicia Abels, MD

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e.Letters to SSV Medicine

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EXECUTIVE DIRECTOR’S MESSAGE “The Painful Dilemma” and Dr. Harvey Rose

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A Posit on Physician Overprescribing of Opiates

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CONVERSATIONS Joe Silva: UCD’s Shift Towards Specialty Care

David Gunn, MS IV

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Marijuana Facts

Timmen L. Cermak, MD

29

Medical Crossword Puzzle

Ann Gerhardt, MD

Bill Sandberg

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The Scientific Method and the Legislature

Assemblymember Richard Pan, MD

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A Day at Rwanguba Hospital, DRCongo

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Ode to Herbert Bauer on His 100th Birthday

Phil Dirksen, MD

Cap Thomson, MD, et al

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Board Briefs

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ACOs: It’s Time to Connect Your Healthcare Castles

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IN MEMORIAM William L. Mahon, Jr., MD

Nathan Hitzeman, MD

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New Applicants

36

Classified ads

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A Bicycling Sabbatical

Larry Wolff, MD

16

Irrational Assessments of Radiation Risk

John Loofbourow, MD

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below.

Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.

All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

SSV Medicine is online at www.ssvms.org/magazine.asp This is the second cover by Sacramento otolaryngologist Dr. David A. Evans.

His remarks: “This image was shot in the front yard in March 2009. Insects are challenging subjects because they move quickly and the depth of field is very narrow with macro lenses.

“In this image I was pleased with the curvature of the newly sprouted layers of leaves over the carapace of the ladybug, as well as the color match between the leaf edges and the ‘shell’ or elytra of the insect.

There is an aphid at the bottom of the image, which is why the ladybug was there in the first place.”

Volume 62/Number 2 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Another aphid may be on the right edge of a leaf, but blurred by the narrow depth of field.

March/April 2011

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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.

2011 Officers & Board of Directors Alicia Abels, MD President David Herbert, MD, President-Elect Stephen Melcher, MD, Immediate Past President District 1 District 5 Robert Kahle, MD, John Belko, MD Secretary Louise Glaser, MD District 2 Robert Madrigal, MD Jose Arevalo, MD David Naliboff, MD Steven Chen, MD Anthony Russell, MD Michael Flaningam, MD District 6 District 3 J. Dale Smith, MD Bhaskara Reddy, MD, Treasurer District 4 Demetrios Simopoulos, MD 2011 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Vacant 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 David Herbert, MD Richard Jones, MD Robert Kahle, MD Norman Label, MD Charles McDonnell, 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 Maynard Johnston, MD Robert Madrigal, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Gerald Upcraft, MD Vacant Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD Very Large Group Forum Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Chair Stephen Melcher, MD Robert Forster, MD George Meyer, MD Ann Gerhardt, MD John Ostrich, MD David Gunn, MS IV Gerald Rogan, MD Nathan Hitzeman, MD F. James Rybka, MD Albert Kahane, MD Robert LaPerriere, MD Gilbert Wright, MD Lydia Wytrzes, MD John McCarthy, 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

“What’s Next? Drugs and Rock-n-Roll?”

A reduction in membership sends a wake-up call to SSVMS.

By Alicia Abels, MD I believe in giving credit when credit is due, so thanks, Mike,1 for giving me the hook for this column with your snarky comment about my first president’s message, “You’ve got us talking about sex — what’s next, drugs and rock n roll?”

Well, as it happened, this issue of Sierra Sacramento Valley Medicine developed the topic of drugs on its own, without my help. Rock-nroll will have to wait for at least another issue, as there is other trouble brewing right here in River City.

Perhaps we (the leadership of SSVMS) have been asleep and a bit complacent, confident that our members understand how important every membership is to our profession, and what the medical society does for them throughout the year. We had a loud wake-up call.

Sutter Medical Group, which has provided some strong leaders to the society locally, statewide and even nationally in the past, and which we have long been proud to say had 100 percent membership in SSVMS and CMA, recently decided to not participate at that level.

Financial uncertainty due to their recent merger of four medical groups may have partly driven the decision. We understand that, and certainly hope to continue discussions about increased membership in the future.

Nevertheless, this was a blow that we did not fully see coming. It’s pretty clear that we need to communicate better with all of you — medical groups and individual docs — on how important the role of the local and state medical societies are to our profession as a whole.

This society was founded in 1850 as “The Society for Medical Improvement.” Times change, practices change, but our medical society and our reason for being is not going away.

We cannot afford to. Medicine is a profession.

We are obligated to serve our patients, each other and our community.

We are also a profession that everyone wants to regulate and emulate. That is what this medical society is about. Maybe a more relevant title for us today would be “The Society for Medical Improvement and Survival of the Profession.” SSVMS and CMA are the only local and state physician organizations that represent, advocate, protect and help all physicians, regardless of specialty, group affiliation or mode of practice.

Doctors are busy people. We struggle with work/life balance. We cannot or do not want to serve on committees, make it to Board of Supervisor meetings or state regulatory hearings. We cannot all volunteer our services or testify before the Legislature. Nor can we be experts on every subject.

But collectively, your medical society dues allow all of this to happen pretty much seamlessly in the background while you’re doing your doctor thing and figuring out how you’re going to spend more time with your family.

Thankfully, there are many of you reading this who lift more than your own weight on committees, volunteering and providing needed testimony. Your medical society is profoundly grateful to you for volunteering your time and expertise for this important and often thankless March/April 2011

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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work. Our dedicated staff works hard every day on your behalf. Our dues support their hard work.

All of us, as members, are providing for the present and future greater good of our physician community, our patients and our community in general. You should feel good about yourselves and the financial commitment you have made.

Therefore, let me again give credit where credit is due — to you, individual members and

groups who continue to realize the importance of your local medical societies now, in the past and in the future. You are brilliant and unselfish in your wisdom and membership. May your numbers flourish aabels.ssvms@me.com 1 That would be Mike Robbins, MD, whom I have known since residency.

SSVMS — its Mission and Functions To read about the mission of SSVMS, go to www.ssvms.org/about/mission.asp.

To read “What Does SSVMS Do Anyway…?” go to www.ssvms.org/about/downloads/whatwedo.pdf

Your care makes all the difference.

Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

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not-for-profit since 1948

Sierra Sacramento Valley Medicine

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

e.Letters to SSV Medicine An Assault on Physician Conscience or Patient Access?

The article “Assault on Conscience” published in the January/February 2011 edition of Sierra Sacramento Valley Medicine describes an impending attack on physicians who do not wish to participate in procedures contrary to their conscience.

Most notably, the author is concerned with potential legislation that would force physicians to participate in controversial services such as abortion or physician-assisted suicide.

While the author gives an example of language removed from the recent Assembly Bill 2747, the argument can be made that there are far more real and existing threats to the physicianpatient relationship.

We believe that bills have already been passed that threaten a physician’s ability to practice within a “shared moral integrity” and “in a manner that best serves the patient.”

For example, many states have passed a variety of laws to limit the access of patients to abortion services. In Oklahoma, the law requires abortion providers to read a script providing details of the fetus’ development and suggesting the fetus may feel pain during an abortion.1 We students see these punitive state statutes as a far greater threat to physician conscience.

As first year medical students, we are taught to prioritize the safety of our patients, despite gender, race, or age. It is difficult to justify concerns about a near attack on physician conscience when a more unjust attack is already occurring on women’s rights and access to safe and timely care.

A human society does not exist where a significant proportion of women will not, at some point in their lives, seek out abortion services.2 In this country, 1.37 million abortions are performed annually and 52 percent of these abortions are performed in women younger than 25.3

An estimated 43 percent of all women will have at least one abortion by the time they are 45 years old. Black females are three times more likely than white females to receive abortion services, and Hispanic females are two times more likely.

This racial disparity is very much thought to be due to lack of access to preventative care and contraception services — the very services threatened by cutting federal funds to Planned Parenthood.1 Hence, rhetoric cloaked in the guise of physician conscience that serves to limit access to patients seeking reproductive services disproportionately affects minority women living in low-income areas. This is a dangerous step backwards in terms of social consciousness and women’s rights.

Regarding concerns about physician-assisted suicide, shortsighted rhetoric among politicians like “death panels” and “rationing” detracts from a much-needed honest discussion on endof-life care.

It does not seem likely that a bureaucrat will force a lethal dose of pentobarbital into a physician’s hand anytime soon, while it does seem highly likely that skyrocketing health care costs and inappropriate heroic care will break the back of our aging populace and tech-driven economy in this very decade!

The hijacking of legitimate strategies such as reimbursing for advanced directive conversations, improving access to hospice, and promoting patient centered comparative effectiveness research by politically-driven agendas not only limits our society’s ability to move the conversation forward in how to get the most of our health care dollars, but severely threatens the physician’s ability to best serve the patient.

As first year medical students, we learn to put our own judgment aside in the interest of our patients. We learn to actively listen to patients’ concerns and help guide them through

March/April 2011

We believe that bills have already been passed that threaten a physician’s ability to practice within a “shared moral integrity” and “in a manner that best serves the patient.”

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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their medical crises. We worry far less about patients dictating their own care than them being afraid to openly discuss their concerns out of fear of judgment. Over four years, we learn history-taking, then physical examination skills, and finally the art of diagnosis. The ability for a provider to connect to a patient in a way that solicits the patient’s trust is endearingly termed “the art of medicine.”

Before we enter into discussions about “poking a vengeful finger in the eye of those whom we disagree” perhaps we should discuss how we as a community of physicians can maintain patient safety while enjoying our work and chosen specialties, how medical educators can increase medical student interest in areas where there is a high need for services, and how best to protect a patient-centered focus in medicine.

— Olivia Campa, MS I — Adam Dougherty, MPH, MS I

Olivia Campa

Adam Dougherty

1 Joffe, Carole. Dispatches from the Abortion Wars. Boston: Beacon Press. 2009.

2 Lichtenberg P et al. A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone. 1999.

3 The Alan Guttmacher Institute and Planned Parenthood’s Family Planning Perspectives. www. abortionno.org/Resources/fastfacts. html.

A Special Reading and Signing by Dr. Rick Hodes Benefitting the Children of Addis Ababa, Ethiopia Friday, May 20th, 2011 6:00PM - 8:00PM Reception to follow Time Tested Books 1114 21st Street Sacramento, CA 95811 $50 General Public $20 Students At the door includes an autographed book! www.jdc.org/donate/hodes Light Refreshments Come hear stories of the lives Dr. Hodes is able to save because of the generosity of people like you.

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Sierra Sacramento Valley Medicine

The Need for — and Joy of — Family Practice I was interested in your article in SSVMedicine about your interview with Dr. Williams. [Hibbard Williams: Early Years of Family Practice, in the Jan/ Mar issue, an interview by medical student David Gunn.]

I spent my entire medical life as a GP and later Family Practitioner, am 88 years old and retired nearly 30 years ago. I have seen a lot of medical practice, both as a physician and as a patient.

Family Practice is here to stay in one form or another; it is needed. Many specialists and subspecialists are not capable of managing an entire patient. It seems that their knowledge of the total patient was wiped out years ago.

A physician’s choice of a specialty should at least partially be based on if he or she wants direct patient contact — and what kind. Lab physicians, pathologists, research physicians and some radiologists have little or no direct patient contact.

One of the joys of family practice is continuing contact over the years with individuals and often entire families of one or several generations.

