2011-Nov/Dec - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2011

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Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE You Change My Life

Alicia Abels, MD

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Medical Waste: To Test or Not to Test, That is the Question

Gerald Rogan, MD

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CONVERSATIONS UCD School of Medicine: Staff Interviews

David Gunn, MD

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BOOK REVIEW ° Bohuslav Martinu: The Compulsion to Compose

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Interview with Bill Sandberg

Alicia Abels, MD

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Mental Health Crisis Triggers Action

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B-17 Checklists and Medicine in the USA

Andrew Klonecke, MD

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A Posit Question on Doctors’ Pay

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Glennah Trochet, MD, Retires as Health Officer

Bill Sandberg, Executive Director

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Dr. Marijuana Inc. is IN

John Loofbourow, MD

Jesse Oehler

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Reflections on a First Year in the Legislature

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IN MEMORIAM Patrick C. Dietler, Jr., MD

Assemblymember Richard Pan, MD

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Board Briefs

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Doctor-ing and Doctor-ers

Ninad Athale, MD

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New Applicants

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Farewell...

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Classified ads

Bill Sandberg, Executive Director

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

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

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

SSV Medicine is online at www.ssvms.org/magazine.asp This is another in a series of covers by Sacramento otolaryngologist Dr. David A. Evans, devans@sacent.com.

“This image shows a collision of two water drops. The first drop is released from a siphon, and approximately 50 milliseconds later, the second drop is released. This first drop strikes the water surface and bounces up, then the second drop strikes the ascending water column and flattens out the top. The collision lasts only four or five milliseconds, so timing is key to capturing the event as there is a very short duration of the flash from the electronic flash unit. This is lit with multiple flashes which are covered with different colored gels to impart the colors to the water.”

November/December 2011

Volume 62/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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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.

Position Available:

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 Ann Gerhardt, MD Anthony Russell, MD Lorenzo Rossaro, MD District 6 District 3 J. Dale Smith, MD Bhaskara Reddy, MD, Treasurer District 4 Demetrios Simopoulos, MD

mmended By re Doctors.

2011 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Satya Chatterjee, MD Richard Gray, MD David Herbert, MD Richard Jones, 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 Ruenell Adams, MD District 4 Demetrios Simopoulos, MD District 5 Anthony Russell, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Russell Jacoby, MD Maynard Johnston, MD Robert Kahle, MD Robert Madrigal, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Gerald Upcraft, MD Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

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Benefits include professional liability insurance, educational allowance, 401(k) plan with employer match, health and dental insurance, vacation, and partnership options.

If you are interested or know someone who might be, please contact one of us.

CMA President-Elect Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Chair Adam Dougherty, MPH, MSII George Meyer, MD Robert Forster, MD John Ostrich, MD Ann Gerhardt, MD Gerald Rogan, MD David Gunn, MD F. James Rybka, MD Nathan Hitzeman, MD Gilbert Wright, MD Albert Kahane, MD Robert LaPerriere, MD Lydia Wytrzes, MD John McCarthy, MD Managing Editor Webmaster Graphic Design

Nan Nichols Crussell 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. ©2011 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

You Change My Life

By Alicia Abels, MD IT’S EARLY OCTOBER, SNOW IS FALLING in the Sierras and the deadline looms for my last column to you as President. As I grow older, every day seems to be a time of both reflection and moving ahead. The clock continues to tick and life inches forward — changes in our lives occur gradually, daily; icons of my generation are dying, retiring; social movements are spreading around the world responding to human rights/social injustices, economic crises, the need for freedom.

Social media are the preferred communication tools for the next generation, but I have yet to personally see the need for Facebook, Twitter or Linkedin despite the constant barrage of invitations. I still prefer a phone call to an e-mail or text for important issues. I do love my iPhone and my Mac, on which I can do all of the above even if I don’t want to. Thank you, Steve Jobs, you changed my life.

Thanks to all of you who work so hard on our various committees and our delegates to the CMA for the time and interest you give to our profession. Thanks to our UCD med students and residents who are so enthusiastic and fresh. I have been so impressed with all of you as I have visited our committees this year.

You change my life. Your work makes all of our lives as physicians and the health of this community better.

I want to thank each of you reading this for continuing your membership and helping to recruit others, as without you, medicine will have no voice. I have been honored to serve as your President this year and have been particularly honored to serve with Bill Sandberg in his final year as our executive director. Thanks again, Bill, and welcome, Aileen. I’ll look forward to working with you in your first months with us starting soon.

Lastly, although it is fatiguing to do so again, I have to ask you to reach out to those in Washington who make the rules that keep us able to earn a living and serve our patients.

Every year of late, we have had to make phone calls, send faxes and e-mails, and plead with our elected U.S. Senators and Representatives to stop the Medicare cuts — the so-called “SGR” or “Sustained Growth Rate” adjustments to the Medicare physician fee schedule which we can just not accept.

Every year we have to go back pleading to stop the cuts, and one of these years — I hope it is not this one — someone is just going to say “no” unless we can finally repeal the SGR. This year, SSVMS joins the CMA, the AMA and a coalition of specialty societies to once and for all, repeal the SGR. For all of you who do not read your blast e-mails or faxes, this year we may be able to get a repeal on this payment methodology. The stars are aligned in that the “Super Committee” (The Congressional Joint Select Committee on Deficit Reduction) must come up with $1.2 trillion in spending cuts (or raise taxes) by November 23, 2011, “or else.”

The “or else” is a “sequester plan” that kicks in with across-the-board cuts of various amounts in different areas. For Medicare it means two percent across-the-board (in addition to the planned SGR reduction), and for defense a 50 percent reduction. Congress may be motivated to pass a big deficit reduction bill this time, because their approval ratings are in the toilet, so to speak. Passing a meaningful deficit reduction bill may help them get re-elected — and some people just don’t care about politics. I just don’t get that!

For better and more detailed information on this campaign to repeal the SGR, background information, links to your representa-

November/December 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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tives and samples of what you should tell your elected representatives, please visit this web link http://cal.md/sgr-adv-kit-2011 or e-mail me and I can e-mail the link or documents to you.

For those of you living in the past some of the time like I am, you can still call the medical

society at (916) 452-2671, and we can either fax or send information to you via the USPS if it is still open by the time you read this column. aabels.ssvms@me.com

The SSVMS Alliance is pleased to acknowledge the following donors to our Community Endowment Fund Spring 2011 Fundraiser Platinum Level ($1000+)—Dr. and Mrs. Jim Andras; Lawrence Bass, MD; Mrs. Katie White.

Silver Level ($100-499)—Dr. and Mrs. Bud Banker; Dr. Col. George Meyer and Carolyn Bolton; Charles Bradbrook, MD; Dr. and Mrs. Donald Brown; Drs. Scarlet La Rue and Harvey Edber; Jon Finkler, MD; Dr. and Mrs. Ray F. Fitch; Dr. and Mrs. Kiernan Fitzpatrick; Nancy Gilbert, MD; Dr. Cary Hart and Mr. Gary Hart; Richard A. Jones, MD; Dr. and Mrs. Forest Junod; Robert Kahle, MD; Dr. and Mrs. Paul Kelly; Roger Lieberman, MD; Wayne C. Matthews, MD;

Dr. and Mrs. John McCarthy; Stephen Melcher, MD; Dr. and Mrs. Robert Myers; Dr. Catherine Nagy and Mr. Orin Brown; Dr. and Mrs. Paul Phinney; Dr. and Mrs. Jack Rozance; Patricia Samuelson, MD; Lee Snook, MD; Dr. and Mrs. Henry Sugiyama; Dr. and Mrs. Hillis Warren; Dr. and Mrs. John Whitelaw.

Bronze Level ($50-99)— Drs. Sallie and Jesse Adams; Dr. and Mrs. John Babich; Drs. Andrea and John Belko; Dr. and Mrs. Benjamin Cutshall; Dr. and Mrs. Richard Frink; Henry Go, MD; Joseph Lash, MD; Gail Pirie, MD; Peter Wu, MD.

The 32nd Annual Wine Tasting and Auction at UC Davis School of Medicine Benefiting the Student-Run Clinics January 28, 2012 • 6 to 10 pm Ticket Information: http://wineandauction.ucdavis.edu

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Sierra Sacramento Valley Medicine

Medical Waste To Test or Not to Test, That is the Question

By Gerald N. Rogan, MD

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

AT A RECENT UCD MEDICAL conference, we discussed the tests for screening patients for hepatitis B: Hep BSAg (CPT 87340: $14.79)1 and, if negative, Hep BSAb (86706: $15.38).

The initial presenter mentioned ordering the two tests concomitantly. But if the Ag is positive, he explained, the Ab test is not necessary.

I suggested, and the faculty agreed, that the Ab test sample should be held by the lab and run only if the Ag test is negative.

We use this hierarchical testing approach for urine cultures. If the urinanalysis (81000: $4.54) is negative, no urine culture (87088: $9.38) is needed. Likewise, an LDL cholesterol measure (83721: $13.66) is not needed if the triglyceride is under 300, because an LDL is calculated from the lipid panel (80061: $19.19). Some docs order additional lipid tests, such as LDL subparticle (83701: $35.55), Lp(a) (83695: $18.54), homocysteine (83090: $24.16), ApoE (82172: $20.19), and HDL subparticles.2 What is the evidence that all these lipid markers are needed to manage patients?

To predict the risk of breast cancer recurrence, some docs order the Oncotype Dx test.3,4 Is it more predictive than the breast cancer recurrence risk score provided by the free online services including Adjuvant! Online and the Breast Cancer Risk Assessment Tool from the National Cancer Institute?5,6 Is comparative evidence available? Should payers require comparative evidence for coverage?

At a recent lecture about osteoporosis, a professor of medicine recommended Vitamin D testing (82306: $42.40), (Self-referred retail price $59.00), for all patients who are at risk for osteoporosis.7 Those who test low would require a six-week loading dose of Vitamin D.

Sierra Sacramento Valley Medicine

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Those testing normal would require a standard dose for preventive purposes.

The professor showed no evidence that the loading dose prevented more fractures than by starting low serum level patients on the standard dose. She did not mention the cost of a Vitamin D test for a patient. I considered her recommendation inappropriate to the health care needs of our population, and told her so privately. She was indignant, and I was shocked and dismayed by her “silo� thinking and lack of relevant evidence.

The culture of medicine drives our standards about the need for testing. The culture is set by academic professors and institutions, through lectures, advertising, and articles. The scientific evidence to support some tests can be lacking, of poor quality, or conflicting, such that the risk-versus-benefit balance cannot be assessed.

Moreover, during lectures about testing, should the presenter show the audience the Medicare allowance for every test recommended?

