2012-May/Jun - SSV Medicine

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2012

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Medicine 3

PRESIDENT’S MESSAGE Moving Forward

David Herbert, MD

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e.Letters to SSV Medicine

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Spitting, Today and Yesterday

Irma West, MD, MPH

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A Posit on Sugar-Sweetened Beverages

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Why Join SSVMS/CMA?

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The SPIRIT Program

Aileen Wetzel, Executive Director

Elizabeth Zima, Staff Writer at CMA

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BOOK REVIEW Blessings of a Faithful Man

by Michael L. Carl, MD

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“Huffing” Freon: A Risky Youth Behavior

Marcelina Jasmine Silva, MS IV

Reviewed by John Loofbourow, MD

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What’s Hot and What’s Not? Early Electro-Thermotherapy

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Many Challenges in Public Health Care

Kent M. Perryman, PhD

Glennah Trochet, MD

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Board Briefs

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Health Reform in 2012 – Crunch Time, Part One

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Meet the Applicants

Adam Dougherty, MPH, MS II

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AMA Foundation Honors SSVMS Member

IN MEMORIAM James O. Farley, MD

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IN MEMORIAM Edward A. Smeloff, MD

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Classified ads

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Vaccine Protection

Assemblymember Richard Pan, MD, MPH

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“Is There a Doctor on the Plane?”

Marion Leff, MD

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

Authors will be able to review articles before publication.

Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.

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

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/magazine.asp The cover photo for this issue was provided by Dr. John Doolittle, a Family Medicine physician for Sutter Medical Group practicing in Roseville, CA. Dr. Doolittle is an avid underwater photographer in his spare time. This photo is of a Spotted Cleaner Shrimp (Periclimenes Yucatanicus) taken off the coast of Bonaire in the Caribbean.

Volume 63/Number 3 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

May/June 2012

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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:

2012 Officers & Board of Directors David Herbert, MD President Demetrios Simopoulos, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD, Secretary District 2 Jose Arevalo, MD Ann Gerhardt, MD Lorenzo Rossaro, MD District 3 Bhaskara Reddy, MD, Treasurer District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristin Robinson, MD District 6 J. Dale Smith, MD

mmended By re Doctors.

2012 CMA Delegation Delegates Alternate-Delegates District 1 District 1 Robert Kahle, MD Reinhart Hilzinger, MD District 2 District 2 Lydia Wytrzes, MD Margaret Parsons, MD District 3 District 3 Katherine Gillogley, MD Ruenell Adams, MD District 4 District 4 Earl Washburn, MD Russell Jacoby, MD District 5 District 5 Elisabeth Mathew, MD Anthony Russell, MD District 6 District 6 Marcia Gollober, MD Karen Hopp, MD At-Large At-Large Alicia Abels, MD Robert Forster, MD Richard Gray, MD Maynard Johnston, MD David Herbert, MD Alexis Lieser, MD Richard Jones, MD Robert Madrigal, MD Norman Label, MD Rajan Merchant, MD Charles McDonnell, MD Richard Pan, MD, Janet O’Brien, MD Assemblyman Kuldip Sandhu, MD Vacant Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD Vacant CMA Trustees 11th District Richard Thorp, MD Barbara Arnold, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

Urgent care, full-time, partnership We are seeking a board certified FP, IM, or EM trained physician who is interested in long-term stability and partnership.

The Doctors Center is an urgent care office in Fair Oaks with extended hours. We are a singlelocation practice and have a close relationship with physicians in our community.

We see a wide variety of interesting patients and procedures typical for urgent care. We are almost fully electronic in our charting and billing, and all records are complete by the time the patient leaves our office (no after-hours charting).

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287

The Doctors Center Medical Group Inc.

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 Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair George Meyer, MD Sandra Hand, MD John Ostrich, MD Albert Kahane, MD Robert LaPerriere, MD Gerald Rogan, MD John Loofbourow, MD Gilbert Wright, MD Adam Dougherty, MS II John McCarthy, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel 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. ©2012 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

Moving Forward

By David Herbert, MD IN THESE TUMULTUOUS TIMES for health care, SSVMS must re-examine how it can serve our members and our community, taking the best from our successful past and adding new ideas and directions. The Board of Directors has discussed this at length, and has agreed that in addition to our traditional work, we should increase our focus on membership and volunteerism.