After I left a small town solo practice to go to a multiple practitioner area, I soon realized there was not one medical problem confronted that some other physician was not better able to handle. But managing the entire patient was my area. I observe that, over the years, Family Practitioners are being respected for this uniqueness.

Financial reward for your work is now a far different story with government intervention. No one knows how this will work out.

Personally it has been a good stable life with no great education debt to haunt me. I had only a rotating internship and passed the Family Practice board with the first group.

I wish you well in choosing your specialty, and a long and happy medical life.

— Buren Krahling, MD burenkrahling@gmail.com

“The Painful Dilemma” and Dr. Harvey Rose

By Bill Sandberg The posit in this issue will likely elicit different responses from different readers. For me it’s a reminder of the position paper SSVMS published in November 1990 and the inspiration behind it, Harvey Rose, MD. The saga begins in the 1980s with Dr. Rose, a legendary member and family practice physician. Because of a heavy load of and interest in treating chronic pain patients, he found himself in serious trouble with the Medical Board of California for inappropriate prescribing. He nearly lost his license. Whether he deserved the wrath of the Medical Board or not is not germane to what he accomplished with the help of SSVMS and the CMA. Dr. Rose was committed to educating the public and his profession regarding the under treatment of pain. To say that he was tenacious and nearly totally consumed with his daily mission is a huge understatement.

My family was accustomed to answering the phone at any hour of the day or night and on weekends to exclaim, “It’s Dr. Rose.” He would be calling me with one story or another about someone in pain, a journal article, the politics of pain, the under treatment of pain or some new idea he had about solutions. I liked him and teased him that his mission was causing me and others a major pain in the-you-know-where.

He could not attend any meeting, anywhere, without taking a moment to preach about the under treatment of pain. Other physicians specializing in pain knew that Harvey did, in fact, have the clinical knowledge and experience.

At about the same time, SSVMS implemented a policy that any member physician, standing or ad hoc committee could research a problem and publish, with Board approval,

a position paper on subjects that needed to be addressed. HIV and health care workers, emergency and trauma center issues, animals in medical research and physician supply are examples of the papers we have done.

One day I finally got Dr. Rose to sit down long enough to consider a course of action. We agreed that a white paper with the right selection of medical specialties was needed to focus attention on the issue. Second, we needed legislation to safeguard physicians and patients from the inappropriate treatment.

After several months of meetings, the “The Painful Dilemma, The Use of Narcotics for the Treatment of Chronic Pain” was published in November 1990. Once released, hundreds of copies were requested from people throughout the United States and indeed the world. For several years, it was the most popular item on our web site www.ssvms.org/resource/downloads/ dilemma.pdf At about the same time, Dr. Rose and representatives of SSVMS started meeting with our local Senator Leroy Greene. That led to passing legislation entitled the Intractable Pain Treatment Act, and a stronger rewrite in 2006.

The law clearly states that physicians who have a medical basis for prescribing pain medications cannot be disciplined or prosecuted for a crime, and it clarifies and expands the permissible prescriptions for pain. The law spells out what steps prescribing physicians can and should take in prescribing to protect themselves and the patient.

Dr. Harvey Rose died in 2008, but his legacy lives on. bsandberg@ssvms.org March/April 2011

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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While incremental changes are made along the way, you’ll still need to continue to make important decisions about health insurance for you and your employees, especially when it comes to managing premium costs.

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This provides significant premium savings that can fund your HSA account.

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your medical rates increasing this year, we might be able to help you offset some of that increase.

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The Scientific Method and the Legislature

By Richard Pan, MD, Assemblymember, 5th District in Sacramento and Placer Counties As a new Assemblymember and one of two physicians serving in the state Legislature, I wanted to share with you, my friends and colleagues, my experiences transitioning from clinical medicine to policy-making. I hope to provide insights into how policy is made and encourage you to help shape it.

A century ago, the Flexner Report placed science at the foundation of medical education.

Since then, the application of science in medicine has led to tremendous advances in health, and students entering medicine are expected to have a solid grounding in science.

As a residency director, I devoted significant effort in teaching residents how to apply the scientific literature to practice. Residents analyzed research papers with the guidance of faculty and presented them in journal clubs.

We would discuss the difference between case-control, cohort, and randomized control studies and define statistical significance by understanding alpha and beta error. Sometimes, we would explore multivariate and meta-analysis methodologies.

Most importantly, we taught learners how to glean what they could use from each study and apply it to the actual clinical decisions. As my residents learned, there was rarely a definitive answer to their clinical questions in the scientific literature; however, an astute clinician would find valuable guidance on what decisions would most likely lead to the desired result.

I also believe that good science improves policy. As Chair of the CMA Council on Scientific Affairs, I strived to present good science on behalf of the Council to inform CMA policy. In addition, Dr. Lee Snook and I explored if the

Council could play a larger role in bringing good biomedical science to state policy-making.

Now, as an Assemblymember, I find that science is highly valued in state government, but poorly understood. There are few members of the Legislature, or leaders in the executive and judiciary branch for that matter, with a background in the sciences.

Legislators are usually given summaries of research results by lobbyists and staff, but rarely the original studies. Now, this is understandable; legislators, like clinicians, rarely have time to read many original studies given the number and variety of decisions that have to be made in a short period of time.

However, a lack of a scientific background can make it difficult to ask the right questions to understand the “science� being presented.

As a legislator, I have already had experiences that demonstrated the gulf to be bridged in applying sound science to good policymaking. In one situation, I did receive an original paper during a discussion. I was pleased to have the paper, but seemed to surprise people when I wanted to address the study methodology before jumping to the results.

In another discussion, I was informed that because there were more papers indicating support for a particular policy, the policy was scientifically sound. When I asked about the quality of the studies published, the person was taken aback.

Like clinical medicine, policy-making and legislating is improved with the application of good science. However, science itself will not provide the answer. In medicine, we take what we know from the literature and also apply

March/April 2011

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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clinical judgment based on individual patient factors to make a clinical decision.

In policy-making, science can provide a factual basis for decisions; however, policy also needs to incorporate our values and judgment.

For example, the decision to regulate air pollution needs good science to provide sound data on the effect of different levels of exposure on people.

However, we must balance what effects are acceptable with the trade-offs involving priorities such as transportation, manufacturing jobs and energy consumption.

Fifty-two years ago, C.P. Snow published The Two Cultures and the Scientific Revolution, describing the breakdown in communication between the sciences and the humanities.

I do not believe there is a conflict between the sciences and the humanities, but it is important that a strong understanding of the sciences is present in making policy for California. I believe that my colleagues also desire the same and that my experiences as a scientist and physician will lead to better legislation. www.asmdc.org/pan

Ode to Herbert Bauer on his 100th Birthday Chorus:

1.

As a lad in Austria he proved he was no fool.

He tutored Greek and Latin and he mastered every rule.

He learned to practice medicine at Vienna’s finest school.

And the Nazis couldn’t catch him when they tried to.

2.

He found his way to London where he and Hanna met.

They brought 200 refugees into their safety net.

California was a promised land they hadn’t conquered yet.

Let’s celebrate the work of the Bauers.

3.

Davis wasn’t Athens, but they were not forlorn.

Oeste Drive was fruitful after Tim and Chris were bom.

Both boys went on to doctorates their walls can now adorn.

Hats off to the work of the Bauers.

4.

Herb’s Letters to the Editors still keep us on our toes.

His gift has been succinctness, not longwinded German prose.

With English learned from Shakespeare he could sanctify a rose What a gift to still have Herbert Bauer.

5.

Peace and Health have been Herb’s dream for nigh 100 years.

War. Plague and Pestilence elicit our worst fears.

Come join the fight to put things right; His legacy we cheer!

Let’s thank the odds that brought us Herbert Bauer.

If it wasn’t for Herbert what would we do?

We wouldn’t have Public Health to fight the flu.

We wouldn’t have Mental Health for me and for you If it wasn’t for the work of Herbert Bauer.

— by Cap Thomson with the Putah Creek Crawdads

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Sierra Sacramento Valley Medicine

ACOs: It’s Time to Connect Your Healthcare Castles

By Nathan Hitzeman, MD As happens in times of uncertainty, medical groups around the country are merging and fortifying their healthcare castles.

Most major changes in healthcare follow monetary incentives, and the incentives are about to change. As the Patient Protection and Affordable Care Act (PPACA) rolls out, the melee to maximize Medicare reimbursement in 2012 through Accountable Care Organizations (ACOs) and to capture newly insured patients in 2014 has everyone poised in anticipation of battle.1 Look closely at your organization’s CEO. Can you hear the clinks of their mail under their nicely pressed suits? Have you seen their shields and crossbows hung behind their office doors?

Do you see their breath steaming the morning air as they watch their troops erect new medical towers? When you mention the word “Kaiser,” do beads of sweat appear on their foreheads while their hands instinctively clench?

Will the battle be won by healthcare organizations which have the highest Tesla MRI or the finest robotic arms to assist in surgery? Will the castle with the most beds and towers and outpatient surgery centers prevail? Accordingly, will patients live and die on the whims of the latest in medical technology? How many castles will it take to make our population healthier?

I, for one, am tired of receiving carrier pigeon type messages from the Emergency Departments of other castles or, in some cases, no messages at all. Perhaps it is time we left the Dark Ages of feudalism and enter a Renaissance period of healthcare. How about communication and coordination of care and investing in people for a change?

Let’s think “outside the castle.” Writer/

surgeon Atul Gawande notes that two decades ago, Denmark had over 150 hospitals for its 5 million people. But after strengthening the quality of its primary care and targeting expensive hot spots in the community, only half of those hospitals remain today.2 Our CEOs have every right to be scared!

Every castle has its faults. I was chagrined recently to see one of our patients get lost between hospital discharge and clinic follow up. Many organizations have home nurses who follow up on recently discharged patients. While the organization I work for has fine nurses who do this job, surprisingly their notes and assessments do not readily reach our EMR. When inquiring when ancillary services would be fully integrated into our EMR, we were told that budgetary constraints are leading to a slower than anticipated rollout.

Meanwhile, a new subspecialty building has gone up with cocktail tours of radiology suites showcasing multimillion dollar scanners. The United States is second only to Japan in number of MRI machines per capita.3 I don’t think more scanners will save our country’s healthcare but apparently they do reimburse well!

The point is this. All of our organizations have money; it’s just not being optimally spent to maximize patient care outcomes. And while technology driven docs want to see the finest facilities that money can buy, how about returning to a basic fundamental truth: patients do better when they have coordinated, guided care with smooth transitions. They also need adequate face time with their doctors.

There needs to be reimbursement incentive for physicians to talk with patients and coordi-

March/April 2011

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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Hence, EMR is becoming another “technological breakthrough” that I fear will not improve quality of care unless we make it more physician and patient friendly.

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nate their care. I would instruct us all to aim our catapults at the RUC (the Relative Value Scale Update Committee) on this point.

Coordination means investing in people and time spent with patients instead of machines and throughput. Our healthcare system has turned into a fast food type industry. We brand ourselves and compete, we waste millions of dollars advertising on why our golden arches are better than the others, and we compartmentalize peoples’ problems into convenient meat patties — that is, organ-based pathologies that lend themselves well to expensive and excessive interventions.

But what about EMR? Will that provide the missing link?

EMR promised coordination and connectivity, and slowly we are making some progress. E-prescribing is convenient and getting lab and imaging results to pop up is great.

Communicating with some docs within the group by messaging is also super.

But EMR is only as good as the investment in the people who use it, and it needs to be tailored to their needs. EMR cannot substitute for an instilled culture of communication among physicians and support staff.