Some docs falsely believe testing is necessary to mitigate the risk of a liability lawsuit, as opposed to a standard history, exam, and documentation. For example, what is the evidence that failure to take an ankle X-ray (73610: $34.44) in the ED (99281: $20.85) places the physician at risk for a lawsuit for a missed ankle fracture?

What actions can be taken to mitigate the risk without taking an X-ray? Data reported to MedPAC shows medical imaging can be inappropriate and the radiation unacceptable, considering the benefit.8 As documented in the ED visit example, Medicare pays more to take a picture than it pays to the physician to decide whether a picture is necessary. Medical groups

install high-tech imaging to make profits. Have abdominal CT scans (74170: $431.28) changed the 20 percent likelihood that an appendectomy (44950: $618.25) will reveal a normal appendix? Do we know when it is safe not to image a patient with the high doses of radiation that CT (5.30mSv) scans deliver? 9, 10 Physicians typically complain about the looming Medicare cuts to their fees, according to the Sustainable Growth Rate (SGR) calculation, in part driven by out-of-control medical imaging.11 AMA attempts to convince Congress not to cut physician fees, but all physicians must educate each other about how we can reduce medical waste, patient by patient.

I believe our professional responsibility includes providing optimal value, which includes knowing when not to order a test, when to postpone it in favor of a less expensive first test, and when to follow the patient for a while without a test.

Without more of the thoughtful physi-

cian leadership displayed at the recent medical conference I attended, medical waste will remain out of control and fee-for-service medicine will soon be marginalized in favor of managed care.

Currently about 50 percent of Medi-Cal patients are enrolled in managed care and the percentage is increasing.

Government and commercial fee-for-service payers cannot effectively control medical waste.

All they can do is cut your fees, delay coverage of new services, reject certain CPT codes, create robust claim edits, force appeals, and conduct audits. The ultimate solution to control medical waste is in the hands of the medical profession, not our professional lobbyists or the government.

The time has come for the medical profession to lead efforts to improve value, starting with medical lectures by thoughtful university professors who understand unmitigated waste is not sustainable.

Medicare pays more to take a picture than it pays to the physician to decide whether a picture is necessary.

jerryroganmd@sbcglobal.net 1 CPT codes are copyright AMA-CPT, Prices are the Medicare allowances in CA1 unless otherwise cited. http://www.palmettogba.com/palmetto/ corporate.nsf/DocsCat/Home 2 http://www.bhlinc.com/ 3 http://www.genomichealth.com/en-US/ OncotypeDX.aspx 4 The retail price on Oncotype Dx is about $3,000, but I could not find the price on the Genomic Health, PalmettoGBA Medicare, or CMS web sites. OncotypeDx has no specific CPT code, but S3854 is available for billing to commercial plans and Medi-Cal. 5 https://www.adjuvantonline.com/index.jsp 6 http://www.cancer.gov/bcrisktool/Default.aspx 7 https://www.directlabs.com/Resources/Vitamins/ VitaminD/tabid/273/language/en-US/Default.aspx 8 http://www.medpac.gov/chapters/Jun10_Ch08.pdf 9 The sievert (symbol: Sv) is the International System of Units (SI) derived unit of dose equivalent radiation. It attempts to quantitatively evaluate the biological effects of ionizing radiation as opposed to the physical aspects, which are characterised by the absorbed dose, measured in gray.

10 The radiation dose of a chest X-ray is 0.1Sv, 1/53rd of an abdominal CT. http://www.radiologyinfo.org/ en/safety/index.cfm?pg=sfty_xray#3 11 Documented in recent MedPAC Reports to Congress.

November/December 2011

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Open Wide...

With Confidence!

It’s Open Enrollment time for the Sierra Sacramento Valley Medical Society-sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

• During Open Enrollment only, members may join as an individual or as a group with your employees.

Sponsored by:

• Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families).

• Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2012.

Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.

Underwritten by:

Administered by:

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

51499 ©Seabury & Smith, Inc. 2011 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • Member.Insurance@marsh.com • www.MarshAffinity.com • CA Ins. Lic. #0633005

Conversations

UCD School of Medicine: Staff Interviews

By David Gunn, MD This is one of a series of interviews with staff members and deans of the UC Davis School of Medicine.

• John Drummer: Academic Coordinator with UCD SOM since 1968.

• Susan Muramoto: Financial Aid Officer, past director of financial aid. With UCD SOM since 1976.

• Carmelina Raffeto: Career advising coordinator. Internal Medicine 1990-1997; Dean/OME since 1997.

• Ed Dagang: Admissions Officer, Director of Admissions with UCD SOM since 1991.

David Gunn: Introductions?

John Drummer: I joined the school of medicine as a laboratory assistant way back in 1968, when I was an undergrad at UC Davis.

The school was just starting at that time. We were in temporary buildings that turned out not to be temporary. I helped to set up the labs for the students, and have since stayed on in the equivalent of the Office of Medical Education.

The original OME was combined as it is now, but it was split into student affairs and curricular support in the early 1980s; then it all came back together again in 1999 until today.

Susan Muramoto: I started at the med school in 1976. I was also in the temporary buildings. I think even at that time it was already student affairs and curricular support.

DG: Susan, you’re a financial aid officer, but you used to direct the department, correct?

SM: I was the director until I had my second child and wanted to go part-time (1983), and the director could not go part-time.

Carmelina Raffeto: I started with the school

of medicine in the department of internal medicine in 1990, [and] stayed with internal medicine for about ten years. Then I was parttime with internal medicine as Faith Fitzgerald’s assistant, and then with Joe Silva in the dean’s office.

Ed Dagang: I started in the SOM in 1992, I believe. I came on board as the Admissions Officer and Director of Admissions. I’ve been there ever since.

DG: Anyone have any burning memories they want to share?

ED: I’m just going to start off by saying I miss the simpler days. There was a dean of curriculum and a dean of student affairs. There weren’t all of these different levels.

SM: And everyone acted together as a team.

It was not, “this is your unit.” and “this is our unit.” It was very much a team approach.

ED: And more camaraderie too...

SM: Yeah, you would walk around and the dean would go, “Hi, how are you doing? Any students? Any questions? Anything you need to bring up?”

DG: It felt smaller?

SM: Very much.

CR: Oh, yeah. It was smaller, as far as the number of deans.

JD: I think some of this is because of the campus. We had a split campus for the vast majority of our history. Years one and two were on the Davis campus. Years three and four were here. So we had a protected academic community in Davis. The first two years the students got involved in the Davis community, it was more relaxed.

CR: Well, at commencement we’d all be

November/December 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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From the point of view of the educational environment, we’re exposing students to the culture of medicine at an earlier stage.

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in the quad; it was very much home. It was simpler; we didn’t have Mondavi.

SM: I used to come over once or twice a week to Davis.

CR: And Hibbard [Williams], the Dean, would come over once or twice a week to meet with students and faculty in Davis.

JD: But then students would get into their third year and they would feel lost. Talk about lack of community. It was a culture shock, even bigger than it is now.

SM: The move to one campus was a good move. I just don’t like all the things that made it a huge conglomerate. Even I don’t know who is our dean and what they do.

ED: I started out with one manager, that was Dr. [Ernest] Lewis, Dean of Student Affairs. Now I have probably four or five supervisors.

CR: You had your dean, like Hibbard Williams (who was my favorite). The Executive Associate Dean was James Castles, and there was Ernie Lewis in student affairs.

SM: If there was a problem with a student, you could just go into their office and [casually say], “Hey, you wanna call him in? We’re worried about him...” and things would get taken care of informally before they got to be big issues.

DG: So if we seem to have lost some of the smaller, informal community spirit, what have we gained?

JD: From the point of view of the educational environment, we’re exposing students to the culture of medicine at an earlier stage. [They have] more accessibility to the clinical faculty; they used to have to come to Davis to teach.

Remember, moving over here was a big cultural change for the medical center as well, and for the academic environment. We’re still learning, too.

DG: What do you think the layers of administration add?

CR: [long silence]...I don’t think that it adds much. I think some of those layers have been required with sexual harassment, discrimination, all kinds of things...not really able to be handled by one dean. It might have just been an ad hoc committee, but now it requires an

Sierra Sacramento Valley Medicine

entire dean. I don’t know if it has more pros than cons; I don’t think so.

DG: One of the arguments for creating a new position is to take on a special project, or to introduce continuity across years.

SM: It gives it more credibility.

DG: Well, it gives it a title.

JD: In the scheme of things, we are probably a fairly rare example of an integrated medical school and health system. So we have a vice chancellor and dean, clinical operations, etc...

It’s a huge job. So it’s predictable that you would have associate and executive deans overseeing research and clinical enterprise. If you look at this center’s record in terms of its ability to do cutting-edge clinical care and research, it’s at the very top of its game. Sometimes those missions are in conflict of the educational mission.

DG: How so?

JD: The faculty have got to care for patients.

We’ve heard from them (faculty), and from the students, that they just don’t have adequate time to teach, to spend one-on-one with students. We have heard from the residents they don’t have time, with the work hour restrictions.

SM: For a time there was a huge focus on research. I know because I took a lot of financial aid funds away from our students and turned those funds into research funds. So it kind of depends upon where the focus of the school is.

JD: We are leaning towards recognizing the potential for inter-professional education and early clinical involvement of the students, more longitudinal experiences, but we’re still learning.

DG: I think about the business triangle of “Time, Quality, Money.” Pick two. You can’t have all three. Maybe there’s an analogy here about patient care, teaching and research?

JD: I don’t think any one of the faculty are now triple threats.

DG: How do you think that admission criteria have changed since you’ve been here?

ED: Community medicine is still really important, family medicine, primary care, community service. For the most part our deans of admissions have maintained the same qualities we’re looking for — people who want to

treat their patients well.

DG: Is that what you’ve seen in the career advising role, Carmelina? That students are similar in that way?

CR: I think so. When we became one school here, it gave first and second years an opportunity to work with third and fourth years here in the clinics. They’re all out there in the community. Students want to be involved in the community.

DG: Susan, how do you think the financial side for students has changed? It seems to be a pretty steady increase? What are students saying now versus 15 years ago? Do students complain about how much it costs, no matter how inexpensive it has been?

SM: They are, but we’re also getting different types of students. A lot more credit card debt coming in. We’re seeing the personality differences too. The current generation is very much “the world is all about me,” 22-24 year olds. They expect money for skiing trips and don’t understand why they can’t get it. Before, everyone used to have a similar debt level. Now we’ve got a group who owes a lot by graduation, and a group who owes very little.

DG: A separation between the haves and the have-nots.