Membership Physician membership in SSVMS and CMA provides both the credibility and the resources that have enabled us to influence health policy.

This includes everything from influencing health care reform to our continued defense of MICRA, as well as CMA’s recent successful lawsuit to block further cuts in Medi-Cal payments. And it is clear that when we look at issues like these, physicians in various practice modes are more alike than different, and when we come together we have a stronger voice.

SSVMS is fortunate to have the support of most of the large practices in our community, as well as many of our solo and small group physicians. UC Davis Medical Group, Mercy Medical Group, Permanente Medical Group, Radiological Associates of Sacramento, Pulmonary Medical Associates, Sacramento Anesthesia, Woodland Clinic and Mercy Radiology all provide membership for interested physicians. (If you belong to one of these groups and are not an SSVMS member but would like to become one, just drop me a note!)

Still, we can do more, and we will be reaching out to non-members to better demonstrate why organized medicine is important to them.

Our members are our best recruiters, so do

discuss membership with your colleagues. If you know of opportunities for the medical society to make a presentation or have a discussion in your practice, just let us know!

Volunteerism Physicians have a long and admirable record of providing voluntary care. Few, if any, other professions have made such contributions to their communities! The need for such volunteer care will change if health care reform is enacted, but it will not go away. SSVMS’ tradition of volunteerism goes back to our founding in 1850 − we were incorporated in 1868, but have been in continuous operation since 1850 − when we helped victims of the epidemics of that time. SSVMS also helped establish the UC Davis School of Medicine and the BloodSource blood bank.

More recently SSVMS has sponsored and organized the SPIRIT program, which, through our physician and corporate volunteers, has provided over $8 million of care. The SPIRIT Program also coordinates physician volunteers for a number of other clinics. Our board has agreed that we should increase our efforts in this area by developing a comprehensive list of free clinics and a process to help willing physicians match their skills and available time with the needs of the clinics.

We also hope to be able to help the public find clinics that can serve their needs. We are quite interested in learning from our members how we can make this process most effective and helpful, so send us your ideas. dherbert@pol.net

May/June 2012

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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e.Letters to SSV Medicine To NG, or Not to NG a) I believe that Dr. Herbert’s column brings up some very important issues and is most informative about the frustrating decisions that face us not only as physicians, but as caregivers within our own families. Having faced this problem a number of years ago with my own mother, it resonated within me. It is circumstances such as this that made me ask “When did dying become illegal in New York?”, because my mother was not demented, but kept saying “It’s enough.” And when it was decided to subject her (age 88) to a feeding gastrostomy (with restraints), I had her signed out AMA and sent out of state to a skilled nursing facility wherein she died peacefully three weeks later. b) As a corollary, it is a reminder of J. Englebert Dunphy’s aphorism when he chaired the Dept. of Surgery at UCSF and was quoted as saying, “Our role as physicians is to prolong living, not to prolong dying.”

Thanks, David.

Al Kahane, MD ajmdkx2@yahoo.com

Is it Time to Tax Soda?

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.

Dear Adam Dougherty, Thank you for your very interesting and informative article, “Is it Time to Tax Soda?” A tax on the poor’s food may seem like a regressive tax and be unpopular. Is there another way to reach the goal of helping people choose healthier foods?

Would it be possible and more popular to tax soda and use the money to subsidize locallygrown fruits and vegetables so there would be no net increase in the cost of food, but there would be a decrease in health care costs due to less obesity and diabetes?

I wish I were made aware of issues and

Sierra Sacramento Valley Medicine

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legislation before California’s Assembly and Senate, and before the U.S. Senate and Congress so that I might voice my opinion. I am aware of www.progressivesecretary.org, but perhaps you know of other sources of information that would be helpful in keeping [us] informed.

Thank you for your article, Sincerely, Bruce Burdick, MD bburdick@surewest.net

Thanks for the email. Yes, the “regressive tax” notion is a concern, and one that comes up with increasing tobacco taxes as well. In this case, the counter argument would be that using the revenue for lunch programs, or as you suggest, to directly lower the price of higher quality food (especially in lower income areas), would put that money right back into the community. I think that’s a great idea, one possibly even worth pursuing at the county level with groups like CCPHA. The food desert phenomenon is also an important challenge, where individuals in low-income communities can pass through miles of fast food restaurants and liquor stores without seeing a proper grocery store or fresh market. South Los Angeles recently passed an ordinance limiting the amount of chain restaurants per square mile, which is a step in the right direction and a good model.