Unfortunately, EMR is experiencing a creep towards information overload and unrealistic expectations upon primary care. When I scan through the wasteland of information in my EMR’s discharge summaries and consultations and template notes, I sometimes wonder how much better it would be if someone closely involved in my patient’s emergency room or inpatient care just called me on the phone and said “Hey, Nate, here’s what’s up with your patient and here’s what you need to look out for in the next few days…” Those kinds of collegial calls are becoming rare.

Furthermore, each EMR upgrade threatens my intimacy with patients even further with new “helpful” pop-up messages, obscure drug-drug interactions, and ridiculously long templates that seem to defy any normal conversation you would have with another human being.

Hence, EMR is becoming another “technological breakthrough” that I fear will not improve quality of care unless we make it more

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physician and patient friendly. At present, it is mostly billing-friendly.

The hospitalist movement has been intriguing. Hospitalists have been strongly embraced by our medical culture because they are human connectors who coordinate care in the hospital. If the entire world were a big hospital, then a hospitalist would satisfy all of our health care needs!

But unfortunately, once a patient leaves the hospital, the patient might as well have landed on Mars as far as the hospitalist is concerned.

The bridge to the castle is drawn up. The moat with crocodiles stares the still recovering patient in the face. Hospitalist handoffs need to improve. Currently, in California, about onefifth of Medicare patients are readmitted to the hospital within 30 days at an additional cost of $17.4 billion.4 So here is my challenge to you Big Feudal Health Care Organizations: Invest in people, communication, and coordination rather than expensive scanners. You may not hear that challenge now, but you will when the ACO money rolls out. The time is coming when the incentive will be to keep our patients well, not sick. Not all castles will be left standing.

I also call on some specialty physicians to come down from their procedure towers and practice more laying on of hands and medication management. Don’t delegate most of the face time with your patients to midlevel providers. It is the patient-physician interview and exam that separates our job from that of mechanics, and some of us have strayed from that time-honored principle.

Furthermore, ancillary staff and EMR need adequate investment to effectively monitor patients and ensure smooth transitions. Primary care docs cannot manage all the EMR details and health maintenance asked of them. Having more EMR pop-ups is not going to make us more productive or better physicians. If I wanted to be a typist, I would have become a court reporter, and my wrists can only tolerate clicking a mouse so many times a day.

Also, staring into a glowing computer screen does not make me feel like I am part of a multidisciplinary team. Where is the team? Give us

more support staff — more dietitians, social workers, nurses, health coaches, fitness facilities, support groups, child obesity programs! A castle is only as good as its people, not its towers.

So here is my charge to you. Let your drawbridges down, connect the EMRs between organizations, get nursing homes on the electronic grid, pay more to geriatricians, hospitalists, and primary care docs. The battle will be won not with scans but with plans, so make good ones.

And let’s stop trying to fluff up our patient satisfaction scores and actually try to satisfy our patients by keeping them out of the hospital!

Grand Junction, Colorado has some of the best health outcomes while spending a quarter less on Medicare patients compared to the rest of the country. An editorialist in the New England Journal of Medicine attributes the success of Grand Junction to the following seven tenets: leadership by the primary care community, a payment system involving risk sharing by physicians, equalization of physician payment for the care of Medicare/Medicaid/privately insured

patients, regionalization of services into an orderly system of primary/secondary/tertiary care, limits on the supply of expensive resources including specialists/beds/equipments, payment of primary care physicians for hospital visits, and robust end-of-life care.5 Health care organizations, legislators, and insurance companies are at a crossroads. Do we keep building up our castles the way we have been doing, or is it time to let down our drawbridges and find our own Grand Junction solution?

Speaking for myself, I don’t want to leave any of our patients swimming with the crocodiles! hitzemn@sutterhealth.org 1 Health Reform Implementation Timeline. The Henry J. Kaiser Family Foundation. http://healthreform.kff.org/timeline 2 Gawande, Atul. The Hot Spotters. The New Yorker. January 24, 2011.

3 Current expenditure. OECD Health Data 2010. www.oecd.org 4 Office of Statewide Health Planning and Development.

“Readmissions to California Hospitals 2005 to 20 06.”

Health Facts. Spring 2010.

5 Bodenheimer T and West D. Low-Cost Lessons from Grand Junction, Colorado. NEJM. 363;15:1391-1393.

March/April 2011

13

A Bicycling Sabbatical

By Larry Wolff, MD Sabbatical n (1903) 1: SABBATICAL YEAR 2: LEAVE 3: a break or change from a normal routine (as of employment).

The author at the start of the finals in the 2 km individual pursuit in Frisco, Texas.

November 8, 2010, marked the end of my four month “sabbatical” and I returned to my practice a philosophically changed man.

The notion of taking time off began percolating in my head a year prior. I figured that since my “racing age” in 2010 would be 60, I would be one of the younger riders in the 60–64 year-old age group in both the United States Cycling Federation and the Union Cycliste Internationale track cycling categories.

I started riding a track bicycle at the Hellyer Velodrome in San Jose in 2008 and recognized that I had finally found my athletic niche. I had been a very mediocre long distance runner for the preceding three decades and my knees finally rebelled. A right medial meniscectomy in 2003 finished any thoughts of future runs.

Cycling was doable and did not leave me

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limping, even after hard rides. Riding on local roads and the beautiful American River Parkway introduced me to a new method of endorphinproduction as well as a whole new cadre of friends.

My goals for riding in 2010 were to compete at the U.S. National Masters Track Cycling Championship in Frisco, Texas, to be held in September and the World Masters Track Cycling Championship in Anadia, Portugal, slated for October.

To be at all competitive at either of these venues, it was clear that I not only needed more time to train, I needed more time to rest. As a solo cardiac electrophysiologist (EP), rest is not part of my scheduled day. Many of the people I would be competing against are already retired and recuperative time is more available to them.

So taking time off from practice seemed like a good idea. To make this a reality, numerous pieces needed to fall into place. The first order of business was to clear this with my wife.

Happy wife: Happy life. This would have obvious financial impact on us. Being the incredible soul she is, she loved the idea.

Next, I had to clear this with the three other EPs I share call with. Would they be willing to not only cover my call but also care for my patients while I was away? No real argument from them.

Hospitals and NorCal had to be notified I would be away and, finally, I would have to let my patients know I would be out of their treatment loop for more than a brief while.

It was decided. I would leave July 1, 2010, and return November 8, 2010 — 130 days of no clinical responsibility. No pager. No call.

Prior to leaving I was cornered by a prominent local cardiologist and told that I was

“crazy.” How could I leave my practice for four months? I might come back to no practice at all.

I had taken time off in June, 2003, to climb Mt. McKinley in Alaska and and January, 2005, to climb Aconcagua in Argentina. My practice survived both sojourns of one month each. With rare exception, the response by my patients on hearing of my current plans was excitement and true happiness for me.

My four month sabbatical passed in the blink of an eye. There were many hours of hard training, to be sure, but they were hours spent doing something enjoyable and entirely for myself. No one’s life depended on any decision I made or didn’t make.

Nights were better. I was sleeping through and waking in the morning feeling refreshed and rested. We visited our daughters in San Francisco and San Diego and spent time with my father. I read six books having nothing to do with medicine.

The bike races went well. I won the U.S. National Championship and earned a bronze medal at the World competition. Standing on the podium at the latter event, I saw my father’s broad smile and knew I had made him proud. It was one of those moments in life to be savored and it is a memory I will carry forever.

There were times in the four months when I didn’t do much of anything. It was from those times that I gleaned perhaps the most substantial lesson of my sabbatical.

I did not feel guilty or antsy about not being productive or not making life and death decisions for others. I realized that while the practice of medicine is intellectually stimulating and challenging, there are countless other ways of achieving satisfaction and fulfillment. The thought liberated me.

An unspoken goal of my time off was to see how I handled not working. I have always been a bit hyperactive and goal-driven. Could I “not work”? Could I be content without a set daily schedule?

To my delight, I discovered that, yes, I can “not work.” This realization resulted in the philosophical change I underwent.

Dr. Wolff and his gold medal, awarded for winning the 2 km pursuit in Frisco.

I returned to work in November, not out of fear of having nothing else to do, but for the simple joy the privilege of caring for my patients affords me.

LarryWolff50@comcast.net

March/April 2011

Dr. Wolff and his father, Kurt, after the podium ceremony in Anadia, Portugal.

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Irrational Fear of Irradiation Energy

By John Loofbourow, 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.

Today, I feel inundated. Outside, the rain, the life blood of California, continues. Inside, on the Tube, the mindless drizzle about potential nuclear disaster continues, day after day, after day.

While hundreds of thousands are displaced from their ruined homes, and thousands are dead and dying in Japan from the tidal wave and the toxic wasteland it created, our alleged professional and free press quickly became bored. It seemed more profitable or less challenging to make ridiculous speculations about the dangers of radiation. “How much radiation will we get here?” is followed by dour predictions and vague, mindless comparisons to past nuclear accidents.

How wearing is this shameless profit-driven hype! And how unfortunate that our public comprehension of ionizing irradiation is so little better than it was three generations ago at the dawn of the nuclear age. Was it not reasonable to expect the media to inform rather than to merely profit through clever exaggeration?

If so, they have failed. “Nucular” or “nuclear,” who cares! Ignorance and fear are the same no matter what its name!

Escaped radioactive particles from Japan, in the very worst of all possible cases, could expose us to less radiation than a flight to New York, or standing in front of a microwave. On the other hand, we are apparently unaware and unconcerned about radiation from medical imaging.

Perhaps our national dosing of medical ionizing radiation is something we are willing to accept for value received. Perhaps it is excessive.

But whichever the case, we generally remain as ignorant of one sort of risk as the other. We

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rush to buy gasmasks, iodine or KI on our way home from a whole body scan. As physicians, we should be well informed about ionizing radiation from any source. We should be expected to have, or to quickly find, the best available pertinent facts. We should thoughtfully consider the risks versus benefits for patients, and avoid unnecessary exposures.

My introduction to nuclear warfare, thanks to the US Navy, dates back to the 70s. Although the more practical facts of the physics haven’t changed much, my knowledge of it, I fear, has gone through quite a few half-lives of attrition.

Hence, I had to look to the internet for some help. I won’t claim that the material to be found there is coherent; it is conflictive and confusing. It is not without bias, because no one puts information on the net or the news without a particular view, or even at times a particular self interest. Furthermore, I am no radiologist.

Surely, in entering all the material in three accompany tables, culled from so many sources, I have made errors. Please point them out for me. With respect and consideration for my radiological colleagues, I welcome and defer to your comments.

Tissue doses are usually measured in ”milli sieverts” (mSv), a quantity of the ionizing radiation dose absorbed and affecting body cells.

While ionizing radiation resulting from nuclear explosions is quite variable due to a number of isotopes and other factors, X-ray irradiation is comparatively uniform, so that mSv are a reliable and useful measure of estimated risk of radiation to people.

The numbers are always open to argument because of the many variables aside from the

amount of radiation in consideration: rational, and less driven by political nonsense; • 1 rem = 0.01 Sv = 10 mSv that unwise dosing of people with medical • 1 mrem = 0.00001 Sv = 0.01 mSv = 10 μSv X-rays will cease; and that the media will act • 1 Sv = 100 rem = 100,000 mrem (or millirem) and report responsibly. But hopes are not always • 1 mSv = 100 mrem = 0.1 rem fulfilled; as both citizens and physicians, we are • 1 μSv = 0.1 mrem wise to maintain an informed perspective in Comparative risk of radiation exposure is case hope betrays us. important and useful both to physicians whose decisions determine the dosages which patients john@loofbourow.com receive, and to the general public, who are exposed to much confusing information and misinformation.