SM: That lower debt group will include students from wealthy families, but also disadvantaged students. Then you have the other students who are financing their education, and that debt is way up there! And that’s different than it used to be. So to publish our average debt as $140,000, it’s actually going to be closer to $100,000 or $200,000. Most students took out loans before; now some students are turning down the loans, just taking the grants. So we know we’re getting different students. We’ve seen a rise in parent income levels. We’re losing the middle-income level students.

DG: When do you think that started?

SM: Maybe 2004-2006? And it was pretty dramatic, very suddenly.

DG: I wonder if that’s due to a general split in our society, or if we happen to be selecting different qualities during admissions that are more prevalent in wealthier families. continued on page 31

November/December 2011

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Book Review

° Bohuslav Martinu: The Compulsion to Compose Author: F. James Rybka, MD, 2011, Scarecrow Press, ISBN 978-0810877610

Review by John Loofbourow, MD Composer Bohuslav Martinu° was a close lifelong friend to SSVMS member James Rybka’s father, and his family.

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.

AT 372 EXTENSIVELY-DOCUMENTED PAGES, this first-person work is never merely a biography of a great composer; it is also a treatise on autism, an autobiography, and a detailed portrait of a family in a complex interconnected 20th Century Euro-American world of classical music. It is epic in scope. ˘ a town of about The story begins in Policka 10,000 on the Bohemia-Moravia border of the Czech Republic. It continues to Prague, Paris, the classical music culture of New York City/ Berkshire America, and back to France. It moves through events of WWII, among famous and familiar classical musicians, as well as to music, places, and names I didn’t know and couldn’t pronounce. Yet it always held my interest.

The author’s intimate knowledge of classic 20th century music, and his careful study of ° autism, as he paints them in the life of Martinu, repeat like musical phrases throughout the story, and make it a symphony of ideas, people and places.

As I read, some universal constructs appear.

First, the apparent relationship between music, mathematics and aberrant social behavior; that has been the subject of several recent hit movies.

On a personal level, my brother-in-law was a well-known mathematician and often found Paul Erdös at his doorstep. In “The Man Who Loved Only Numbers: The Story of Paul Erdös and the Search for Mathematical Truth by Paul

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Hoffman,“ Erdös was totally obsessed with his subject — he thought and wrote mathematics for nineteen hours a day until the day he died.

He traveled constantly, living out of a plastic bag, and had no interest in food, sex, companionship, art — all that is usually “indispensable to a human life.” Is that recurring condition predominately related to DNA or to environment or to coincidence, or all three? Who can ° required lifelong help say? In any event Martinu from friends like the Rybkas, from the women in his life, and from other musicians to meet the basic needs of living so he could compose so voluminously and successfully.

The second but related construct is that of a professional musical culture, especially found in musical families. I am well acquainted with one where each member plays a principal instrument many hours a day, as well as many other instruments. Music is the galactic center of their

° Bohuslav Martinu (1890–1959) is believed to be the first composer ever to be documented with an autistic spectrum disorder.

He composed over 400 symphonies, operas, ballet scores, and other orchestral works.

The author, Dr. James Rybka, was a close family friend.

Reflections on a First Year in the Legislature

By Assemblymember Richard Pan, MD, MPH “Every system is perfectly designed to get the results it produces.” — W. Edwards Deming “The less that people know how sausages and laws are made, the better they’ll sleep at night.” — Chancellor Otto von Bismarck A YEAR AGO, I WAS ELECTED TO THE California State Assembly after winning one of the most contested Assembly races in the state.

Having served as Chair of the CMA Council on Legislation, I already had exposure to the state legislature, but transitioning from medicine to public office in the legislature has been an eyeopening experience.

Serving in public office and in the legislature

is the ultimate generalist position. Legislators face a wide variety of issues ranging from health to education to transportation to crime to fiscal issues and more. Eventually, a vote has to be cast on a bill — a bill that is the result of a variety of compromises.

While you have a small staff and lobbyists who come to explain, it is difficult to acquire a deep understanding of the impact of over 2000 bills plus amendments submitted during a legislative session. Often you have to depend on your colleagues for guidance. Thus, as one of two physicians and a handful of health professionals in the legislature, my views and perspectives on health issues can carry particular weight. But this will only be the case if I protect continued on next page

continued from page 12 life, the essence of every hour of every day, every get-together; the entire family lives in a supranational universe of music schools, symphonies ° was the Rybka and concerts. Perhaps Martinu connection with that musical galaxy.

The question remains whether genetic or cultural influences predominate. Maybe they are both a sine qua non for great musicians.

The last construct, a sobering one, is this: when one sees another person, we only see a face, a physical being. What we don’t see, cannot see easily, is the human depth there — the personal history, breadth of life lived, joys celebrated, the sorrows endured; and especially, what that person we perceive visually knows and understands about life that we, who look on, do not.

I “know” the author of this book, even though I don’t know him. He is a very active physician member of the Sierra Sacramento Valley Medical Society. To read his book is, therefore, a double joy for me. Beyond the fact that it’s a beautiful work into which he poured effort, time and much of himself, in reading it, I was pleased to think I know the author just a little better. He is the same man as he was before he wrote, and before I read, but I am now different.

To read sometimes expands our lives. Dr. Rybka’s book does that for me. Thanks, Jim, for your fine book, for expanding my little world, and for the warm, intimate way you did so.

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.

john@loofbourow.com November/December 2011

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my integrity as a source of health information, even when I may disagree on policy.

With relatively short term limits in California, long-term planning is difficult. To learn the history of a particular piece of legislation, I often have to depend on staff or lobbyists; almost all of my legislative colleagues have not been in office long enough to fully selfinform unless they were previously legislative staff. This difficulty struck home at a committee hearing on a bill establishing a pilot program.

I asked at the committee hearing how the pilot would be evaluated and when the committee would receive the results. My fellow legislators noted that few of us would be in the Assembly at that time and that the staff and lobbyists would inform our successors about the results.

With the emphasis I have given to evaluation in my academic and community work, I could not help being dismayed.

Perhaps the most difficult aspect of serving

1-800-901-5830 • • • • • •

33 years of medical experience 1,600 Northern California physicians 45 well-trained & professional operators State of the art computer technology Discounted rates for new SSVMS accounts Spanish, Chinese and Russian spoken

in the legislature is the current state of politics.

Polls have indicated that voters are less tolerant of compromise, and redistricting has made politics particularly acute this year. Because of term limits, legislators do not have time to build consensus between stakeholders for major pieces of legislation while serving in one house, so there is constant maneuvering for the next office.

Differences instead of agreements are emphasized. While I and others have built positive relationships with colleagues across the aisle, it is almost impossible to achieve agreement on major issues like the budget. If representative democracy is to be successful, voters need confidence in the judgment of their representatives instead of binding them with pledges.

I continue to practice medicine as a volunteer at the Oak Park Community Health Center at The EFFORT once a week. I ran for office because of the challenges facing my patients, and continuing to practice medicine keeps me grounded as well as happy.

While the legislature can be a frustrating place, it also provides opportunities for problem solving. I intend to seek re-election so I can continue to work on the problems facing our state, and I also look forward ultimately to returning to practice and using my experience in public service to improve the health of California. assemblymember.pan@asm.ca.gov

What is it?

This item is in the SSVMS Medical History Museum.

Can you guess what it was used for? See page 21.

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Sierra Sacramento Valley Medicine

An Invitation to All SSVMS Members, Alliance Members & Guests The Sierra Sacramento Valley Medical Society and Alliance Invite You to Attend the 2012 Annual Awards, Installation and Dinner Thursday, January 12, 2012 Hyatt Regency Hotel, Sacramento 6:00 pm Social / 6:45 pm Dinner / 7:30 pm Program

Retirement Recognition William A. Sandberg “Celebrating 25 years as Executive Director”

Welcome Aileen E. Wetzel, Incoming Executive Director

Installation David A. Herbert, MD, President 2012 2012 Officers and SSVMS Board of Directors

SSVMS Award Presentations Golden Stethoscope  Medical Honor  Medical Community Service

SSVMS-Alliance Award Presentations Dorothy Dozier Helping Hands  CMA-A Dedicated County Member Sponsored by NORCAL Mutual Insurance Company

Doctor-ing and Doctor-ers

By Ninad Athale, 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.

“WHEN ALL ELSE FAILS, LISTEN TO THE PATIENT.” As a medical student at UC San Diego, this was the advice that was given to me by a greyhaired physician, a well-respected man with years of experience and a leader in his field. He gave me this advice with the look of someone dispensing some hidden truth, some pearl of wisdom long forgotten. And when he uttered these words to me, I could only think of one response: Duh. Most physicians now in practice may not realize the extent to which “doctoring” is taught in today’s medical school curricula. Some form of this class — whether it is called “Behavioral Sciences,” “The Patient-Doctor Relationship,” or simply “Doctoring” — exists everywhere. These courses emphasize the “art” of medicine — how to communicate effectively, be more empathetic, and how to ensure one’s own well-being in a field that can be, at times, brutal.

As one of many new facilitators for the “Doctoring” course at the UC Davis School of Medicine, I have come to realize the true value of providing this kind of formal training in medical school. As I watched one of our students wrestle with interviewing a simulated patient — an actress portraying a survivor of domestic violence, I remembered my own medical school experience of practicing an interview on this sensitive topic and how much I learned from struggling in that controlled environment.

Most medical students now find such “profound” aphorisms like “listen to the patient,” and “empathy is important,” as meaningless and self-evident, and perhaps rightfully so. What is more important is, “how to portray yourself as empathetic” or “how to be an active listener while still typing your note.”

There is a subtle difference here; I believe

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that certain qualities (like empathy), once thought to be innate and unteachable, now are skills which need to be taught and fine-tuned.

Thus, we are at a very interesting point in medical education.

On one hand, the sheer volume of information that new physicians have to process is staggering. There are new drugs on the market every week. The internet is both an incredible resource and an incredible junkyard of misinformation. It is becoming less common to encounter a patient with a single diagnosis and more common to encounter one with profound co-morbid conditions and psychological issues.

In light of these facts, courses on “Doctoring” are absolutely vital, as the role of the physician is rapidly changing. More is required of us than vast amounts of book knowledge. The focus of decades of medical education has been reductionism and the pursuit of zebras rather than that of horses.

It is time we address the whole patient and strive to be good “horse-whisperers” instead.

For example, 25 percent of all medical expenses are due to the results of addictive behaviors; and good interviewing techniques and establishing therapeutic rapport with patients is key in combating these unhealthy behaviors.