As far as staying informed, I suggest signing up on the californiahealthline.org listserv as a good place to start. They are a project of CHCF. Health-access.org and itup.org are other great places to follow pending legislation in the state and receive alerts.

Best, Adam

Executive Director’s Message

Why Join SSVMS/CMA?

By Aileen Wetzel, Executive Director CONSIDER THIS — There is no other organization created for the sole purpose of representing the interests of all physicians. We’ve made it easy for you to join. Simply sign and mail the Teddy Roosevelt postcard inserted in this issue. We will work directly with your office to complete your membership application. Why join? With the CMA, SSVMS has fought for issues crucial to the practice of medicine, including: Protecting Medi-Cal Access • Stopped the proposed 10 percent cut to Medi-Cal reimbursement by suing the State of California.

• Stopped $137 million in Medi-Cal physician payment cuts for services provided to children.

Medicare Payment Reform • Stopped the 27.4 percent cut to physician Medicare reimbursement scheduled to occur in 2012.

• CMA/SSVMS continues to work with the Congressional Leadership to permanently repeal the Sustainable Growth Rate (SGR).

• Successfully lobbied the Centers for Medicare and Medicaid Services (CMS) to drop a proposal that would have reduced payments to California physicians by $150 million.

Budget Battles • Protected the Healthy Families program.

• Preserved $7.3 million to provide vaccines for low-income, uninsured Californians.

• Secured $4.4 million in additional funds to the Every Woman Counts breast and cervical cancer screening program.

• Prevented any diversion of the $55 million in Maddy Fund monies, which provide critical resources to reimburse physicians for uncompensated care provided in the ER. • Protected funding for the Emergency Medical Services Commission, which oversees planning for emergency services.

• Organized a large patient, provider and

health plan coalition, the Alliance for Patient Care, to ensure that key healthcare programs were not cut out of the state budget.

Health Care Reform • SSVMS/CMA continues to work closely with CMS and HHS to ensure that efforts to implement federal health care reform are physician-led and patient-centered.

• Developed a reference piece for physicians on EHR implementation.

Protecting Physicians & Patients • Successfully stood in defense of California’s Medical Injury Compensation Reform Act (MICRA) before the 5th Appellate District Court, which upheld MICRA’s constitutionality.

• Successfully stopped bills that attempted to erode California’s ban on the corporate practice of medicine. SSVMS/CMA worked with community clinics and other stakeholders to stop AB 1360, an attempt by hospitals to directly employ physicians.

• Stopped several legislative attempts to expand the scope of practice of allied health professionals, including the following: - Blocked the implementation of new standards to certify optometrists to treat glaucoma by filing a lawsuit.

- Put on hold regulations limiting the ability of physicians to employ physical therapists.

- CMA continues to litigate its lawsuit against the State of California to stop the expansion of the scope of practice of nurse anesthetists.

• In 2011, CMA’s Center for Economic Services (CES) successfully recouped over $2.8 million from payors on behalf of member physicians.

• Filed a formal complaint with the Department of Managed Health Care regarding the Blue Cross Special Investigations Unit’s illegal recoupment policies.

Public Health • Recent victories include the Governor’s signcontinued on next page May/June 2012

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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Book Review

Blessings of a Faithful Man Author: Michael L. Carl, MD, Tate Publishing 2011, ISBN 978-1613467428

Reviewed by John Loofbourow, MD THIS IS AN INTIMATE, AUTOBIOGRAPHICAL work by an SSVMS colleague, Michael Carl, MD, an Emergency Medicine physician whose life has been marked by a series of life-altering events. With these events his Catholic faith first formed, then became the most significant aspect of both his personal and family experience.

It is a detailed and clear first-person story by a physician after a long, challenging, and varied life. His rather licentious and rebellious youth was followed by marriage, a very successful entrepreneurial plumbing business, and the first life-altering episode the young couple faced: a child with Tetralogy of Fallot. That not only introduced them to the Catholic faith, but planted in the author a desire to do more with his life.