Estimated irradiation for medical procedures For example, airport screenings have caused much concern. However, one would undergo Procedure Dose in mSv 400 airport screenings to absorb the same mSv as chest X-ray 0.1–0.2 one chest X-ray; 12,000 screenings compares to each dental X-ray 0.2 head CT 1.5 one mammogram; 20,000 screenings compares mammogram 3 to one abdominal CT scan; 40,000 screenings CT abdomen 5.3 is comparable to one whole body scan, 60,000 chest CT 5.8 to one barium enema, and 80,000 screenings to virtual colonoscopy 3–8 one neonatal abdominal CT scan. heart CT and angio 6–13 Estimates of relative radiation risk from barium enema 12–15 medical imaging are extremely variable. Yet it is angio/vascular study 19 clear that cumulative doses are increasing, and infant Abdomen CT 20 that medical radiation exposure can be signifiangio/cardiac study 70 cant.

The accompanying tables are a conflation of my remote memory and the harvest from the Estimates of acute (or per day) radiation dose Dose in mSv net today. Here are a few net.ferences to get you started: living within 10 miles of the 3 Mile Island accident 0.01 http://xkcd.com/radiation/ emedicine.medscape.

Sacramento to Paris commercial air flight 0.085 com/article/1464228-overview; dose limit for workers in a life saving emergency 250 and one hour next to the Chernobyl meltdown 300 http://www.fda.gov/Radiation-EmittingProducts dose causing transient symptoms 400 /RadiationEmittingProductsandProcedures/Medical dose causing severe radiation sickness or death 2000 Imaging/MedicalX-Rays/ucm115329.htm. lethal dose 3000–4000 But the sources are so many, so variable, and so easy to access, that for more, I will ask you, dear reader, to Estimates of average yearly radiation exposure Dose in mSv jump into the net and flail about there on your own! background radiation (earth sun, etc) 2–3 While there is much disagreeliving within 50 miles of a nuclear power generating plant 0.009 ment over the numbers, I living within 50 miles of a coal powered generating plant 0.03 found the accompanying dose daily use of a computer screen or other CRT 0.1 estimates of interest. I used commercial full time occupational high altitude air travel 2 only mSv for comparisons. maximum allowed accumulated radiation for nuclear plant workers 50 One can hope that airport lowest one year dose clearly related to cancer 100 screening will become more

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A Posit on Physician Overprescribing of Opiates “Physicians overprescribing opiates are major contributors to prescription drug abuse.”

prescribe.

Agree, 68; Disagree, 51; No Opinion, 1.

Thirty-nine comments follow.

We have used email posits during more than 10 years. Discourse among colleagues is a vital aspect of any functioning medical society and a posit is simply a way to promote discussion among us about topics of interest in medicine.

Where else can we so freely agree to agree or to disagree with so many other members we don’t often see?

Some of the comments below are quite intriguing or surprising; most are eloquent.

And all are frank expressions of opinion by colleagues. Opinions like these, freely expressed, are almost always more significant than carefully crafted and guarded B.S. Take a few moments to read the commentary below. — Ed.

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.

Of course not. Abuse and addiction have complicated roots and causes in the individual.

The sources of abused opiates are diverse — could be family, friends, and dealers, and sometimes, of course, doctors.

Could doctors do a better job at identifying red flags for addiction and a better job of explaining the inexorable process of physical dependence that occurs in the context of using opiates for chronic pain? Definitely. But physicians often don’t explain narcotic dependence/ withdrawal adequately. And, although they often fire a patient who is misusing, they don’t as often know where to refer them, or what kind of treatment works. They may not even see opiate addiction as an illness to be referred for treatment.

While all this is getting better, the cartels have realized that pills are the royal road to

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Some physicians overprescribe, but most under-

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heroin, so they are marketing pills. And opiate addiction is on the rise, especially among the youth. Doctors are not the cause of this. That’s a societal problem. The whole thing is like a Sartre play: The Plague or No Exit. It’s way beyond the physicians’ ability to deal with the pain, psychiatric, social, economic, and psychopathic aspects of the problem…and do it in 10 minutes!

When you hear people talk, especially from social model, non-medical, recovery or law enforcement, ”It’s those damn overprescribing doctors!” Of the 1/3 of patients who want opiates, it is likely a large percent who are addicts should be referred to methadone or buprenorphine treatment. We tend not to get these referrals, or they just look for another doctor. NIDA [www.nida.nih.gov/nidahome.html] is working on some tools to help screening and we have the CURES [http://ag.ca.gov/bne/cures. php] process which can be of great help with the doctor shoppers. — Jack McCarthy, MD Some physicians overprescribe, but most underprescribe. Prescription drug abuse is a major problem that is increasing in severity and presents a serious problem for our society.

Access to these medications is universal and they have found their way into all aspects of our society.

The responsibility of the prescribing physician is paramount. In our duty to relieve pain and suffering, we often compassionately prescribe medications to our patients. When chronically administered, monitoring of such medications becomes a necessity. Navigating the obstacle course of prior authorizations, costs of care, point of service monitoring the complexities of addiction medicine in the pain patient and

a myriad of other issues makes prescribing hazardous and laborious.

Despite our best efforts, drug diversion still occurs and must be monitored and suspected.

That is why we use “universal precautions” with all of our patients with mandatory Urine Drug Screening — random, for cause, and before initiating therapy. We also use blood monitoring to document systemic effects of opiates as well as blood levels of prescribed medications.

The art and science of pain medicine, more art than science, requires constant vigilance.

Our understanding of pain and its treatment continues to evolve. Opiate analgesic therapy is just one small part of pain medicine and should be considered in the whole context of treatment with goals for outcome and measurements for improvement in the quality of life and functionality as best as possible. — Lee Snook, MD About 1 in 4 of the patients I see at the county clinic want long term opiates. Some need them. It is difficult to tell who. This uncertainty was no different in 1973 when I worked my first ER shift. What is “overprescribing”? For example, narcotics are not listed in the treatment guideline for fibromyalgia. Is a narcotic for a fibromyalgia patient “overtreatment.”? Does fibromyalgia exist?

Should physicians be the front line “police” to contain narcotic abuse? At the county primary care clinic, we test some pain patients’ urine to verify opiates are present. Is the test effective?

An abuser could simply take a pill before a visit and sell the rest of the prescription. How would we know? Should the urine test be paid out of law enforcement budget instead of health care budget? — Gerald N. Rogan, MD It’s not physicians, it’s the system. Dealing with chronic pain is difficult and poorly rewarded. We are dammed if we do and dammed if we don’t. We don’t offer adequate alternative care for chronic pain and the attendant psychiatric problems. It is faster to hand out pills than to spend the time it takes to really understand the patient and treat the problems.

— Joanne Berkowitz, MD While I concur with the posit that overprescription of opiates contributes to prescription

drug abuse, I fear an overreactive legislative or regulatory response to this problem. Through education of physicians, elimination of the requirement for triplicate prescriptions, and the growth of expertise and programs in hospice, palliative care, and pain medicine, we have made great strides in improving the management of pain, dyspnea, and other distressing symptoms in our cancer patients as well as many others with terminal illnesses.

I believe the answer to this problem is to attack the source of abuse: the pain clinics which are little more than “pill mills” which prescribe whatever the client wants without doing a proper medical evaluation and providing ongoing management of chronic pain. If we respond with new laws and regulations limiting prescription of and access to narcotic analgesics we are doomed to regression to where we were 10–20 years ago when patients suffered needlessly because of prescribers’ lack of appropriate prescription pads or fear of prosecution for providing compassionate care to their terminally ill patients. — Mark Blum, MD I am of the opinion that the great majority of physicians are probably underprescribing when you take into account the vast numbers of patients with chronic pain problems. In view of the fact that it is very difficult for patients to get prompt appointments…not destroying unused portions of scripts contribute to abuse…inefficient primary care physicians, one must lean to the side of possible overmedicating rather than have patients suffering with conditions they have no control over. We went through this sort of problem in the earlier days of Harvey Rose and his efforts to provide better quality of life to his patients. — Hal Renollet, MD …[To quote] Dr. Mitchell Katz…in a Sept 13, 2010, article in Archives of Internal Medicine.

“The patient returns for follow-up visits and tells you that the pills work but that they sometimes take an extra pill and could you please increase the number so they ’don’t run out before the next visit.’ Before you know it, the patient is on a high dose of an opioid, and you are unsure whether you have actually helped them. What you know is that you have committed yourself

March/April 2011

Dealing with chronic pain is difficult and poorly rewarded.

We are dammed if we do and dammed if we don’t.

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Just say no!

Most of the problems are musculoskeletal in nature which, in the absence of a broken bone, should preferentially be treated with NSAIDs and muscle relaxants, in conjunction with physical therapy or stretching exercises with emphasis on improved range of motion.

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to endless negotiations about increasing doses, lost pill bottles, calls from emergency departments, worries that your patient is selling the drugs, and the possibility that one day, your patient will take too many pills, perhaps with alcohol, and overdose.”

Part of me wants to invoke the National Rifle Association defense of guns, “Guns don’t kill people, it’s the people who use them.” Well, unfortunately, guns and opioids both kill people and both are too easy to obtain in this country.

As much as I hate Big Brother stuff, we need some kind of regulatory agency to say ”no” to demanding patients. — Nate Hitzeman, MD (Agreeing) This is a difficult problem, as there are obviously too many prescription drugs available to the public, but it is never “my patient” that is the problem, always somebody else’s.

My perspective, with corrections medicine, where the #4 leading cause of death is overdose, usually with a medication not prescribed to the inmate, demonstrates the problem, though perhaps more intensely than in the “free” community. It is difficult to tell a person, “You aren’t hurting,” when you don’t know how they feel. We, therefore, require objective evidence of moderate-to-severe pain as a basis for providing long-term narcotic prescriptions. — Richard Gray, Jr., MD The easy access to and abuse of oxycodone as a street drug for profit is an unanticipated consequence of the campaign to liberalize the treatment of chronic pain. Control will require a national registry of patient pain prescriptions to stop the abuser obtaining a prescription for a multiple month supply of oxycodone from doctors in different states, as occurs now. — Richard Park, MD Must define “overprescribing” in a way that most physicians and the laws are in agreement — which I do not see happening any time soon.