In short, the physician still holds a timehonored position of trust for patients. Patients are more likely to divulge important health information to us than they would to anyone else. We just need to ask the right questions in the right way. But in order for us to ask the right questions, as a profession, we have to be able to teach this skill.

We still have not figured out how to best teach doctoring. I believe that “Doctoring” classes serve as a great start. Although some students criticize them as artificial at times, these classes provide a safe environment which

affords students introspection, cognitive development, and most of all, practice.

Yet another challenge is getting real-world clinic and hospital settings to affirm these values so that students do not feel a disconnect when they enter their clinical years and find that many physicians do not practice evidence-based medicine, spend adequate time with their patients, or show appropriate cultural sensitivity.

Although I was fortunate to go to a residency program in family medicine that fostered these skills after medical school, I fear that my experience was the exception rather than the rule.

There is a great need not just for “Doctoring” courses, but also, for lack of a better term, “Doctor-ers,” or role models and educators who can appropriately teach these skills in an innovative and yet scientifically-driven way. There are some examples such as the Paired Observation and Video Editing course developed at the University of Washington (http://courses.washington.edu/pove/), or even using improvisation

comedy techniques (http://www.ncbi.nlm.nih. gov/pubmed/21869654).

I believe there are many more ideas out there, some of them effective and some probably a waste of time. The time has come to really find out which is which, and how we can incorporate these ideas in medical school, in graduate medical education and even in terms of CME. The time has come to take seriously the education of a new generation of doctors with more than just a handful of clichés. nathale@clinicole.org Ninad Athale, MD, is a recent graduate of the Sutter Health Sacramento Family Practice Residency Program, and currently volunteers as a Doctoring 3 facilitator at the UC Davis School of Medicine, as well as in the Student-Run Free Clinics. He is currently working at Community Health Clinic Ole in Napa with an underserved population.

Your care makes all the difference.

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

www.bloodsource.org

|

not-for-profit since 1948

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.

November/December 2011

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Farewell...

By Bill Sandberg, Executive Director

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.

AT A RECENT RETIREMENT PARTY, the person being honored gave a speech that sounded like his life was over. My retirement will be a new, exciting chapter shared with my family, friends, and special interests. It will be a life of limited deadlines and worries over things I cannot change. The passion and strong feelings I have for physicians and health reform, however, will remain with me forever.

I have learned a great deal working for hospitals for 15 years, and during my 25 years in this position representing physicians. You start your career thinking you are the smartest kid on the block and as the years tick by, you learn how little you actually know about anything!

I have served 31 presidents in this position, a number of them when we managed the Yolo County Medical Society. They have kept me on my toes, and have stimulated new ideas and approaches to old problems.

Thank you to the hundreds of members I have met and served over the years and to the hundreds that I have never spoken to. Thanks to my terrific staff: Chris Stincelli, Janice Emerson, Kris Wallach, Le Pham, Marti Hill, Melissa Darling and Shannon Buchan. Thanks to my wife, Charlotte, for her support and patience.

Finally, I want to congratulate and encourage everyone to welcome Aileen Wetzel who will work alongside me in November and December. She will become Executive Director on January 1, 2012. Aileen is uniquely qualified for this position. She has the passion and fire in her that are necessary to succeed here and she understands the challenges faced by solo physicians and medical groups.

Aileen was the Associate Director of CMA’s Center for Economic Services, a team focusing on economic, legislative, regulatory and

Sierra Sacramento Valley Medicine

Outgoing Executive Director Bill Sandberg

Incoming Executive Director Aileen Wetzel

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legal issues impacting physician practices. She is CMA’s managed care contracting expert and co-author of multiple CMA and AMA toolkits, including “Taking Charge: Steps to Maximizing Relationships and Preparing for Contract Negotiations – A Focus on Payor Contracting,” “Back to Basics: A step-by-step guide to maximizing your cash flow – A focus on the physician office and collections process,” AMA’s Benchmark Capitation Guide, and numerous other economic advocacy toolkits, guides and publications.

Prior to joining CMA in 2000, Aileen served as National Vice President of Managed Care for Integrated Orthopaedics, Inc., a large physician practice management company. Aileen has also served in numerous leadership positions for large integrated hospital systems including Columbia/HCA, National Medical Enterprises and Charter Healthcare. As Columbia/HCA’s Regional Director of Business Development and Managed Care, Aileen managed staff at 11 hospitals in the Greater Houston area. She was the founder and Executive Director of Medical Center Healthcare Alliance, one of the first organized hospital/physician organizations in the state of Texas.

Aileen holds a BA in International Business and Economics from the University of Washington and an MA in Communications Management from the University of Southern California. She is active in her community and is a regular volunteer with the Pancreatic Cancer Action Network (PANCAN) and Grace Foundation Equine Rescue.

Thank you everyone for making my career with SSVMS stimulating and rewarding. bsandberg@ssvms.org

retiring | re•tir•ing | 1. shy, fond of being on one’s own; 2. Bill Sandberg

By Alicia Abels, MD BILL SANDBERG IS NOT REALLY SHY, but he is retiring at the end of this year after 25 years of extraordinary service and leadership as the Executive Director of SSVMS. Though we all know Bill in his role through SSVMS, many of us are not aware of his background and many accomplishments.

Bill started his professional career in Sacramento as Program Director for the Sacramento Association for the Retarded in the early 1970s. During our professional liability crisis of 1975, he was Director of Public Relations and Development at Roseville Community Hospital administering their physician recruitment programs and public education efforts as well as establishing their fund development program.

From there, he left our area to work for Ballard Community Hospital in Seattle as the first president of the Ballard Community Hospital Foundation, implementing numerous community relations and service programs within the hospital’s service area.

He was recruited to his position with SSVMS in 1986 when he was Director of Public Relations for the Group Health Cooperative of Puget Sound and Founding CEO of the Group Health Cooperative Foundation in Seattle.

Bill has served twice as Chair of the Medical Executives Conference of the California Medical Association and currently serves as Advisor to the Board of Directors of NORCAL Mutual Insurance Company. He is a Past President and APR of the Public Relations Society of America, Puget Sound Chapter, and is certified by the National Association of Hospital Development.

Bill is a member of the American Association of Medical Society Executives and the American

Society of Association Executives, the Sacramento Health Improvement Project and Future of the Safety Net for Yolo County. He is a past member of the Board and Past Vice-Chairman of the California Medical Association Foundation, and was Founding Director of the Center for AIDS Research and Education and Services. He has served in the past on the Community Health Advisory Committee of Sacramento County.

He is also a member of numerous other ad hoc committees and task forces dealing with health care issues in our region.

Bill has been an exemplary steward of SSVMS in all ways, representing us well in our own medical family of CMA and its component societies, but also externally in our community to various boards, agencies, politicians, health plans, and patients, among others. He has the respect of all who have worked with him.

Through the years, Bill has been a confidant to, and has counseled, countless physicians in transition or in trouble. No one knows this medical community like Bill.

Largely because of Bill’s efforts, SSVMS has maintained a strong and active medical society that is the envy of most others in the state in terms of member recruitment, retention and cohesiveness of its board, despite our very competitive healthcare environment and membership diversity. Bill has been fiscally wise when guiding the Board in its decisions, resulting in our society’s healthy financial shape. He has developed a devoted staff that all work as hard as he does for you.

Through the years, Bill has developed a network of friends who revere and love him.

Although most of us are sorry to see him leave his position at the medical society, we are happy

November/December 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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I have always tried to heap praise where praise is due.

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that he is going to be able to have some free time to spend on his many other interests and, of course, with his wife, Charlotte.

As Bill will hint in some of the Q and A below, some of his years here were longer than others.

Q. Bill, what events or people have affected you most during your tenure here?

A. There are so many individual members that I couldn’t possibly list them, but I think they know who they are. I have always tried to heap praise where praise is due. If there was one person, it would have to be Dr. Jim Hamill who called me at home in Seattle and offered me this job on October 20, 1986.

It was a wonderful birthday present, and the start of my career here.

Q. You have done so much for our community and medical society — what accomplishments are you most proud of?

A. Getting SPIRIT and Adopt-A-School Projects started, accomplishing a merger between the Yolo County Medical Society and Sacramento-El Dorado Medical Society, transitioning from the Medical Library to the Medical History Museum, blowing the whistle on gag orders in managed care contracts and stopping the IPAs from terminating physicians without hearings. I am proud of the great Medical Society staff. I am also proud of the help and assistance we have delivered to the hundreds of physicians with every possible problem you can imagine.

Finally, we have not increased dues in 25 years and actually cut dues by $65.

Q. We know your job is not always easy even though you love it. In retrospect, what was your most difficult year here?

A. It was a series of years in the late 80s and early 90s when a major medical group failed.

Physicians were being fired and laid off, IPAs were terminating physicians, for-profit HMOs (about a dozen of them at that time) were “losing claims” and just not paying physicians. New groups were being formed, and there was a general state of confusion, frustration, changing and evolving loyalties, moral and ethical dilemmas. It was the height of the “Physicians Burnout” period. It was also an exciting and personally rewarding period because we were advocating for our members and patients on multiple issues and multiple fronts.

Sierra Sacramento Valley Medicine

Q. You’ve always been a good story teller.

Are you able to discuss any near calamities that you were able to avert?

A. Yes, but I can’t discuss them publicly. The calamity stories cannot be told without breaches in confidentiality, unnecessary embarrassment for those involved, being sued, or all of the above. There are some real doozies. They would illustrate what lengths we go to serve our members.

Q. What stands out as the funniest (ha-ha funny) experience you’ve had at SSVMS through the years? What makes you laugh the hardest now when you think about it?

A. My staff agrees with these two: I was interviewing a potential new employee. I leaned back in my swivel chair and fell over turning a perfect backward roll. Except for the hunk of skin cut out of my ankle, I was unhurt. My staff rushed in, and they all started laughing. I was really embarrassed! They also liked to make fun when things I wore didn’t match (I’m color blind). They all came in one day and laughed in unison at my mismatched shoes.

Q. What experience stands out as the funniest (odd funny) that you had in your capacity as executive director?

A. We had a female employee with us for some time, and we learned several years after she left that she was a he. Only one employee claims to have known this, but that person never said anything.

Q. You have been quite the “Super Star” at SSVMS including doing a lot of the building updates and repairs yourself. You are a known gadget/technophile. Are there interests or hobbies you have that our members would find surprising?

A. Our employees call me the Building “Supe,” because I have chosen to fix things here when I can to save some money and time. I took four years of ceramics, two of which were from Ruth Rippon. I enjoy woodworking, fixing stuff, and solving mechanical or practical application problems. I also enjoy geology, science, fishing and being at the coast.

Q. What parting advice do you have for us as an organization, or for Aileen Wetzel who will be coming in as your successor?