Despite having no scientific or scholarly background, he — and they — began the long road to medical school and to an EM residency at UC Davis. It was a road, however, with huge obstacles. That remarkable journey, where personal life-threatening challenges continue to be encountered today, has not ended. He,

himself, was treated for cancer of the mouth during medical school. The book was written after Dr. Carl was back at work as an EM physician following treatment for lung cancer, and a subsequent brain metastasis.

The first-person details are the essence of his story. As I read, I was very much reminded of The Confessions of Augustine, published in about AD 397. Yet I think Dr. Carl’s message seems clearer and more genuine than Augustine’s 13 Books (Chapters). The language is clear and modern; it is unaltered by the miasmas of translations.

Carl is not a world-shaking Archbishop at the peak of power. Perhaps that’s why his voice seems more genuine than Augustine’s, though Mike Carl speaks in the relatively empty arena of a secular America. Augustine ends his tome with: Gratias Tibi Domini, Thanks be to Thee O God. That works for Mike Carl too: “ … this is a story that must be told for one reason only: because God told me to tell it.” (Prologue). john@loofbourow.com

Why Join SSVMS/CMA? continued from previous page 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.

ing of bills that allow individuals to purchase sterile syringes at pharmacies without a prescription; require health insurance policies to provide coverage for maternity services; prohibit minors from using tanning beds without parental consent; allow minors to get the HPV vaccine without parental consent; and prohibit the sale, manufacture or distribution of products containing BPA, if the product is intended for a child three years or under.

Your membership in SSVMS/CMA makes it possible for us to continue our advocacy efforts. Not a member? Simply sign and mail the postcard inserted in this issue, or contact the medical society at 916/452-2671 or info@ssvms. org. For more information on member benefits, visit us at www.ssvms.org or www.cmanet.org. Let me know how SSVMS/CMA can help you and your practice. awetzel@ssvms.org

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Sierra Sacramento Valley Medicine

Many Challenges in Public Health Care

By Glennah Trochet, MD MOST PHYSICIANS THINK OF Public Health as healthcare for the poor or uninsured. Although this is an important aspect, it is only one of the many responsibilities of local health officers in California. These are licensed physicians who are appointed by the local governing authority (58 county boards of supervisors and three city councils) and who must enforce laws and ordinances that protect public health. The Public Health Officer is the only physician in a jurisdiction who has police powers and can issue orders of isolation and quarantine.

In medical practice, we see patients individually. In public health our responsibility is to the community, not just to an individual patient. During the 20th century, a large part of public health responsibilities were related to containing the spread of communicable diseases. In California, there are over 80 diseases that are reportable to the health department.

Most of these are communicable diseases.

When there is a communicable disease threat, such as exposure to meningococcal meningitis, health department personnel rely on the private sector to provide post-exposure prophylaxis or evaluation and treatment services for their patients, while individuals who do not have health insurance or access to a physician have been treated in government-run clinics.

Although the responsibility for communicable disease control has not disappeared, in the 21st century chronic diseases will affect the health of the population to a much greater degree than previously. This is why public health practitioners have given so much attention to obesity prevention, active living, community planning and tobacco

control. It is important to note that public health practitioners cannot formulate policy without data, and the data is provided by all the medical practitioners who diagnose and treat patients, and fill out birth and death certificates and confidential morbidity reports.

I was Sacramento County Public Health Officer from 1999 until September 9, 2011.

This was the most rewarding and challenging position I have ever held. I had the privilege of working with a team of public health professionals who are unmatched in their expertise and dedication to our community.

The field of public health is so broad, that one can learn something new every day.

I enjoyed working with community-based organizations to bring about changes in behavior, in policies and in laws that would benefit health.

We had significant successes: decrease in tobacco use due to our Tobacco Control Coalition that has been working for the past 40 years to educate our community about tobacco, and to pass laws that prohibit smoking in restaurants, bars and in the workplace; effective response with law enforcement to widespread fear caused by the anthrax attacks of October, 2001; control of West Nile Virus by supporting the SacramentoYolo Mosquito Vector Control Agency’s efforts, and establishment of programs to access clean syringes in the City of Sacramento. We also face significant challenges: the STD rates in Sacramento County are among the highest in the state and the trend continues to go upward; infant mortality and maternal mortality may be increasing; we must do more to address the root causes of violence in our community.