— Albert Kahane, MD Yes, for storefront pill-mills — not for the majority of physicians treating pain appropriately. — David Naliboff, MD Just say no! Most of the problems are musculoskeletal in nature which, in the absence of a broken bone, should preferentially be

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treated with NSAIDs and muscle relaxants, in conjunction with physical therapy or stretching exercises with emphasis on improved range of motion. Doctors giving narcotics for muscle pain are causing more harm than good, as the amount of rebound pain and tolerance exceeds the benefit of using these drugs. A little bit of education goes a long way with most patients, and the rest are usually drug-seeking, to which doctors need to be able to “just say no!” — Peter Ash, MD Patients not destroying unused portions of scripts contribute to abuse. — Phil Dirksen, MD There will always be a segment of society that falls victim to the potential abuse of these drugs, some because of the glorification of their use by members of society who “grace” the tabloids” and others through no fault of their own. Those [who] would blame physicians are truly myopic. — Reinhardt Hilzinger, MD As an emergency physician, I see patients who are critical of me when they receive prescriptions for small quantities of opiates. “Dr. X gives me 100 Vicodin at a time.” —Norm Label, MD After 38 years of practice in California, I now realize that the use of liquid marijuana in the form of glycerine based tincture could reduce the cost of treating acute and chronic pain, cure addiction to heroin, cocaine, alcohol, methamphetamine, tobacco, oxycontin, vicodin, etc., [and] substitute for Prozac, Cymbalta, Valium and Ambien in the treatment depression, anxiety and insomnia…and be the treatment of choice for migraine, fibromyalgia…

The reason cannabis tincture is safe and effective is because, unlike smoking, vaporizing, and eating the marijuana, the addict or person in pain can measure the number of dropperfuls (usually 3–5) absorbed under the tongue to provide 6–8 hours of restful sleep…symptoms can be [relieved] by one dropperful in a cup of tea during the day [while] the person can still function. One fluid ounce of the tincture costs $20 and lasts 5–7 days; or 4 ounces ($80) for the addict’s 3-week cure at home is the equivalent to one month at the Betty Ford Center!

If California’s Medical Board and Board of Pharmacy implement regulations whereby any

licensed physician can prescribe the cannabis tincture only as a Herbal Remedy and only available from licensed pharmacies, removing marijuana dispensaries from the picture, and making the pharmacies responsible for quality and potency, the state will make tremendous savings in its health care and prison budgets. — Geoffrey E. Woo-Ming, MD Hard to define “overprescribing” when we don’t have therapeutic blood level guidelines.

Narcotic prescription diversion is a major problem, but remains undefined. — Colin Spears, MD I don’t believe the premise that physicians are overprescribing these dangerous and legally dangerous drugs….

Filching from the unsuspecting is most likely. If organized medicine accepts this guilt trip, then honest and skilled use of these drugs by ethical MDs will cease. Too dangerous (legally), for the doctor; too bad for those suffering in pain. — Cleve Baker, MD Not only is this a problem for the patient, but the number 1 drug of choice for teenagers are those in the home medicine cabinet, especially opiates. We do not do a good job with acute pain — why do surgeons give a 30 [day] supply of opiates for simple procedures; [we] do an equally bad job with chronic pain — more opiates rather than looking at antidepressants, cognitive behavioral therapy, etc. — James Margolis, MD Patients who are in pain require treatment.

This issue has nothing to do with physician “overprescribing.” What has helped in California is the CURES program and the Patient Activity Report it generates. This allows physicians to be alerted to potential “doctor shopping”... — Demetrios Simopoulos, MD I agree. If I have to refill a narcotic for what I expected to be a short-lived course, I always discuss with my patient the risks of continued narcotic use, potential for abuse, etc. If a third refill is requested, I bring her into the office for a face-to-face discussion to find the reason for continued narcotic use. If she has chronic pain with no pathology, then I refer her to Pain Management. — Anne Srisuro, MD

(Agreeing) A posit suggestion: Branded drugs are generally overpriced in the USA. — Emil Tanghetti, MD You worded the posit incorrectly. Of course over prescribing contributes to drug abuse.

Underprescribing, such as denying dying patients narcotics, is wrong also. — Allan Galbreath, MD (Disagreeing) My position likely stems from the fact that I palliatively treat cancer patients often near the end of life. — Derrick Schmidt, MD While I do believe that there are some physicians who freely prescribe opiates, I don’t think that is representative of most. I believe most physicians are responsible in their prescribing of narcotic pain medications and there are patients who know how to work the system. They know that we have an obligation to treat their pain or we risk being sued for not doing so.

The systems that are put in place like pain contracts and tracking systems that identify patients getting meds from multiple sources, help tremendously in reducing the amount of abuse that goes on. — Monique Ross, MD A few bad apples are a problem — but generally physicians are helping to alleviate real pain. — John Lewin, MD Doctors need to adequately take care of their patients’ pain. Some need more than others. — Ronald Rogers, MD Pts do need pain relief and there are limited options available besides opiates. — John Wiesenfarth, MD [I agree, however,] there is a database called “CURES — Prescription Drug Monitoring Program” by the Department of Justice Bureau of Narcotic Enforcement where controlled substance prescriptions filled at pharmacies can be tracked. If all physicians were to sign up for this system, we could assure that we do not perpetuate overprescribing opiates in the future.

— Pankaj Patel, MD Way too many opiates are prescribed in the U.S. when compared with the rest of the world.

— Robert Ruxin, MD I think all physicians should Just Say No like any other drugs…and deliver the same message

March/April 2011

I believe most physicians are responsible in their prescribing of narcotic pain medications and there are patients who know how to work the system.

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and let patients know that it is not acceptable to abuse [a] prescription drug. If [we] are not united, patients will doctor shop and find someone that is willing to prescribe. — Vong Lee, MD, Pain goes untreated due to providers’ fears of patient addiction. They are doing harm. — Sundance Fairchild-Manning, MS IV But not anywhere nearly as causal as are lying, falsifying, manipulative, addicted patients who prey on a broken legal system with minimal resources for cross-verification of prescriptions. — James Rybka, MD We are too paranoid about the issue to be major contributors. But, we can contribute to the problem by not reassessing our patients in a timely manner, or considering co-diagnoses and treating those as needed. — Kimette Marta, MD I feel that the major contribution to this problem is the lack of surveillance and

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communication between the pharmacy and the provider. With the addition of pain as the fifth vital sign, it is difficult to ignore the complaint of pain, and at times we are forced to prescribe medication to relieve this common complaint.

— Julieta Dominguez-Jones, MD Before you prescribe always check his or her pharmaceutical records, [you] will be surprised a lot. — Daksha Shah, MD I am sure that there is a group of MDs as in any other job in life that overdoes the prescribing of pain meds of all sorts, but the vast majority of physicians are responsible and manage pain appropriately (some too stringently in fear of overdoing it). There is a social overdoing… medications and OTC and laws churned out (like legal marijuana); pain pill addiction can be of and by the people, induced knowingly, enjoyingly or ignorantly as the case may be. It is a social animal. — Elisabeth Matthew, MD

Conversations

Joe Silva: UCD’s Shift Towards Specialty Care The former School of Medicine Dean at UCD discusses the push for more grant funds.

By David Gunn, MS IV This is the second part of a 6-part interview series that reflects on how UC Davis School of Medicine was founded as a school focused on primary care and has evolved into a leading NIH research institution.

The interviews include four Deans (Drs. Williams, Silva, Lazarus, and Pomeroy), Dr. Earl Wolfman (first Division Chair of Surgery, and friend of Dean Tupper), and staff who have served for decades.

Joseph Silva, Jr.: Tupp [Dean C. John Tupper] was very sound and savvy: always active in organized medicine. He had been at Ann Arbor, I didn’t know him when I was there — about three years after he left — but his footprints were all over the place. He was very powerful in the medical society, and Detroit county. He came out here and saddled up to the medical society, in fact we wouldn’t have gotten started without the help of the Yolo County Medical Society and Sacramento, and then they did merge into the tri-county medical society. I came out and Tupp got me involved right away.

David Gunn: I was just reading a book about Osler, and one of his tenets was “Get Involved in the Medical Societies”; it guards you against self-centeredness. Anyway, I’d like to get a brief history of your time here at UCD SOM, with an eye to try and answer the question, “Where have all the primary care schools gone?” UCD started as one. Where and when did we start to be more research and specialty focused?

JS: I can’t give you a precise date. But you’re quite right — Tupp felt it was very important we do primary care training. After he stepped down as Dean, he was a member of Yolo County

community health program. I had a lot of conversations with Tupp about how he got the school started, and he said it was rural then, and we needed good doctors. San Francisco [UCSF] didn’t want to help us too much in the beginning, but then later on once he was training all of these primary care people they knew it was a good thing, and started to bring assets up to build the school.

So we had the initial primary care drive, and I think kept it up until probably about...well, I retired in 2005, but by then we had already started to notice an erosion. We used to be 50–55 percent primary care. Internal medicine counts towards that too, of course even though we know one-half to two-thirds go into some subspecialty.

DG: So when you say 55 percent, you mean family medicine, internal medicine and pediatrics?

JS: That’s right. There was a time when OB/ GYN was trying to step under that label, but they really didn’t practice in the name of undifferentiated patients coming in [to a clinic]. It really started to erode back in...well, we started to talk about it with [Dr.] Klea Bertakis back around 1994–1995. We were worried about the sliding after [Dr.] Jerry Lazarus got here.

We noticed family medicine took a big hit.

And even in internal medicine, there were a number of spots that weren’t filled in the mid90s. In fact, the match day that year occurred on a Friday, and they called it Black Friday. People started to realize the economic factors were important. The student debt rate was starting to increase. They used to be able to walk out of here around $40–$50,000 in debt.

March/April 2011

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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DG: So it was the Chancellor who told you.

JS: Yeah, he said we needed to go up in NIH rank.

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DG: What was an average physician’s salary around that time?

JS: Pediatrics, 100–115. Family medicine, 130.

Internal medicine, 130–140. There wasn’t that much of a spread. I think lifestyle became more important to students, too. Also more students come in married now, and don’t forget that the other specialties are doing some pretty exciting stuff. If you look at where the dead-waters were, of where the talented people were in the 1980s and early 90s, hardly anyone went into psychiatry, pathology, neurology, anesthesiology, because, of course, there wasn’t much to do. But you look at the things these specialties are doing now...

DG: Hibbard [Dr. Hibbard Williams] seemed to think that the staff and faculty wanted the school to be recognized more, to have more esteem. And he thought NIH grants, more research and more specializations was the way to get there.

JS: Well, I think that is true. When I was chairman of medicine, we had very little research funding, around two-million dollars, and when I left I think we had thirty-million. [Dr.] Fred Meyers, when he took over the department, groomed it even more.

I didn’t really want to be Dean, actually, I just wanted to be chair of internal medicine and teach. A number of the chairs and the chancellor asked me to pick it up. We decided for our first strategic plan, to advance in the research ranks.

One way you can measure that is with grants. For every dollar we put into the research effort, there was around five dollars in return.

We put in mentoring of fellows, made certain new faculty had protected time in the first few years. We went for years around 40-44 million.

Eight years later we are at 110 million dollars.

DG: So when you came in, why was it important to increase the funding?

JS: Well, funding is only one measure...

DG: But that was the metric you decided to focus on...so why the focus there?

JS: Well, if you look at where we were in the NIH ranking...that was the thing the chancellor and provost was holding my feet to the fire over.

The provost particularly.

DG: Who was that?

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JS: Bob Grey [Robert D. Grey, now Chancellor at UC Riverside], in those days.

DG: So it was the Chancellor who told you.

JS: Yeah, he said we needed to go up in NIH rank.

DG: Do you have any idea of why that was important to him?

JS: If you look at any measures of academic universities, the Davis campus was doing a lot of research programs. We did a lot with engineering, veterinary, agriculture too... they were also trying to increase funding.

DG: Yeah, but those schools were not founded by the state Legislature with the express directive to create primary care physicians.

JS: Well, we had a mission to do that, but there weren’t any magic numbers laid out that we had to fulfill. Irvine and San Diego had the same pattern.

DG: I bring all this up because from what I read, Dean Tupper got the medical school founded based on his being sound and savvy with the Legislature in identifying the need of rural primary care.