A. I will give her the same advice that was given to me by a senior medical society executive years ago. He said, “Bill, remember that this is their club

not yours. Your job is to help them run the club as efficiently as possible, help the leaders achieve their goals and stay out of the politics as much as possible.

And, never forget that you are not a member.”

Q. What do you see as the greatest challenges for our organization in the near future and for the long term?

A. Short term or long term, it’s always about proving our worth to those who are paying dues.

Some demand greater proof than others. What we (SSVMS, CMA and the AMA) do for physicians and accomplish on their behalf is not something you can easily communicate and sell. Without our

work, things would be in a terrible state. Let’s never loose sight of doing what is best for patients with a conscious effort in doing it efficiently and with empathy.

On behalf of all of the physicians of SSVMS, I want to thank you, Bill, for all the dedication and hard work you have given to our organization over the past 25 years. It has been a joy having you as our Executive Director, and I know personally that I will miss you greatly. aabels.ssvms@me.com

Mental Health Crisis Triggers Action WITH THE REDUCTION IN MENTAL HEALTH services by Sacramento County and the severe cutbacks in neighboring counties, our region’s emergency departments have been severely impacted by seriously ill mental health patients. In 2010, immediate past president and psychiatrist Stephen Melcher, MD, met with the SSVMS Emergency Care Committee to discuss these issues.

One of the major problems identified by the Committee was the lack of access to the various admissions policies for the five local inpatient psychiatric hospitals. Over the course of a year, the administrators of Heritage Oaks, Sierra Vista, Sutter Center for Psychiatry, the Sacramento County Mental Health

Treatment Center and Woodland Health Care’s facility worked on the development of a matrix detailing the acceptable admissions criteria of each facility that addresses 23 medical and physical conditions.

Scott Seamons of the Hospital Council of Northern and Central California and SSVMS helped bring the necessary parties together. The matrix was adopted in August. The use of the matrix will improve the entire process for patients, inpatient mental health facilities and EDs by standardizing the process as much as possible.

The SSVMS Emergency Care Committee included the Chief ED physicians from all of our major hospitals in El Dorado, Sacramento and Yolo Counties.

What is it?

This tool was a shoestretcher for bunions, donated to the SSVMS museum by Dr. Max Shaffrath. The museum is located at 5380 Elvas Avenue in Sacramento, and is open to the public.

November/December 2011

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B-17 Checklists and Medicine in the USA

By Andrew S. Klonecke, 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.

IT WAS A BEAUTIFUL FALL DAY IN Dayton Ohio in 1935. The U.S. Army Air Corps was holding a competition for its next generation long-range bomber. Everyone knew that this was not going to be much of a contest as Boeing’s Model 299 was considered the handson favorite, much superior to what Douglas or Martin had designed. The “flying fortress,” as it was dubbed, could carry five times as many bombs as the army had requested and flew faster and farther on a tank of gas. This competition was a mere formality so that the army could order 65 of these new planes. This was going to launch a great new era for the AAC and, of course, an extremely positive bottom line for Boeing.

All began well as the glistening all-aluminum bomber rolled out on the tarmac. Despite its enormous (for that time) 103-foot wingspan and four engines, it looked sleek. Major Ployer Hill, the army’s most experienced test pilot, guided the plane down the runway to a smooth liftoff. But then the unthinkable happened.

After climbing to 300 feet, the plane stalled, turned on one wing and crashed in a fiery explosion. Major Hill and two of the other four crew on board were killed.

Boeing, obviously, did not get the contract that day and nearly went bankrupt. The Army called for an investigation, but found no mechanical problems. It was pilot error. The aircraft was substantially more complex than previous aircraft and Major Hill, despite paying attention to all four engines, retractable landing gear, new wing flaps, electric trim tabs and the hydraulically-controlled, constant-speed propellers, had forgotten to do a very minor

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task which was to release the locking mechanism on the elevator and rudder controls. It was simply too much plane for one man to fly.

The army loved this plane and bought a few anyhow to test drive. A group of test pilots was assigned to figure out how best to fly this plane.

They resisted the notion that it would simply require more pilot training because after all, wasn’t Major Hill the most trained and experienced the Army had to offer? What they came up with was a very simple solution — the pilot’s checklist. The plane was just too complicated to be left to the memory of any one pilot to fly.

The Army then went on to fly this plane 1.8M miles without incident and eventually bought 13,000 of them. It became known as the B-17 bomber and gave the U.S. a distinct advantage in the air during World War II. So, what has this got to do with Hospital Acquired Infections (HAI) and medicine in general? In a recent study of 41,000 trauma patients, it was determined that they had 1,224 different diagnoses in 32,361 different combinations. Is this like having to land 32,261 different airplanes, and has medicine now entered the B17 phase? After all, we have our crashes, just like Major Hill — two million patients get hospital-acquired infections, 40 percent of CAD and 60 percent of DM patients get incomplete or inappropriate care and up to 50 percent of surgical complications may be avoidable.

Peter Pronovost, an intensivist at Johns Hopkins, thought about this as he contemplated the 11 percent central line infection rate in his ICU in the mid 1990s. He wondered about the concept of the list that the army

pilots had created some 60 years earlier, and that commercial airline pilots still utilized, and he wondered whether that might be of benefit to his patients in the ICU. He noted the critical steps required to insert a central line that would not become infected included hand washing, cleansing the patient’s skin, using sterile drapes, gowning and gloving and then applying a sterile occlusive dressing to the insertion site. But when he observed, he saw that in one third of procedures, at least one step was skipped.

He was able to enlist the administration’s support to authorize the ICU nurses to stop any physician who did not follow the five-point checklist during a central line insertion. After this was initiated, the ten-day line infection rate went to zero! This prevented 43 infections and eight deaths, while saving $2 million. Next, Dr. Pronovost attacked ventilator care and then the nurses and doctors were invited to create lists for any other procedures. The end result was that it cut average length of stay in half.

What is there not to like about preventing infections, decreasing mortality and saving lives? Yes, the physicians had to invest extra time to follow the checklists and had to endure the nurses’ scrutiny to make sure the lists were followed, but look how much the patients gained. And ultimately, the physicians would gain not only respect for the high quality of their work, but also the great self-satisfaction that would come from doing the right thing. If the physicians continued to skip one or more steps in every procedure, the patients would pay the price, sometimes with their lives.

(A personal note: While in the CV surgical ICU after bypass, I watched the sink and gel like a hawk and you can be darn sure I made everybody wash before touching me; maybe patients should be provided checklists as well as professionals!)

Do we really need checklists to get the jobs done consistently and correctly? It turns out that a major benefit of using a checklist is that it helps memory recall, especially the mundane, and it makes explicit the minimal expected steps in a complex process. For example, one in thirteen hospital deaths is due to hospital-

acquired sepsis. In Northern California, hospital-acquired pneumonias, C. difficile infections, surgical site infections, central line infections and catheter associated UTIs affected some 5,700 patients last year, causing about 500 deaths and 46,000 extra hospital bed days.

What is interesting about HAI is that many of the drivers of these infections should be easy to control including hand washing, isolation and room cleaning. Reducing unnecessary antibiotics and PPIs are additional factors. When hospital staff are asked if they wash their hands or not, 81 percent said that they did in one study; but when the secret shoppers went into the hospitals and observed for this behavior, the results indicated that only 26 percent to 71 percent actually did.

Atul Gawande, MD, (surgeon, author, journalist and head of the Global Patient Safety Challenge of the WHO) defines an effective system as one that is data driven, which lets you know whether you have succeeded or failed in a particular circumstance; which lets you use both this data and the experience of its members to devise solutions; and to implement those solutions. The latter requires a new emotional intelligence for healthcare providers, namely humility or the recognition that we all can fail.

We must believe that discipline and standardization can reduce failure, and that others can save any of us from failure no matter where in the hierarchy they stand. These are not the traits that most of us were taught as we became doctors, nurses, pharmacists, techs, etc. The higher we were along the pecking order, the more authority we had, and the less we were questioned by underlings who knew that a chief was doing something wrong.

This has been noted in other industries as well. In his book Outliers, Malcolm Gladwell devoted a chapter to Korea Airlines back in the 1990s. They sustained multiple airline crashes, to the point that the airline was nearing bankruptcy and the country was so humiliated that the government took over the company. The average loss rate for the airline industry was 0.27 passengers per million miles flown. Korea

November/December 2011

It turns out that a major benefit of using a checklist is that it helps memory recall, especially the mundane…

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There is some concern that standardization and adoption of best practices conflicts with personal autonomy; some have suggested that this can lead to a decrease in physician satisfaction.

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Air’s loss rate was 17 times higher at 4.79 per million miles. The U.S. military would not let our troops fly Korea Air, and even President Kim de Jaeng switched to Asiana.

It turned out that the biggest cause for Korea Air’s troubles could be traced to something called PDI for Power Distance Index. This is a measure of how much a culture respects and values authority. Korea has one of the highest PDI scores, indicating an extreme respect that all had for the captain and how no one would contradict or intervene even when it was obvious that a great disaster was going to occur.

Something had to change.

Cho Yang-Ho, who received his MBA from USC, was put in charge and was able to change the culture by installing a systems approach that would minimize the personality-driven, top down culture that was the legacy of Korean business managers at the time, who tended to value intuition and responding to orders. Cho relied more on technology, creating a central clearing house to monitor and investigate safety reports and audit findings. All divisions were ordered to share and coordinate data, and all where expected to follow the established procedure. Young pilots were trained to speak up when it was time to speak up. It was Atul Gawande’s system15 years pre-Gawande.

Some hospital systems have many crashes too: C. diff infections, hospital-acquired pressure ulcers, wrong-side surgeries, “never” events.

When a safety questionnaire that measured the teamwork climate was administered to ORs and inpatient service, the higher teamwork scores correlated with lower rates for hospitalacquired C. diff rate, and hospital-acquired pressure ulcers. Those facilities that scored high on teamwork had a rate of HAPU of 0.4 per year vs. a rate of 2.9 per year for those scoring low. For never events, one every ten months in those facilities scoring the lowest (under 60) and one every 32 months where teamwork was highly rated.

There is some concern that standardization and adoption of best practices conflicts with personal autonomy; some have suggested that this can lead to a decrease in physician satisfac-

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tion. By why wouldn’t we think a little differently about this? Why wouldn’t we be more satisfied with better outcomes that result when we function as a team, when we rely on those around us to help us be successful and keep us from failing, when we use a checklist, when we wash our hands, etc.?

Sure, it may take a little longer to wash and gown up before putting in that line, visiting the patient one last time, sewing up that laceration.