The economic downturn of the past four

May/June 2012

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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County

years resulted in budget cuts at all levels of government. Because prevention services are not a priority for the Sacramento County Board of Supervisors, public health programs are the first to be cut and the last to be restored. Decisions made in 2008 about the clinic programs that serve the uninsured resulted in lawsuits and huge cost overruns that added to the county’s fiscal problems. As a result, there have been severe cuts to public health programs, most of which are now funded almost exclusively with state and federal money.

Sacramento County has several layers of management, beginning with the Board of Supervisors, which has a County Executive.

Then there are three agencies with their agency heads who report to the County Executive. The Department heads report to the agency heads.

So the divisions of Public Health and Primary Health are in the Department of Health and Human Services in the Countywide Services Agency.

Board of

Letter to the Supervisors

Because prevention services are not a priority for the Sacramento

Supervisors, public health programs are the first to be cut

Dear Members of the Board of Supervisors, This is my final communication to you as the County Health Officer. I know that what I have to say here may not be received well by upper management. I hope that you will protect the leadership and staff of the Division of Public Health from any retaliation that may come their way because of what I say here. Please be aware that this is my opinion alone and not that of anyone else. I make these recommendations after careful thought and based only on my experience of 22 years within the Department of Health and Human Services and my broad knowledge of medical issues as well as of public health.

The Department of Health and Human Services is an amalgamation of health programs

and the last to be restored.

Upon my departure in 2011, I sent a memorandum entitled “Public Health and the Organization and Leadership of the Department of Health and Human Services” to the Board of Supervisors. It accurately reflects my opinion of the current administration of the department and is reproduced below:

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and social services programs. The leadership of the department since its inception has been in the hands of individuals with no background, training or interest in public health matters. Over the years, these DHHS directors have appointed leadership in some health programs that also do not have the background, training or experience necessary to manage these health programs. As a result, you have received recommendations that were contrary to the best interests of the community or of the county, sometimes with catastrophic policy and fiscal results for all of us who live in Sacramento County.

Currently the Department of Health and Human Services is facing several lawsuits, some of which, if not all, could have been prevented if there had been seasoned and knowledgeable leadership at the helm. Despite my knowledge and experience working in the county clinics as a staff physician for four years and Medical Director for six years, my expertise and advice has not been sought, and when offered, has been ignored since the time that Jim Hunt was director of this department.

The current leadership of the Division of Primary Health does not have the medical background necessary to make informed decisions about the programs that they manage. The Medical Director does not appear to have any management authority in the current structure. Discretionary programs such as the Behavioral Health Initiative or the Low Income Health Plan have taken precedence over mandated programs such as Tuberculosis Control, STD clinical services or the county primary care clinics. Resources have been diverted to these favored programs to the detriment of the others.

For example, there was such an urgency to make the Behavioral Health Initiative an FQHC, that as a result the county clinics lost their identification number for billing Family PACT last year. Services for Family PACT, which reimburse the county for STD, family planning and laboratory services provided to low-income individuals in the county, were reduced significantly, resulting in the loss of over $200,000 of revenue to the Public Health Laboratory last fiscal year and an unknown amount of revenue for the county clinics. Restoring this funding stream and the clinical services that have been reduced, has not been a priority for the Director or for the Division of Primary Health Leadership. continued on page 10

Many Changes in Public Health Care continued from page 8 As you might expect, my questions and comments about these issues are not welcome. I believe that professional expertise must be returned to the health programs in the department. I recommend that all health programs in both the Division of Public Health and in the Division of Primary Health should be consolidated under the authority and supervision of the County Health Officer. If the next Health Officer is an individual with management experience, you might be able to save the cost of several management positions in the Division of Primary Health that are currently held by non-licensed personnel, and therefore, are inefficient in the execution of their tasks. That funding could then be directed to providing direct services to the community.

It is certainly possible that my perspective is in error. I recommend that the CEO hire an outside

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consultant who will report directly to him, and who is knowledgeable in the organization of county health services, to review the current organization of the Department of Health and Human Services and the qualifications of those in management positions, and recommend structural and management changes that would improve efficiency, be cost effective and meet the needs of our community.

It may be that after an impartial analysis occurs, that you might receive the recommendation that the Department of Health and Human Services should be split into a Health Department, led by the Health Officer, that manages all health programs and a Department of Social Services that manages Child Welfare and Adult and Senior Services. trochetg@gmail.com

Health Reform in 2012 – Crunch Time, Part One

By Adam Dougherty, MPH, MS II This is the first piece in a two-part series on a decisive year in health care policy.