JS: That’s right, he was, it was. Whether you like it or not, there was no one in the state Legislature after a few years who really beat on the school much. All those people left by the late 1970s. Tupper leaves for a variety of reasons and Hibbard comes in and brings some new science.

Hibbard was right, the basic scientists in place were very frustrated, they didn’t have enough bodies, they were always teaching, their grad students weren’t as good. It takes a lot of work to build a research machine. There was no one out there to ring a bell and say, ”Hey, you defaulted on a promise — we’re cutting back on funding.” That never really occurred.

DG: What I hear from the alumni today is not, “When is Davis going to get more research funding?” but, “Why aren’t more GPs coming out of Davis?” It sounds to me that both you and Hibbard are saying that ”a school grows and changes over time.”

JS: It does, it really does. One of the reasons research was taken up so seriously is that we had a lot of people in the community who were having to go to UCSF or Stanford for the serious

illnesses. Now we can provide the same basic research that leads to clinical protocols that are cutting edge, and the populace benefits from that, too. There’s a fair bit of drug development and testing here, too.

DG: Hibbard Williams told me that one of Tup’s methods towards building enthusiasm in new students for family practice was to instill in the school dynamic and engaging family practitioners, and have that energy bubble over. At least my experience was that a lot of the reaching out that we got from other departments came from the specialists.

JS: Well, I don’t know what the tenor of the teaching is now. But even for internal medicine I had trouble getting faculty to get very happy about internal medicine — because they just felt it was a lot of hard work, people weren’t happy, their hours were very long.

It’s pleasurable but draining to be a primary care doctor. I’ve done it for years. I had a general medicine clinic in Michigan. I did ward rounds, besides ID (my specialty). It’s not like going in and doing your three or four procedures that can bring a lot of reimbursement. There’s no doubt you could change this thing tomorrow if you change radically how you reimburse for service. This is nothing new. This goes back to 1966 when I was an intern — there was a world of difference out there and you could see it.

DG: When you took over from Lazarus, you were aware that things were becoming more specialty focused. What efforts did you make to quell that tide?

JS: Oh, nothing. I fostered it. I felt we could do a bi-part mission, and we did for a number of years. But I think the indebtedness now has been a real detractor. But I think you need to change reimbursements. There are some new schools like Hofstra in New York, that will pay 25 percent of your tuition, but you have to sign an agreement that you’ll come and train as a primary care intern and practice for five years.

DG: How did you transition over with Dr. Pomeroy.

JS: Well, Claire was my student at Michigan, I was her advisor when I was a professor. She was a superb student. I was looking for an

executive associate dean about two and a half years before I stepped down. Previously it was Jim Cassels, and Tom Andrews.

You really need a strong executive associate dean. She came out and applied, and we worked well together. I gave her the research enterprise, so I could try and develop more notoriety for Davis. We had consultants come in and they said we were an incredible success story. But a lot of people didn’t know about us, so they encouraged us to have more of a national presence, join more societies. I got injured in the military, so I don’t like flying much, but did it. I didn’t select her, [but] I was pulling for her enormously...

DG: Where is UC Davis going?

JS: I’m very pleased with what’s occurring on here. You wouldn’t recognize it from what it used to be, very few faculty would. dgunn11235@gmail.com

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

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Marijuana Facts The Risk of Addiction.

By Timmen L. Cermak, MD This article is reprinted from a special edition of San Francisco Medicine of June, 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.

Marijuana is a marvelous story. I mean that scientifically; more specifically, neuroscientifically.

It was not until 1960 that Raphael Mechoulam, an Israeli researcher, was able to work out the molecular structure of THC, delta9-tetrahydrocannabinol — the main psychoactive ingredient extracted from the oily resin produced by the cannabis plant. However, for almost more than three decades, the mechanism by which THC interacted with the brain remained a mystery.

Dr. Allyn Howlett paved the way out of this mystery in 1988 when she first demonstrated the existence of cannabinoid receptors in the brain. After that, the new field of cannabinoid neuroscience took flight. Two years later, Dr. Miles Herkenham used a labeled cannabinoid agonist to map the concentration of what was soon to be called CB1 receptors (CB2 receptors, discovered in 1993, are located primarily outside the CNS) in several species. Then Dr. William Devane, working in Mechoulam’s lab after leaving Howlett’s, announced discovery in 1992 of the first endogenous cannabinoid — anandamide.

The basic research blueprint — extract the psychoactive substance from a plant’s oily residue, label it, discover and map receptor sites within the brain, and then find the endogenous ligand for those receptors — replicates the path earlier paved by opiate researchers. Except the endocannabinoid system is at least tenfold the size of the endorphin system. In fact, according

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to Mechoulam, “The cannabinoid receptors are found in higher concentrations than any other receptor in the brain…and the endocannabinoid system acts essentially in just about every physiological system that people have looked into…”

For researchers, the “cannabinoid story” has shifted radically from marijuana to the brain, from the question of why marijuana makes people “high” to the question of what functions this massive neurochemical system underlies.

To begin, our endocannabinoids (at least four different endogenous ligands have been identified) are neuromodulators, not neurotransmitters. Rather than transmit detailed information, endocannabinoids act in a retrograde fashion at synapses, reaching back to enhance or dampen input from incoming neurons. Rather than being stored in vesicles, like most neurotransmitters, the endocannabinoids reside within the neuronal membrane itself (remember, THC is fat soluble) and become available as needed to modulate efferent input.

The endocannabinoid system is tonically active, meaning that it exhibits a constant level of ongoing activity that can be either increased or decreased in order to modulate a function — appetite, for example. Anyone who has been in the thrall of increased cannabinoid stimulation knows what the “munchies” are — an increased appetite for comfort food. On the other hand, decreasing endocannabinoid activity below its usual tonic level by administering a cannabinoid antagonist (for example, SR141716A, or Rimonabant) leads to a loss of appetite. More strikingly, administering SR141716A to newborn rat pups in the first twenty-four hours of life

(when the concentration of endocannabinoids in the brain is at the highest) leads to a failure to suckle, and death.

An intriguing window into the overall value of our endocannabinoid system is provided by CB1 knockouts — mice genetically engineered to have no CB1 receptors, and thus no functioning endocannabinoid system in the CNS. A variety of interesting differences exist between CB1 knockouts and their normal brethren.

CB1 knockouts display hypomotility when put into a maze. They explore their environment less. They have better memories. Anyone who has run a personal experiment with increasing cannabinoid stimulation might remember the decline in short-term memory that ensued. One downside of better memories is that CB1 knockouts also show decreased forgetting of aversive memories. For example, classical conditioning using punishment is highly resistant to extinction. One might speculate that veterans with posttraumatic stress disorder who have an inclination to use marijuana might be reacting to the temporary balm it provides for their aversive memories. Animal studies indicate that AM404 (an inhibitor of eCB breakdown and reuptake) may be a more effective enhancer of extinction.

Perhaps most significant is the increased mortality that CB1 knockouts show, not from any single cause but from a wide variety of normal illnesses. The speculation is that the endocannabinoid system continuously modulates a wide array of physiologic functions, thereby increasing the flexibility an organism’s responses to the changing environment.

Without this ongoing capacity to modulate such functions as memory, pain threshold, appetites, attention, motor activity, fear/anxiety, and novelty/familiarity (to name a few), an animal is restricted to a more narrow range of physiological and behavioral responses. Such rigidity leads to a wearing down of the various organ systems more quickly, and hence to early mortality.

To summarize up to this point: Every cell in our body contains the DNA to produce cannabinoid molecules and complex protein receptors.

The CNS produces large quantities of both,

relative to other neurochemicals, to create a pervasive modulatory system that enhances the brain’s flexibility and adaptability to a changing environment. Maintaining the endocannabinoid system in good tonic balance is presumably a good strategy for staving off mortality.

This brings us to the topic of addiction. Is there evidence for marijuana (i.e., THC) addiction? And, if so, what is the clinical significance of marijuana addiction?

There are four lines of evidence of physical addiction and withdrawal caused by THC. First, administering THC for seven days, followed by SR141716A (a cannabinoid antagonist that leads to sudden displacement of THC from cannabinoid receptors), produces similar symptoms across several species — snout rubbing, difficulty sleeping with characteristic EEG disturbances, “wet-dog shakes,” and so on. Second, clinical reports by humans seeking treatment for marijuana dependence include similar symptoms of irritability, anxiety, insomnia with characteristic EEG disturbances, restlessness, etc. Third, epidemiologic studies reveal that approximately 9% of people who begin smoking marijuana at twenty-one years old or older eventually satisfy the criteria for cannabis dependence.

The fourth line of evidence is the sine qua non for any addictive substance: THC causes a rise in dopamine levels in the nucleus accumbens (often called the reward center). While this is often equated to producing pleasure, complicated research on the distinction between “liking” and “wanting” is forcing addiction medicine to generate a more sophisticated picture of the neural mechanisms involved in the development of dependence.

Liking is related to opioid, cannabinoid, and GABA manipulation in parts of the palladium, and in only a small portion of the nucleus accumbens. There are plenty of experiences stimulated by THC that people like: relaxation, a sense of novelty (especially as concerns sensory stimuli), an altered attentional focus, reduced pain, timelessness, and so on. While marijuana stimulates these experiences, it also can leave the brain altered when used too consistently, because it can so excessively stimulate cannabi-

March/April 2011

The fourth line of evidence is the sine qua non for any addictive substance: THC causes a rise in dopamine levels in the nucleus accumbens (often called the reward center).

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There is no doubt that many Californians like marijuana.

The more penetrating question lies in why so many want it with such passion.

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noid receptors that they begin to down-regulate, by as much as 60% in some areas of the brain.

As a result, any cessation of exogenous stimulation (stopping smoking marijuana, for instance) leads to a relative cannabinoid deficiency state, generally considered to be unpleasant.

Wanting, on the other hand, is a motivational force rather than a hedonic experience.

Wanting is related to dopamine manipulation in the ventral tegmental area (VTA) and large parts of the nucleus accumbens. While the mechanisms underlying liking develop tolerance (through receptor down-regulation), the mechanisms underlying wanting become sensitized by continuous or large uses of a drug of addiction. Over time it takes less exposure to the drug, and fewer cues from the environment, to stimulate wanting and the deep motivation to obtain and use a drug, even when the pleasure value of the drug may have waned considerably.

There is no doubt that many Californians like marijuana. The more penetrating question lies in why so many want it with such passion.

Is this simply a matter of libertarian fervor? In some cases, yes. But why would such fervor be attached to the issue of access to marijuana?

Many would argue that devotion to the issue stems from the need to protect vital supplies of a medicine that has become essential to their well-being. Perhaps. But addiction medicine practioners confront such fervent attachment to a variety of psychoactive drugs on a daily basis.

While no one writhes in uncontrollable agony from marijuana withdrawal, as some opiate addicts do in the absence of their drug, researchers do find a significant connection between pot’s subtle symptoms of abstinence and relapse behavior. Many people “prove” that they are not dependent on marijuana by abstaining for weeks, then find themselves “wanting” to smoke it again to calm the irritability they attribute to life’s stresses rather than to ongoing withdrawal.

Discerning when patients are truly treating an underlying medical condition with “medical” marijuana from when they have smoked heavily enough to down-regulate cannabinoid

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receptors (thus requiring exogenous cannabinoid stimulation in order to feel “normal”) is complex. It is also imprecise. This discernment can be accomplished only within the context of a good therapeutic alliance with a patient who is willing to explore the conundrum honestly.