There are shortcuts we can take everywhere, but the question we need to ask is, “Who will pay the price?” Yes, we do pay the price of time. But if we don’t, then the patient may have to pay the price, and it could be a steep price indeed.

And ultimately, if too many patients pay the price, then we as medical professionals will pay the ultimate price of poor quality medicine.

So what does this all have to do with consistency? And, what is consistency? Per dictionary. com, among several definitions are these: — steadfast adherence to the same principles, course, form, etc.

— agreement, harmony, or compatibility, especially correspondence or uniformity among the parts of a complex thing.

Medical professionals make up a complex organization to provide a complex service to patients. If we are consistent, we will communicate with each other in a uniform manner, we will agree on how best to care for the patient and we will stick together. We will consistently do the right thing whether it be patient-centric scheduling, making sure our patients get all their cancer screenings, or helping a colleague who asks for our assistance.

We will consistently track our own performance looking for ways to improve our patient care, and we will share best practices that we have adopted and adopt best practices others have developed. We will consistently rely on others to help us do the right thing for the patient, acknowledging that we can all help one another to succeed, and that the chances of failure become greater when we attempt to do it alone. andrew.klonecke@kp.org

A Posit Question on Doctors’ Pay BACKGROUND: On August 12, 2011, the American Academy of Family Physicians announced “a lawsuit filed by six primary care physicians in Georgia that seeks to terminate the current relationship between CMS and the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, as a step toward achieving a more equitable payment system that accurately reflects the value of primary care physician services.” Website: http://www.aafp. org/online/en/home/publications/news/news-now/ government-medicine/20110812ruclawsuit.html Currently, the RUC has 29 members, 23 of whom come from medical specialty societies, and acts as an expert panel making recommendations on the relative values of various CPT codes. The panel deliberates behind closed doors with little transparency. Over the last 20 years, CMS has accepted 94 percent of the RUC’s recommendations. [Reference: see Dr. George Meyer’s article in the Sept/Oct SSVM.] The lawsuit seeks to have the RUC declared a Federal Advisory Committee, which would force officials to open up the RUC’s proceedings and records to the public. In addition, the lawsuit attempts to stop the implementation of the 2012 Physician Fee Schedule, claiming it discriminates against primary care services.

QUESTION: Do you think specialty services are overvalued relative to primary care services?

Responses: Yes, 52 / No, 13. Seventeen comments follow: __________________________ A sharper dichotomy would be between compensation for thinking and compensation for doing. Thinking/reasoning/educating are

vastly undervalued. And so long as CMS disproportionately rewards the performance of procedures, they will be done in excess, continuing to drive up the cost of healthcare for everyone.

— Howard Slyter, MD The problem is not if specialty or primary care is over or underpaid. The issue is providers are underpaid and the RUC is a mechanism to balance a budget. The AMA represents only about 35 percent of physicians, and I do not feel they really represent the other 65 percent. The goals of transparency and representation are laudable! — J. Dale Smith, MD Value should be based on number of years of training, degree of expertise, experience, and other agreed-upon criteria. — Alton Curtis, MD There is no question that primary care physicians are severely undervalued relative to specialists and that the RVRBS is directly contributing to the demise of primary care, especially internal medicine. The US will soon face a future without internal medicine physicians. Meanwhile, in many areas in the US, specialists now earn ten times what primary care physicians earn. The PPRC and the RBRVS were supposed to correct this inequity. Instead it has made it much worse. — Michael Patmas, MD …both services are undervalued and [the] system should be more transparent. — William Bommer, MD I would say that preventative care and the medical management of conditions is grossly undervalued. Procedures are definitely overvalued. Procedures lead to money. Counseling and discussion and advice lead to little money. I think that primary care needs to be rewarded more than it is today; by how much I can’t say. Since there is a finite amount of money available, if one area has increased reimburse-

November/December 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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…Society has to decide whether primary care is of greater importance/ value than tertiary care.

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ment, another area has to suffer decreased reimbursement. … Society has to decide whether primary care is of greater importance/value than tertiary care. Society hasn’t done this. Based on reimbursement rates, the government and the medical profession have already done so. They obviously feel that tertiary care is of greater importance than primary care. A total hip is of greater value than managing hypertension, etc. I should state that I’m a primary care (pediatrician) physician. — Maynard Johnston, MD The most critical problem is that there is no mechanism for routinely reassessing how many minutes of physician effort are necessary to provide a specific service, and thereby routinely re-evaluating the RVUs assigned to that service.

Many specialty services, such as CT scans and colonoscopies, are overcompensated simply because physician productivity has improved and a productive physician can provide the same (or better) service in less time than was necessary a decade ago. We need a transparent and equitable process that routinely captures these gains in efficiency and productivity, for the benefit of the entire economy. Thanks to barriers to entry, ineffective competition, asymmetric information, and regulated pricing (in which the RUC plays a major role), health care is virtually the only sector of the economy in which improved efficiency and productivity do not lead to lower prices. — Patrick Romano, MD, MPH I would also like to see Psychiatry and OBGYN acknowledged as primary care. — Christopher White, MS IV Taking away money from specialists will not help primary care; better to get more money overall for medicine. — Christian Serdahl, MD “Equitable”?!? Let’s be honest. This is just one specialty desiring a larger slice of a pie (that was initially cut unfairly with FP’s initial approval) that is quickly shrinking. — John Tucker, MD Why is this controversial? It is a fact that in countries where there is no great disparity between what surgeons and family practitioners earn, such as Russia, − surprise! − there are more female surgeons than male, and no shortage of family practitioners. You cannot blame our smarter medical students when they see the Sierra Sacramento Valley Medicine

longer hours, lower earnings and greater difficulty in keeping up-to-date, why they eschew family practice − that’s why they’re smarter! — Geoffrey Woo-Ming, MD CMS, under Congressional approval, should allow primary care physicians to have their own global budget for Medicare fees, apart from the budget for all other physicians, thereby dividing the SGR calculation into two segments. Using this approach, Medicare should establish parity reimbursement for PCPs compared with the weighted average reimbursement of all other specialties combined. Primary care medicine will not flourish without parity reimbursement.

— Gerald Rogan, MD Particularly for surgical services, because the payment is “global” and all post-operative care is included, the per-hour rate I believe is lower than for office-based services. Plus we have the onus in plastic surgery of having to “prove” medical necessity practically each and every time, so that payment is delayed by “appeals,” which increases cost and further dilutes reimbursement. — Debra Johnson, MD But no matter what the change for the better or worse, [it’s] too late for us doctors in [our] late 50s and beyond. — Pau Fong, MD I’m embarrassed about how little my Internist gets paid from my insurance which is Medicare. — Peter Carruth, MD The highest value health care systems, when thought of as a pyramid, invest in the base, [consisting of] a strong primary care system focused on wellness and prevention. Our pyramid is upside down, where high-cost, technologically-advanced, illness-centric services predominate; changing the RUC is a promising step to right that pyramid. — Adam Dougherty, MSII The problem is not the relative value; the problem is that all reimbursement is too low and is decreasing. As a retired medical provider who is now a Medicare consumer, I am seeing reimbursement drop from 1/3 of billing to 1/5 of billing. I also hear from friends that care is becoming more difficult to obtain (e.g. the Mayo Clinic is not accepting Medicare patients). People value the outstanding medical care that is available in our country. Lawsuits and a major publicity campaign

Glennah Trochet, MD, Retires as Health Officer

By Bill Sandberg, Executive Director GLENNAH TROCHET, MD, SACRAMENTO County’s Public Health Officer, retired in September. She worked for the county for 22 years. Her first positions were with the county clinics as a treating physician and later as the medical director of the clinics. She served as Public Health Officer for 12 years. A search is on for her replacement. After some time off, she will become the Medical Director of the Midtown Medical Center, a clinic that serves low income families.

Throughout her service as Public Health Officer, Dr. Trochet distinguished herself in Sacramento as a dedicated physician and public servant. Over the years she developed a very productive and trusted relationship with the news media and used that relationship to keep the public informed on a broad range of public health issues including blood-borne diseases, sexually-transmitted diseases, whooping cough and other childhood vaccinations, tuberculosis, obesity, West Nile Virus, rabies, alleged cancer clusters and public health issues surrounding the September 11, 2001 attacks and the resulting fear over bio-terrorism.

Dr. Trochet met regularly with the Board of Directors, the Public and Environmental Health Committee, the Emergency Care Committee

and the Child and Adolescent Health Services Committee of the Sierra Sacramento Valley Medical Society.

Much of the admiration and respect she earned came from her efforts to encourage the Sacramento County Board of Supervisors to approve a trial program of allowing the sale of a limited number of syringes to individuals through pharmacies who volunteered to participate. The statewide program, which was included in the passage of enabling legislation, was intended to prevent the spread of blood-borne diseases by intravenous drug users. Despite the support of the Diabetes Foundation, the Dental Society, the Medical Society, BloodSource, UCD Medical Center and dozens of other community organizations, the necessary votes to pass the measure were not there. However, Dr. Trochet was successful in securing a positive vote for implementation by the City of Sacramento.

With the recession, Dr. Trochet saw her budget cut drastically, and year after year she saw the decline of the preventative health programs.

SSVMS, at deadline, was planning a special reception in her honor. bsandberg@ssvms.org

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

continued from page 26 need to focus on increased reimbursement for all practicing physicians. Infighting for shrinking dollars is self-defeating. Are we divided and conquered? Or not? We do have a choice. —

Richard Park, MD Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors.

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Dr. Marijuana Inc. is IN

By Jesse Oehler

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.

IT IS A LAID-BACK CALIFORNIA coastal town like so many others. A slight ocean breeze of optimal temperature soothes the bronzed, sun-soaked skin of easy-going locals who play beneath 300-plus annual days of sunshine. As California’s great coastal route eases into one of the city’s main thoroughfares, the diverse signs of the California lifestyle become apparent.

Businesses buzz with activity: a pet shop, a local eatery, a hardware store and a discount clothes outlet. Day laborers linger outside the local lumberyard, hoping today will bring work for cash. Young surfers, surfboards saddled aside classic beach cruisers, head eagerly west toward that elusive perfect wave. A homeless man, a drifter and a drug addict occupy their respective corners, confident in the charitable natures of passersby and daily commuters.

Upon arrival in this vibrant community, it is easy to miss a small white house with green trim just off the freeway. It is an unimposing structure, invisible to many who pass by every day. But for a steadily increasing number of patrons, and for the culture of California — ever a national trendsetter, this little business office reflects one of the most fundamental changes in law and attitude in decades. For a year I was office manager of this California Medical Marijuana Clinic.