THE DECISIONS MADE IN 2012 WILL dictate much of the health care landscape for decades to come. At the state level, implementation of the Affordable Care Act (ACA), an uncertain future for Medi-Cal, and a seemingly neverending state budget struggle are the major foci. The national spotlight includes a Supreme Court ruling on the individual mandate, the “budget trigger,” and the November elections.

As a medical student with an interest in public health policy, I like to follow these developments because my classmates and I worry about the current health care system, how it will sustain the public in the coming years and our role as future physicians.

March 23rd marked the two-year anniversary of the passage of the ACA into law. It is by no means a perfect fix to our health care system, but even at this early stage in its rollout before the major reforms in 2014, health care reform has already lead to real programs helping real people today.

For example, the unethical practice of rescissions and denial of insurance based on pre-existing conditions for children are a thing of the past (and will be for adults in 2014).

Over 2.5 million young adults aged 19-25 have gained insurance through their parents’ health plan.1 The Pre-Existing Condition Insurance Plan (PCIP) has provided vital services to nearly 50,000 previously uninsurable individuals, with the California PCIP enrolling over 5,500 people.2 Finally, in 2011 alone, over 54 million

Americans (and 6.2 million Californians) received preventive services with no cost sharing because of the ACA, a crucial step forward for public health. Furthermore, preventive medicine outreach to minority populations can be challenging. But nationwide in 2011, an estimated 6.1 million Latinos, 5.5 million African-Americans, 2.7 million Asian Americans and 300,000 Native Americans with private insurance received expanded preventive benefits as a direct result of the new health care law.3

State Perspectives The Golden State has positioned itself as a pacesetter in health reform. The California Health Benefits Exchange (HBEX) will be an innovative, competitive marketplace that will empower millions of consumers to choose the health plan and providers that give them the best value.

California has taken advantage of numerous federal funding streams offered through the ACA. This has pumped millions of dollars into the state for the following activities: dynamic payment and delivery reforms through the Center for Medicare and Medicaid Innovation (CMMI), community clinics and teaching health centers, and local health coverage efforts offered through the 1115 waiver known as the “Bridge to Reform.” Programs like these offer relief to the many county and state programs that have seen their dedicated funding streams evaporate in the last several years.

Yet, just at the moment that “help is on the way,” a perpetually anemic state budget has placed programs like Medi-Cal on the carving table. A looming 10 percent Medi-Cal rate cut

May/June 2012

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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has already

for physicians has prompted a federal lawsuit challenging those cuts. The rate cut fight has gained national attention and puts the state and feds between a rock and a hard place.

If the cuts are upheld in federal court, this would essentially allow other states (like the anti-ACA red ones) to get a backdoor to dismantling pieces of the ACA through similar cuts and challenges. If overruled, it would be back to the budget-cutting drawing board for Governor Brown and Company. While unified opposition against the cuts are important for the physician voice, the bigger problem is the FMAP formula that determines how much California gets from the feds for Medi-Cal. As a young, “high-income state” with a large low-income population, we bleed federal tax dollars to states who can enjoy better matching funds.

On a positive note, though, 2013 will bring two years of federally funded parity for Medi-Cal to match Medicare reimbursement levels for many services.

lead to real

Federal Contention

…health care reform

programs helping real people today.

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Few Supreme Court rulings have had more publicity, anticipation and significance than the challenges against the ACA’s individual mandate.

This was exemplified by the unprecedented six hours of oral arguments heard by the Court on March 26-28, the longest in modern history for a case. How the Court ultimately rules in the next month or two will have major implications.

There are several pieces to the lawsuit.

Perhaps not to be left out of the “can-kicking down the road” mentality embraced in state and federal legislatures, the Court dedicated two hours of argument to the option of invoking the Anti-Injunction Act. This option essentially states that a challenge to the individual mandate cannot even be heard before the law — or “tax,” so to speak — is imposed in 2014. But both sides of the individual mandate argument would prefer a decision now versus this prolonged uncertainty.

An accompanying challenge put forth to the Court is the Medicaid expansion component on the grounds of undue costs to states. Many experts believe that upholding such a claim

Sierra Sacramento Valley Medicine

would threaten the status quo of numerous federal-state contracts beyond just Medicaid, so the expansion is likely to be upheld.4,5 The next issue to be addressed is whether the mandate is “severable” from the rest of the ACA, and whether the whole law must be invalidated if the mandate is indeed found unconstitutional.