Patients need to be viewed in a similar manner whether they are using marijuana or Vicodin. While either might be a useful medication, getting high every day through excessive use is still getting high every day. And relying solely on a patient’s judgment of what is the best medication for a given symptom is to abandon the scientific principles at the core of our medical training.

Timmen Cermak, MD, is president of the California Society of Addiction Medicine. He is currently in private practice in psychiatry in Mill Valley.

References: Devane WA, Dysarz FA III, Johnson MR, Melvin LS, Howlett AC. Determination and characterization of a cannabinoid receptor in rat brain. Mol Pharmacol. 1988. 34(5):605-13.

Cannabinoid system in neuroprotection. The Third National Conference on Cannabis Therapeutics. University of Virginia School of Medicine, 2004.

Fride et al. Critical role of the endogenous cannabinoid system in mouse pup suckling and growth. European J of Pharmacology.

2002. 419;207-214.

Marsicano et al. The endogenous cannabi-noid system controls extinction of aversive memories,” Nature. 2002. 418(6897):530-4.

Chhatwal J P, Davis M et al. Enhancing cannabinoid neurotransmission augments the extinction of conditioned fear. Neuropsychopharmacology. 2005. 30(3):516-24.

Zimmer A, Zimmer AM et al. Increased mortality, hypoactivity, and hypoalgesia in cannabinoid CB1 receptor knockout mice. Proc Natl Acad Sci USA. 1999. 96(10):5780-5.

Rubino, T., G. Patrini, et al. (1998). “Can-nabinoid-precipitated withdrawal: a time-course study of the behavioral aspect and its correlation with cannabinoid receptors and G protein expression.” J Pharmacol Exp Ther 285(2): 813-9.

Budney, A. J., J. R. Hughes, et al. (2001). “Marijuana abstinence effects in marijuana smokers maintained in their home environment.” Arch Gen Psychiatry 58(10): 917-24.

Johnston LD, O’Malley PM, Bachman JG. National survey results on drug use from the monitoring the future study, 1975–1994 (Vol. 1). 1995. Washington, D.C.: U.S. Department of Health and Human Services.

Gardner EL. Addictive potential of can-nabinoids: The underlying neurobiology. Chem Phys Lipids. 2002. 121(1-2):267-90.

Robinson and Berridge. The incentive sen-sitization theory of addiction: Some current issues. Phil Trans R Soc B. 2008. 363:3137– 3146.

Romera J. Effect of chronic exposure to delta9-tetrahydrocannabinoloin cannabinoid receptor binding and mRNA levels in several rat brain regions. Brain Res Mol Brain Res. 1997. 46(1-2):100-8.

Medical Crossword Puzzle I hope this amuses you. I didn’t use a computer crossword program, so there are a lot of abbreviations and even some letter combinations that aren’t words (they don’t have clues) and a few entries that aren’t medical. I hope this challenges those of you who are better wordsmiths than I to produce a better puzzle. The solution is on page 32.

— Ann Gerhardt, MD Across 1 Posterior 7 Length 11 Blood pressure top number (abbrev) 14 (Suffix) Condition 17 (Prefex) Related to deposition of plaque 18 Defibrillator (abbrev) 19 Best to get at least 8 hours per day 23 Psyche, as in, You’ve lost your…

24 Neon 25 Lost his life 26 Protruberance caused by a virus 27 Diabetes treatment 29 Sullen 30 Rapamycin target 31 During which the heart fills with blood 34 Regular rate or railroad (abbrev) 35 Expand, as in blood vessel or esophagus 38 Don’t do this to the medical record 39 Relating to the cheek 42 A really bad heart condition (abbrev) 43 Drug for rate, fibrillation control 45 In cardiac surgery, minimize pump-____ 46 Pertaining to the ear 47 Poet Cummings’ first initials 49 Functional unit of heredity 50 Relates to the ileum 51 Tuberculosis treatment (abbrev) 52 Heart attack (abbrev) 53 Be happy with ___ treatment that works 55 Peripheral unit of lymphatic system 57 Respiratory therapy (abbrev) 58 Loss of sensation for surgery (old spelling, with a as third letter) 62 Lanthanum 63 Thin plate or flat layer 64 Large volume stools 65 Manic treatment (abbrev) 66 New World cutaneous leishmaniasis

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Common name for sputum Relating to winged structure Sickness Sources of companionship or infection Emotion stimulating the sympathetic nervous system Medications batched by ___ from manufacturer Each (abbrev) Mental image or concept Nobel Laureate for liver therapy for anemia Fabric adhesive material Dye for MRI, for short Terror (Latin) Sacculated cavity containing intestine and fluid Salivary

Down 1 Father 2 Ear inflammation 3 Study of deformation & flow of matter 4 Lab test indicating inflammation 5 Short for American Revolution or Arkansas 6 General goal for cholesterol 7 Systemic inflammatory response syndrome (abbrev)

8 Scan for cancer extent 9 Merck’s first drug ___ revolutionized pharmaceutical marketing 10 Middle 12 Index for body size (abbrev) 13 Access code for computer programs 14 Sphincter of ____ 15 Toughen or harden by use 16 Bacteria which turns pus orange/red 20 What patients wish healthcare providers would do more of 21 Otolaryngologist (for short) 22 Pertaining to lung 28 Excessive sun turns skin to _______ 31 At times a heart attack will _____ a patient from further smoking 32 Unique antigenic component 33 Goal 36 Salt of a plant polyphenol used to stain wood and clarify wine 37 Lipogranulomas 40 In the Periodic Table, has atomic number 3 41 Sudden change in condition 42 Pulmonary embolism (abbrev)

44 Obsolete term referring to spleen 47 Organ for vision 48 Reduce or mitigate symptoms 51 Sedentery lifestyle or quiescent disease 52 My (in Spanish) 54 Slender rod of metal to affix bone 56 Twice 59 Used to cover patient to protect modesty 60 Effective AIDS treatment (abbrev) 61 Surgical knife 63 Os lunatum (moon) 64 Alcohol withdrawal reaction (abbrev), as in “the ___” 67 Mineral-spring health resort 69 Fish egg mass 71 Levo72 Audible, emotional expiration 73 Prefex referring to the front 78 24 hours 79 Prefix meaning bad 80 Vasodilator, anesthetic, two year-olds’ favorite word 83 By mouth (Latin abbrev) 84 Pulmonary embolism (abbrev) 85 Before meal (Latin abbrev)

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A Day at Rwanguba Hospital, DRCongo

By Phil Dirksen, MD In the last issue, the author wrote about 30 years in the Democratic Republic of Congo. This follow-up article is about one day there.

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.

The roosters in the village have been crowing for the past hour. Now, at 6 a.m., the sun leaps from the horizon and the world on the equator changes from darkness to full daylight in less than 20 minutes. The day has begun at Rwanguba Hospital, Democratic Republic of Congo.

Getting ready for the day, a quiet time, a quick breakfast of hot cereal and fresh pineapple or papaya, a short devotional and prayer for the day...and off for the hospital.

A landslide has blocked the rutted road just beneath our home, so we slip through the thorn and bamboo fence. We slide down the steep, muddy path through the gardens and around the corner of mud and thatch huts to the “pick up point” below the slide.

The battered hospital pickup arrives to carry us and straggling staff the 3/4 mile to the hospital. We arrive at 7:30 for morning praiseprayer devotions with the staff of 80 workers, ambulatory patients and patient guardians (the family members assigned responsibility for the patient’s dietary and general bed care).

Testimonies and praise of God’s faithfulness, healing and salvation spill from overflowing hearts. Prayer requests for safety, food for starving families and grieving from senseless killings, rapes and maiming pour from sobbing broken hearts...

This is the most important part of the day: it focuses both the purpose and the power of Rwanguba Hospital. It is said that at Rwanguba,

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people find healing, strength and hope — because “that’s the place they pray with people.”

Then off to the wards for two hours of teaching and patient care. Our entourage includes 12 fourth-year nursing students, 2 medical interns, the attending national surgeon-physician/hospital administrator, the nursing director, 6 ward nurses and myself.

The 20-bed women’s ward is filled with patients with AIDS, malaria, pneumonia, anemia, chronic abdominal pain and post-op patients from surgical repairs for incontinence from child-birthing and gynecological tumors.

The 20-bed men’s ward includes similar medical problems. In addition, there are several gunshot and machete hacking victims from guerilla violence. Several men are post-op from surgical relief of urinary obstruction and chronic bone infection with large, open draining wounds.

In the pediatric ward, with 20-plus children and their mothers, we find severe malnutrition requiring IV hydration and/or feeding tubes; and associated infections of pneumonia, cholera, dysentery, malaria, intestinal parasites, anemia, large abscesses, and gangrenous stomatitis (a soft tissue infection which eats through the cheek leaving a draining hole).

The 20-bed maternity unit is overflowing with newborns and their mothers. Here I find my wife, Zana, interacting with the staff and distributing layettes for the babies (little caps and jackets knitted by women’s groups in supporting churches).

Lastly, we’ll stop by the isolation ward and encourage the newly diagnosed tuberculosis patients, many with AIDS. Just this week we arranged a separate isolation meningitis ward

and instituted an effective treatment plan for semi-comatose seizing patients with suspected meningitis and cerebral malaria.

The operating room is preparing the first of three major surgical elective cases of the day, so we’ll take 30 minutes to see several of the 30 patients with surgical/medical problems selected by our clinic staff for us to evaluate today. First, we greet a young pastor and his wife with infertility issues. The laboratory studies reveal that the wife tests positive for HIV. How did the wife of a pastor contract this virus? In this forgotten war-torn corner of the world, she has been raped by soldiers. We ask our hospital chaplain to assist us in counseling and consoling this couple.

The OR team informs us that the first surgical patient of the day is ready, so up we go one floor to the operating room. Our patient has a large obstructing goiter. She has been prayed with and induced under general anesthesia by our national board-certified nurse anesthetist.

We scrub, gown and glove, have a quick word of prayer with the staff and for the patient and proceed with the 2 1/2 hour procedure.

Following a successful operation, we return downstairs to continue consulting some of the remaining 30 surgical patients.

The second major surgical case will also be a teaching case for the national doctor and his entire OR surgical team from a charity hospital 50 miles down the road. He wishes training in surgical care of urinary obstruction in elderly men. Because of security issues, it’s essential that he and his surgical team return home before sunset. But first we eat together by having a coke and little packet of glucose biscuits (like animal cookies). This is our mid-day “meal,” usually eaten about 2 p.m.

To the office to continue “chipping away” at the waiting, seated line of surgical consultations; to the OR for the third elective case of the day; to the office. It’s now after 6 p.m. and we’re near to “wrapping up the day.”

The equatorial sun has dropped off the horizon and suddenly it is black night; the stars touch the earth. Feeble headlights of the rattling windowless pickup lead us back up to the “pick

up/drop off point”; up the steep, wet, slippery, muddy path through the gardens and around the thatch mud huts, through the hole in the thorn and bamboo fence, and home.

Zana has hot soup and freshly baked bread waiting for me and whomever I may have brought home, usually a doctor or patient staying over for an early morning case.

We share our day together, thanking God for his faithfulness, the tireless committed staff at Rwanguba hospital, and the partnership of individuals and churches in the States who understand in a practical way what it means to “help carry the burdens of their brothers and sisters in Congo and so fulfill the law of Christ.”

It’s 2 a.m. and there is a banging at our back door...someone is shouting, “Hodi, hodi,” (Hello, hello). It’s the night guard from the hospital, along with three soldiers, here to escort me to the hospital for an emergency C-section. Through the hole in the thorn and bamboo fence...