In 1996 the state of California passed proposition 215, otherwise known as the Compassionate Use Act of 1996. It used simple, straightforward text, to “ensure that seriously ill Californians have the right to obtain and use marijuana for medical purposes where that medical use ... has been recommended by a physician who has determined that the person’s health would benefit form the use of marijuana in the treatment of cancer, anorexia, AIDS ... and other illnesses for which marijuana

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provides relief.”

The ambiguous law permits a physician to provide “oral or written approval or recommendations” for the use of medical marijuana; the physician would not be punished for doing so, so long as no other laws were violated.

At first Federal agents routinely busted up medical marijuana operations, claiming that California was in direct violation of federal law, despite the 10th amendment, which provides that powers not granted to the Federal Government or prohibited to the states by the Constitution are reserved, respectively, to the states or the people.

Citizens had a range of emotions, ranging from outrage to relief; most were confused as to the exact definitions and limitations of the use, obtainment and prescription of marijuana. The Compassionate Use Act, Senate Bill 420, was passed into law in California in 2003 to address these problems. Its overall effect was to clarify and to better define the parameters of proposition 215. The bill authorized a voluntary state I.D. card program, and a uniform procedure for issuing medical marijuana recommendations.

The office where I worked was owned by a businessman and a doctor, neither of whom I met during my entire stint as an employee there.

All business between my employers and me was conducted via phone and email. In this way I was hired, paid and instructed in my work. The doctor hired a physician’s assistant to perform evaluations of patients and to justify or deny the marijuana recommendation.

I was provided a stamp to reproduce the doctor’s signature at the bottom of the recommendation letter, before we sent clients off to a marijuana dispensary we worked with closely. When questions were later raised regarding use of a stamp, a local doctor was hired to come once a week and pre-sign 100 or so

blank letter templates. The next week the same doctor reviewed the recommendation letters that had been produced and signed the next 100 templates. After her review, all patient documents were scanned and uploaded to the computer, and the hard copies were destroyed. I deposited income in a bank account.

The owners were opening new offices at a fast rate. In the time that I worked for them they opened two more nearby offices. It was rumored that they would be moving on to Colorado shortly, following the legalization there. The fee for our service was $100, but was not charged if the client did not receive a recommendation letter.

During my year I only saw two patients denied recommendation; one had made the mistake of saying he suffered from bi-polar disorder, and the other said that she was schizophrenic. In neither case is marijuana advised.

(But clients were often alerted by literature online, or word of mouth, not to divulge this sort of information during their evaluation.)

I was paid a $1-per-patient bonus on top of my normal generous rate of pay. I would often make $20 in bonuses during the business day from noon to 6 pm Monday-Saturday. Similarly, the physician’s assistant was paid a $15 bonus for each successful recommendation.

My routine at work was simple. I had a laptop, a printer and a scanner. I would open the office, and let patients in (there would almost always be a line outside the door to start the day). The waiting area was one large room with the physician’s assistant’s office off to one side.

I would take a copy of the patient’s California I.D., the first and most basic requirement for consideration for medical marijuana “prescriptions.” I would present the patient with a generic form for information such as name, phone number, medications taken, and what the patient’s complaint was. Much information, such as address and email was not filled out, nor did we require it.

The patient was then ushered in to the physician assistant’s office for evaluation while I would prepare the recommendation letter.

This was an official-looking document that had a physician’s statement describing benefits possibly attributable to marijuana, and recommending its use in this client/patient. The I.D. was scanned and copied to the form. At the bottom were a line for the doctor’s signature and a line for the patient to sign. Lastly, a pressure embossed seal was placed at the bottom of the letter, which would be ready for the patient’s signature about 10 minutes into their evaluation.

There was an expectation that all patients would be given a recommendation. In the rare case that a patient was denied, their physician’s review sheet would be filed away as incomplete, and their letter would be shredded. Whenever there was a denial, a call would invariably come from the boss in Southern California with an inquiry as to why this patient had not been given a letter.

After the patient exited the practitioner’s office, I would take their $100 and give them their letter with directions to the nearest marijuana dispensary. I would then log on to an official online medical marijuana patient database, and enter in the information of each patient who had been issued a recommendation. Each patient had an identification number, and each letter displayed a phone number and a website by which one could confirm the legitimacy of the recommendation letter. Marijuana dispensaries throughout California could confirm the client identity or the validity and term of the “prescription” via the website, or by calling our office. We provided one-year recommendations, with 1/2 off for patients who renewed at our office.

Police officers could also call or go online to verify the certificate, or could call our office. The complete database was only accessible to our doctors, the owners and me. It was not made public, and could not be seen by government agencies or police.

Our patient base was very broad, and to say the least, the terms “seriously ill,” and “chronic pain,” qualifying conditions outlined in the medical marijuana legislations, were very broadly interpreted. Patients came from

November/December 2011

The author, Jesse Oehler, graduated from college and found no job until he placed a resume online and was hired to manage this “clinic.”

He did so for almost a year until moving to South Dakota.

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The CMA, California’s largest doctors’ group, in October adopted the Lyman committee recommendations favoring marijuana legalization.

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all walks of life, and with all kinds of conditions. Government workers, drifters, parolees, gang members, drug dealers and grandmothers would all come for our service. There were men and women of every race, age and condition. Parents came in with 16-year-old children where both parent and child received recommendation letters — the parents would sign for the children. If a patient had an I.D. or suitable proof of California residency, they were most of the way to legalized marijuana.

In my experience the most common patron was a 20-something with “back pain” or “headaches.” We required very little evidence of a patient’s condition, and sometimes none at all.

A bottle of prescription pills, an X-ray report, or a handwritten note from a doctor sufficed.

I have mixed feelings about my involvement in the medical marijuana industry. At times I felt very good about helping patients who were clearly sick or in pain. These sometimes were people with AIDS, cancer, or M.S. These patients would have tears in their eyes that peered at us from behind stacks of medical records, as they expressed their gratitude that we could provide this service to them, thankful for medicine allowing them to sleep, to stomach food, and to be able to focus on something other than their pain or other disease symptoms.

I felt dirty when a pack of 21-year-olds came in, 10 strong, having just made a two-hour road trip from another city, all with “headaches,” “knee pain,” “insomnia,” and “intense back pain.” As they emerged triumphantly from the evaluation and waited for their friends, some would make calls, joyfully informing them that “Yes! It really works; can you make it down here? “ What I have written here is not an exposé; it is simply an attempt to describe a small part of the process where marijuana, like alcohol and tobacco, becomes an industry. Don’t imagine this was a poorly-run business. We always followed the letter of the law exactly, because the California medical marijuana industry is

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operated for profit, where foolish management leads to business failure.

I have no strong opinions about how our business was conducted, because it was all done within the confines of the law. I felt saddened when I saw people abuse the law, but I have no illusions; this happens whenever laws are made. It seems to me that if marijuana were legalized, competition would lower prices, tax revenue would increase, and perhaps crime and abuse of the law would diminish. But that will be decided by the people of California, as it should be. jptoehler@yahoo.com Editor’s comments: 1) An online search reveals over 100 local marijuana dispensaries and grower clubs in Sacramento County, and spotted on Watt Avenue recently was a human moving sign proclaiming “Marijuana Prescriptions Available Here.” (A prescription, of course, would provide for a specific drug, a dose, a quantity, and instructions for use; it would be filled by a pharmacist. By contrast, a marijuana buyer’s certificate allows the purchase of an undefined dose, in an unspecified quantity, of an unnamed species or modification of a marijuana species, from any dispensary allowed to provide it. 2) Sacramento County has been considering marijuana regulations. While proposing to control dispensaries, the proposal also legalizes production, keeping it indoors and away from public view. 3) An ad hoc CMA committee chaired

by SSVMS member Donald O. Lyman, MD, suggests, in part: • “Reschedule” medical cannabis in order to encourage research leading to responsible regulation.

• Regulate recreational cannabis in a manner similar to alcohol and tobacco.

• Tax cannabis.

• Facilitate dissemination of risks and benefits of cannabis use.

• Refer for national action.

Staff Interviews continued from page 11 ED: I don’t know how to answer that question.

JD: That’s interesting.

SM: There are some studies that show that some students in that middle income bracket don’t feel they can handle loans and are more likely to just enter the workforce.

CR: 20 years ago a student who was 30 — they were going to be married with a family.

That’s different than today.

SM: We used to have an average entering age of 27 or 28. Now we’re down to...

ED: 24.

DG: And has that also happened over the same time period?

SM: Yeah. And having all of these young kids impacts services, expectations. They’re not grownups yet.

ED: They’re applying in droves. We’re getting fewer of the older applications. They don’t want to leave the workforce for the pre-med requirements, medical school, not to mention residency.

JD: I’m going to go way back to the 60s and 70s and talk about community involvement. This school was founded on that premise, because of a shortage of physicians. Irvine, San Diego, Davis. We attracted students and admitted students based on that charge. But, the students who came to us were activists about health care. They were active, started the free clinics, and that tradition has been strong our entire history.

SM: Davis has always reached out to disadvantaged populations.

JD: As you know with the Bakke decision.

[Regents of the University of California v. Allan Bakke, 1978]. We were really trying to get underrepresented minorities.

ED: And that still springs up occasionally.

JD: On financing, I think that’s one of the

most critical problems that we have right now with our students. It used to be that you could go to medical school for a reasonable amount of money. It used to be a great deal. It’s not a great deal anymore. And we don’t have endowments and scholarships equivalent to places like UCSF. We need scholarships. We need money.

CR: They’re leaving with such debt that they look at specialty care. $200,000 worth of debt!

ED: We’ve gotten to the point, though, where even the amount of scholarships we offer them doesn’t make a difference anymore. We’re all equal now, as far as the cost of education.

In terms of holding, attracting and recruiting applicants, we’ve increased our scholarships this year, and a lot of students aren’t biting.

SM: A $20,000 scholarship plus $13,000 in grants isn’t going to do it. I want more.

ED: We don’t know what the other schools are offering them, but even though we could never offer these amounts in the past, it’s not doing the trick.

DG: What is the total cost of attendance?

SM: In-state, including housing, is just under $57,000. It’s an additional $12,000 for out-ofstate. Over the last few years I hear students say, “Why would I come to Davis? I can get this somewhere else.” I don’t have much to say that can convince them, other than, “Do you want to stay in California? Go wherever you think you’re going to fit best.” If you’re trying to do it based on money, you don’t do a UC, or at least you don’t do Davis. We can’t come close; you’re going to have major debt. That’s impacting which students we get.

ED: They’ll stick with the name-brand school.

DG: Thanks everyone for the great conversation.

It used to be that you could go to medical school for a reasonable amount of money. It used to be a great deal.

It’s not a great deal anymore.

dgunn11235@gmail.com

November/December 2011

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In Memoriam

Patrick C. Dietler, Jr., MD 1923-2011

On August 1, 2011, I said goodbye to my longtime friend Pat Dietler. Pat and I started our private surgical practices the same year. We have been friends and colleagues for over 50 years.

Born in Butte, Montana in 1923, Pat was raised in southern California. He obtained his BA from Fresno State University in only three years, while working to pay his expenses and playing on the football team. Following graduation, Pat went on to medical school at George Washington University in Washington D.C. After earning his MD Degree in 1948, Pat returned to southern California for his internship at Los Angeles County Hospital (1948-49), before heading back to George Washington University for his surgical residency (1949-53).

He then fulfilled his military duty while serving as Chief of General Surgery at Fort MacDill Air Force Base in Tampa, Florida. In 1955, Pat and his young family returned to California, this time settling in Sacramento, where Pat began his surgical career.

Dr. John Tupper, founding Dean of UC Davis School of Medicine, and Dr. Earl Wolfman, founding chair of the Department of Surgery, asked Pat and me to teach at the newly-started UC Davis School of Medicine. As assistant clinical professors of medicine, we spent many late nights honing our skills in the basement lab and mentoring residents.

During his distinguished surgical career, Pat served as Chief of Surgery at Mercy and Sutter Hospitals, Staff President of Mercy Hospital, and President of the Sacramento Surgical Society. He was also certified by the American Board of Surgery.

Pat and his wife, Dolores, traveled exten-

sively. Since Dolores was in charge of their packed social calendar, they regularly attended operas, symphonies, and art exhibitions. Pat enjoyed working in his garden, especially tending to his prized roses, and following Notre Dame sports.

An avid golfer, Pat insisted on carrying his own golf clubs for 18 holes until he was 80 years old. After a round of golf, Pat always ordered a chocolate milkshake in lieu of a beer.

Dr. Pat Dietler died on August 1, 2011, just short of his 88th birthday. He is survived by his loving wife, Dolores, his two sons, Michael (Ingrid) and Tom (Mary), his brother, John, and his two grandchildren, Andy and Kelly.

Patrick C. Dietler, Jr., MD — Robert B. Harris, MD

Editor’s Note: Dr. Patrick Dietler’s numerous honors included being elected to the SmithReed-Russell Medical Honor Society in 1948, and becoming a Life Member of the American Medical Society of Vienna in 1980.

Touching tributes posted in the online funeral guestbook tell of gratitude and admiration from former patients who were helped

by Dr. Dietler’s surgical efforts many years ago and who are going strong today. The last one perhaps sums it up: “Fifty years ago, Dr. Dietler gave me a second chance in life by performing a difficult liver damage surgery when I was seven. He has truly been an Angel in my life, as I’m sure in many others.” — Rod Rodriguez, Roseville, CA

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Board Briefs September 12, 2011 The Board: President, Alicia Abels, MD, introduced the new executive director, Aileen Wetzel, to the Board members. Ms. Wetzel will begin her new position with SSVMS on November 1 and will officially assume the executive director position following Bill Sandberg’s retirement on December 31, 2011.

Requested a letter be sent to UCDMC requesting assistance in resolving the difficulty physicians in the community are experiencing in referring patients to UCD who have presented with an unusual condition that would make an excellent teaching case for the University.

Serving as the Administrative Board to the Community Service, Education and Research Fund (CSERF), the Board received an annual update from Kris Wallach, Project Manager.

CSERF is a non-profit, 501 (c) (3) organization established by the Medical Society as a vehicle to involve physicians and the larger healthcare community in community services, education, and research. The primary programs are the SPIRIT Project, the William E. Dochterman Medical Student Scholarship Fund and the Sierra Sacramento Valley Museum of Medical History.

Approved the Second Quarter 2011 Financial Statements and Investment Reports.

Approved the recommendation from the Scholarship and Awards Committee to provide grants from the William E. Dochterman Medical Student Scholarship Fund to the following medical students: Kellen T. Galster, Andrea L. Nos, Daniel C. O’Brien, Erin N. Platter.

Approved the endorsement of Richard Thorp, MD, 11th District CMA Trustee, as a candidate for 2012 CMA President-Elect.

Approved the following appointments to the SSVMS Delegation to the CMA representing

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Sierra Sacramento Valley Medicine

District 3: Katherine Gillogley, MD, Delegate, and Ruenell Adams, MD, Alternate-Delegate.

Extended appreciation to Stephen Melcher, MD, for facilitating discussion among the Emergency Care Committee and the representatives from the local psychiatric facilities, which led to the development of the document, Comparative Acceptable Admission Criteria for Local Psychiatric Facilities. The goal of this coordinated effort was to develop an at-a-glance document for hospital staff to reference and to see comparatively what each facility requires prior to admission. This will save both time and costs by eliminating unnecessary labs and the need to obtain additional labs when the patient is transferred to a psychiatric facility from the emergency room.

Received notification that John Loofbourow, MD, will be retiring from his position as Editor of Sierra Sacramento Valley Medicine at the end of the year. Nate Hitzeman, MD, has agreed to replace him and chair the Editorial Committee.

Ann Gerhardt, MD, will serve as vice chair.

The Board extended its appreciation to Dr. Loofbourow for his years of service as Editor.

Approved the Membership Report For Active Membership — Asma Azhar, DO; Ritu Bhatnagar, MD; Leo L. Chen, MD; John F. Coleman, MD; Kapil Dhawan, MD; Vishal S. Doctor, MD; Christine Bl Doherty, MD; Sean D. Doherty, MD; Cassie L. Durawa, MD; Andrew D. Giem, MD; Jaspaul, S. Gogia, MD; David B. Honeychurch, MD; Frank Hung, MD; Parisa Kashkouli, MD; Seema M. Khan, MD; Jason H. Kim, MD; Paul S. Kwon, MD; Lei Li, MD; Sara P. Modjtahedi, MD; Dennis H. Nguyen, MD; Nhan T. T. Nguyen, MD; Jaclyn K. Pasko, MD; Katrina U. Reyes, MD; Archan M. Shah, MD; Heather L. Tiska, MD; Angelique C. Tjen-A-Looi, MD; Luca U. Trento, MD; Summer R. Youker, MD; Leanne L. Zhang, MD. For Resident Membership — Elizabeth P.

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

Azhar, Asma, Family Medicine, WUHS, College of Osteopathic Medicine 2004, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 973-5243 Bayati, Reza, Internal Medicine, Tehran University 1988, Elite Medical Specialty Clinic, 8863 Greenback Ln #208, Orangevale 95662 (916) 626-4838 Chen, Leo L., Neurology, University of Michigan 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5175 Constantinescu, Octav C., Anesthesiology/Pain Medicine, UC Los Angeles 2007, UCDMC, 4860 Y St #3020, Sacramento 95817 (916) 734-6824 (Resident Member) Copenhaver, David J., Anesthesiology/Pain Medicine, UC Los Angeles 2005, UCDMC, 4860 Y St #3020, Sacramento 95817 (916) 734-6824 Doctor, Vishal S., Otolaryngology, University of Southern California 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322 Durawa, Cassie L., Emergency Medicine, State University of New York-Buffalo 2008, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000 Fitzgibbons, Lynn N., Infectious Disease, UC San Diego 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Giem, Andrew D., Urology, Loma Linda University 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5355 Gogia, Jaspaul S., Orthopedic/Spine Surgery, UC San Francisco 2005, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000

Hung, Frank, Family Medicine, Medical College of Wisconsin 2008, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5100 Kashkouli, Parisa, Internal Medicine, Drexel University 2006, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-7506 Kim, Jason H., Otolaryngology, New York University 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322 Kinnucan, Elspeth R.E., Orthopedic/Hand Surgery, New York University 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Kobalter, Kris F., OB-GYN, UC San Francisco 1989, Tahoe Women’s Care, 1067 – 4th St, South Lake Tahoe 96150 (530) 543-5710 Modjtahedi, Sara P., Ophthalmology/Vitreo-Retinal, UC Los Angeles 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015 Mohammed, Imran, Pulmonary/Critical Care Medicine, Stanley Medical College, India 2000, Pulmonary Medicine Associates, 3637 Mission Ave #7, Carmichael 95608 (916) 482-7623 Pasko, Jaclyn K., Pediatrics, UC Davis 2008, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000 Rubinstein, Brian K., Otolaryngology, Finch University of Health Sciences/The Chicago 1996, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5880 Salazar, Suzette A., Internal Medicine, University of Santo Tomas, Philippines 2001, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040

Schweissinger, Daniel L., Anesthesiology, The Royal College of Surgeons, Ireland 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Shah, Archan M., Pulmonary/Critical Care Medicine, Mahatma Gandhi/Mumbai University, India 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Stayner, Richard S., Anesthesiology/Pain Medicine, University of Minnesota 2007, UCDMC, 4860 Y St #3020, Sacramento 95817 (916) 734-6824 (Resident Member) Wang, Jonathan C., Radiology/MRI, UC San Francisco 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Wongngamnit, Narin, Psychiatry/Addiction/Pain Medicine, Indiana University 2006, UCDMC, 4860 Y St #3020, Sacramento 95817 (916) 734-6824 (Resident Member) Xu, Weimin, Family Medicine, Sun Yat-Sen University, China 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Youker, Summer R., Dermatology/Mohs Micrographic Surgery, University of Texas Health Science 1998, 2805 J St #100, Sacramento 95816 (916) 492-1828 Young, Douglas G., Internal Medicine, Washington University 1990, 3840 Watt Ave #E, Sacramento 95821 (916) 488-6200 Young, Ryan, Anesthesiology/Pain Medicine, University of Southern California 2006, UCDMC, 4860 Y St #3020, Sacramento 95817 (916) 734-6824 (Resident Member) Youssefi, Rod R., Pain Management/Anesthesiology, Northwestern University 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6353

continued from page 34 Chase, MD; Ashby J. Wolfe, MD. For Reinstatement to Active Membership — Paulette J. Jenison, MD; Erin B. Marcin, MD; Voltaire V. Sambajon, MD; Lisa A. Swensson, MD; Rachel Weinreb, MD. For Retired Membership — Earl F. King, MD; Mark J. Zlotlow, MD.

For Resignation — Duva Appleman, MD (moved to Roseburg, Oregon); Anna A. Barber, MD (moved to Spokane, Washington); Susan S. Lin, MD (transferred to Placer-Nevada); Monique B. Ross, MD (transferred to AlamedaContra Costa).

November/December 2011

35

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