Home at 4 a.m., for two more hours of sleep. Thankfully, emergency night cases only occur once or twice a week! I remember that tomorrow we need to visit the large nutritional feeding center in the center of our hospital complex to help the staff address those issues.

The ”day” is over. sacpkd@comcast.net

March/April 2011

It’s 2 a.m. and there is a banging at our back door...someone is shouting, “Hodi, hodi,” (Hello, hello).

Buildings at Rwanguba Hospital; the main facility is in the background.

31

Board Briefs March 14, 2011 There was no Board meeting in February.

The Board: Approved a request from the Californians Allied for Patient Protection (CAPP) to hold a political fundraiser for Assemblyman Richard Pan, MD, at SSVMS on April 18, 2011.

Approved the 2010 End-of-Year Financial Statements and the 2010 Fourth Quarter Investment Reports and Recommendations.

Approved the policy “Interviewing Candidates for Public Office.” The California Medical Association Political Action Committee (CALPAC) requests SSVMS interview candidates for the California State Senate and Assembly.

Occasionally, the American Medical Association Political Action Committee (AMPAC) requests SSVMS interview candidates for Congress. In these situations, SSVMS is asked for its recommendation on which candidates to support with a campaign contribution. The policy provides guidelines for members of the candidate interview committee.

Approved nominations of Anthony Russell, MD, and Marvin Kamras, MD, to serve on the Sacramento County GMC Advisory Committee.

There are approximately 160,000 Medi-Cal patients in Sacramento County enrolled in multiple HMOs in Sacramento Geographic Managed Care (GMC). Since its implementation on April 1, 1994, GMC has not had a local oversight body. Last year, new legislation allowed the Board of Supervisors to establish a GMC Advisory Committee.

Approved the Membership Report: For Active Membership — Ranjani R. Kalyan, MD; Sholeh Rahimi, MD; Shiena Sharma, MD.

32

Sierra Sacramento Valley Medicine

For Government Membership — Bruce P. Barnett, MD For Active 65/20 Membership — Dale R. Butler, MD For Retired Membership — Andrew M. Hazen, MD; Elizabeth A. Kubiak, MD; Gail K. Mynard, MD; Eric Nielsen, MD; Robert H. Talkington, MD; Ruby S.N. Yu, MD. For Resignation — Samuel A. Applebaum, MD (active member of Placer-Nevada) ; Matthew C. Carnahan, MD (moved to Santa Rosa); Kenneth A. Frank, MD; David L. Haugen, MD (retired); Benjamin Ling, MD; Robert S. Peck, MD; James S. Peng, MD (moved to New York); Wendy J. U. Yang, MD (transferred to Santa Clara); Sidney Yassinger, MD. Received a report that the Sutter Medical Group Board of Directors has decided to pay Society and CMA dues for the first 50 of its physicians who contact the group requesting payment of their 2011 dues. The 50 physicians eligible for payment include those from Sierra Sacramento Valley Medical Society, PlacerNevada Medical Society and Solano County Medical Society. SSVMS will send invoices and a copy of its accomplishments to all of its members of Sutter Medical Group. The Board approved extending the deadline for payment of dues to these members.

Serving as the Board of Directors to the Community Service, Education and Research Fund (CSERF), the Board approved a recommendation to not re-apply for Continuing Medical Education (CME) accreditation in 2012, since it did not achieve the desired result of encouraging SSVMS committees to develop activities to meet perceived community needs.

In Memoriam

William L. Mahon, Jr., MD 1922–2011

Dr. “Bill” Mahon, age 88, was lost to our community following a brief illness. He died peacefully on January 4, surrounded by his immediate family. Diagnosed with pancreatic cancer in early December 2010, he knew his prognosis and courageously chose to have supportive care only.

I called him from Maui and asked if he was going to have chemotherapy, and he replied “Therapy! I have IV therapy, pain therapy, physical therapy, occupational therapy, and sex therapy. None of it is working.” His sometimes offthe-wall sense of humor prevailed to the end.

He loved to play on words and was a master of the one liner.

Bill was a member of the Sacramento El Dorado County Medical Society from the beginning of his practice in Fair Oaks in 1952 until his retirement in 1999. He was also a Fellow of the American Academy of Family Practice.

He was a true member of “the greatest generation,” as penned by Tom Brokaw. Born and raised in coastal South Carolina, he finished his pre-med education with a degree in chemistry from the University of South Carolina in 1943.

He joined the Navy as a line officer and served his country during World War II experiencing heavy combat in the South Pacific.

Following the war, he did postgraduate work at the University of North Carolina, then attended the Medical University of South Carolina in Charleston, earning his MD in 1950. There he met and married his wife of 60 years, Yvonne, who was graduating from nursing school at the same time.

While in the Navy, Bill fell in love with California. He chose a general rotating internship with Sacramento County Hospital, after which he returned to South Carolina to briefly practice in Calhoun Falls. He returned to Sacramento

County Hospital for a year of family practice residency. Other members of that class included Joel Janvier, Alex Janushkowsky, and Arthur Trent, all of whom served our community with distinction. Bill established his family practice in Fair Oaks, and later Carmichael, until his retirement in 1999, a span of 47 years.

Bill and I were first cousins — our mothers were sisters. He was also my godfather and my closest friend and mentor. It was during his brief period of practice in Calhoun Falls that Bill introduced me to medicine. I was 15-years-old and my parents allowed me to return to South Carolina to work for him during the summer months.

The idea was for me to help with William L. Mahon, Jr., MD driving (although I had no license) and to work as his assistant, learning to do laboratory work, take X-rays, and assist with minor surgery. I witnessed my first vaginal birth and first abdominal surgery. With this introduction to medicine, I was hooked for life and my bond with him was sealed.

Look in the dictionary under physician and you should find a reference: “See under William L. Mahon, Jr., MD.” He was, in my opinion, the definition of a physician. He was kind, compassionate, caring, and always giving. He was loved and admired by patients and colleagues alike.

His skills as a diagnostician were superb and his treatments accurate. The physicians to whom he referred patients were always impressed by the thoroughness of his workups, the appropriateness of the referrals, and the clarity of his records.

In addition, he was a highly skilled assistant at major surgeries, anticipating the needs of surgeons and understanding the complexicontinued on next page March/April 2011

33

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. — Robert A. Kahle, MD, Secretary Melnikow, Joy, Family Medicine, UC San Francisco 1984, UCDMC, 4860 Y St #1600, Sacramento 95817 (916) 734-3160 Temporini, Humberto D., Psychiatry/Forensic Psychiatry, Universidad Del Salvador, Argentina 1993, The Permanente Medical Group, 7300 Wyndham Wy, Sacramento 95823 (916) 525-6100

William H. Mahon, Jr., MD

Crossword Solution from page 29

D O R S A T H E D I E D T O R D I L A S O T P G E A N Y L A L L I U I L L N A E A T F R E N T E

continued from previous page ties of the surgical procedures. I often remarked to him, “You could have done this yourself” to which he replied, “No, no, it is all yours, B.J.” Bill’s impact on his patients and friends is reflected in the numbers who pursued medicine as a career because of his influence. I can personally count three physicians who chose this career because of him. He will be greatly missed.

He is survived by his wife, Yvonne, daughter, Marie Versteegh of Carmichael, son, William L. Mahon III of Fair Oaks, and daughter, Patricia McQueeney of Grove City, PA, six grandchildren, 4 great grandchildren, and brothers James Mahon and Robert Mahon of Carmichael.

— Ben Berry, MD

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Sierra Sacramento Valley Medicine

A L S P R O I E W A R T S T E A L O L N E I L N O D E A M I N A T A O E S S I D E G A D R O H Y D

A N D S L I D I A S E D I T T I M E E O N R T Y D S P I T P E T S A E P P R O C E

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B P O M I N D I N D I L A R I C E U Y S T H E H E A E A L E A R # T T A

S I N O U R P E E M S I C 6 A R L O P E E S I A L I

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The practice of medicine is about to undergo revolutionary change. Are you prepared?

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• HIT: Interoperability, Meaningful Use, Quality Measurement and Reporting • Health System Reform and the Physician Workforce • Practice Management: Reengineering Your Practice for Survival • Managing Change Effectively • Physician Leadership in the Era of Reform

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To Register: 800.795.2262 caleadershipacademy.com

The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical Association designates this educational activity for a maximum of 18.75 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of March/April 2011 Medical 35 their participation in the activity. The credit may also be applied to the CMA Certification in Continuing Education.

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2011 Medical History Lecture Series Presented by the Sierra Sacramento Valley Museum of Medical History

Healing Music: Magic & Medicine 7 p.m. July 13 Presented by Georges M. Halpern, MD, PhD

Music produces an emotional reaction and attenuation of the human stress response in the listener despite serving no essential biological need.

Music is one of the few activities that involves using the whole brain. It is intrinsic to all cultures and can have surprising benefits not only for learning language, improving memory and focusing attention, but also for physical coordination and development.

Magical Medical History Tour 7 p.m. November 9 Presented by Faith Fitzgerald, MD The series of cases of famous people, their illnesses, their accomplishments and associated interesting things.

These are ‘cases’ designed to illustrate the rich access all doctors have, through their patients, to history, literature, art, philosophy, music, poetry, religion, in fact, all things pertinent to human beings.

Open to the Public. Admission is free.

Reservations are requested to ensure adequate seating; please call (916) 452-2671. All lectures are held at the Medical Society – 5380 Elvas Avenue, Sacramento.

36

The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego.

IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

Membership Has Its Benefits!

Free and Discounted Programs for Medical Society/CMA Members Auto/Homeowners Discounted Insurance

Mercury Insurance Group 1.888.637.2431 or www.mercuryinsurance.com/cma

Car Rental / Avis or Hertz

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Clinical Reference Guides

Epocrates discounted mobile/online products www.cmanet.org/benefits/epocrates_guides.asp

Conference Room Rentals

Medical Society 916.452.2671

Credit Card

CMA rewards credit card, Bank of America 1.866.598.4970

Office Supplies/Equipment – Staples, Inc. Save up to 80%

Members-only discount link www.cmanet.org/benefits

Healthcare Information Technology (HIT) www.cmanet.org/hit Resource Center HIPAA Compliance Toolkit

PrivaPlan Associates, Inc. 1.877.218.707 / www.privaplan.com

Insurance Life, Disability, Long Term Care Medical/Dental, Workers’ Comp, more...

Marsh Affinity Group Services 1.800.842.3761 www.marshaffinity.com/assoc/cma.html

Legal Services & CMA On-Call Documents

800.786.4262 / www.cmanet.org/member

Magazine Subscriptions 50% off subscriptions

Subscription Services, Inc. 1.800.289.6247 / www.buymags.com/cma

Medic Alert

1.800.253.7880 / www.medicalert.org/cma

Merchant Services/Payroll Services/ Check Management

Heartland Payment Systems 1.866.941.1477 www.heartlandpaymentsystems.com

Practice Financing Reduced Loan Administration Fees

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Reimbursement Helpline Assistance with contracting or reimbursement

CMA 1.888.401.5911

Security Prescriptions Products

RX Security www.rxsecurity.com/cma.php

Travel Accident Insurance/Free

All SSVMS Members $100,000 Automatic Policy www.ssvms.org/about/downloads/ travel-accident-ins.pdf

Sierra Sacramento Valley Medicine

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