While many of the smaller programs in the law can indeed be detached from the individual mandate challenge, the interdependence of guaranteed issue, community rating, health exchange subsidies, and the mandate — the major pillars of the ACA — will likely be seen as inseverable.

Finally, there is the mandate itself. While opponents believe that an individual mandate violates the Constitution’s Commerce Clause and that the “inactivity” (i.e. not buying health insurance) of the American people cannot be regulated, there is ample precedent to the contrary.6 In 1790, the first Congress (encompassed largely by the framers of the Constitution) required all ship owners to provide medical insurance for their sailors.

In 1792 came the individual mandate to purchase a firearm (let your Amendment-rightsimagination run wild on that one), and in 1798 sailors were required to purchase hospital insurance for themselves.

Most relevant, though, is the 1942 Supreme Court case that upheld congressional authority to regulate the “noncommercial activity” of wheat growers, or more plainly that wheat which is grown but not sold. This ruling was reaffirmed in a case brought to Justice Roberts’ Court in 2005 regarding medicinal use of home-grown marijuana. Congress only lacks Commerce Clause power when a regulation is not economic in nature.

Few could argue that health insurance is not economic at any local/national or public/private level, as nearly every citizen is guaranteed to access health care at some point in his/her life.

If market-based health care is a concept that we, as a nation, wish to preserve, while also assuring this care is eventually paid for, then the grounds for this economic standard become prudent, and more so, self-evident.

Given recent rulings and precedent, I predict Justice Kennedy will join the four liberal Justices in upholding the mandate. Chief Justice John Roberts may also rule in favor in order to improve the Court’s perceived certainty on the issue. Thus, summoning my inner oracle, I predict the 2012 Roberts Court to uphold the law with a final ruling of 6-3!

1 Sommers, B., Schwartz, K., 2.5 Million Young Adults Gain Health Insurance Due to the ACA, ASPE, December 2011 2 Kaiser Family Foundation, statehealthfacts.org, March 2012 3 Sommers, B., Wilson, L. 54 Million Additional Americans are Receiving Preventive Services Coverage Without Cost Sharing Under the ACA, ASPE, February 2012 4 Cohen, G., Blumstein, J., The Constitutionality of the ACA’s Medicaid-Expansion Mandate, NEJM, 2012; 366:103-104 5 Judge David L. Bazelon Center for Mental Health Law, Florida v.

HHS, Jan. 2012 6 Elhauge, E., The Irrelevance of the Broccoli Argument against the Insurance Mandate, NEJM, 2012; 366:e1

apdougherty@gmail.com

AMA Foundation Honors SSVMS Member UC DAVIS MEDICAL STUDENT Adam Dougherty, MPH, MS II, has been named a recipient of the American Medical Association (AMA) Foundation’s 2012 Leadership Award. This award provides medical students, residents/fellows and early career physicians from around the country with special training to develop their skills as future leaders in organized medicine and community affairs.

The AMA Foundation honored 30 individuals with Leadership Awards at its annual Excellence in Medicine Awards ceremony, which was presented in association with Pfizer, Inc., on February 13, 2012 in Washington, D.C. Recipients of the award are recognized for demonstrating outstanding non-clinical leadership skills in advocacy, community service and education.

AMA Foundation President, Dr. Owen Garrick, presided over the awards ceremony and praised the Leadership Award recipients, stating, “These dedicated medical students, residents and physicians are deeply committed to transforming their communities and improving the health of their neighbors. Our hope is that celebrating the efforts of these medical leaders will inspire us all to give back to our communities, as they have done.”

Prior to medical school, Mr. Dougherty was the Policy Director at Insure the Uninsured Project, a health policy think tank located in Los Angeles. He has published numerous reports and white papers on federal and state health policy topics, with notable focus on the Patient Protection and Affordable Care Act.

Mr. Dougherty currently holds leadership positions with the AMA, the California Medical Association, and the California Academy of Family Physicians, and is on the Editorial Committee of the local medical society journal, Sierra Sacramento Valley Medicine. He is also the Policy Coordinator for the Men’s Health Caucus of the American Public Health Association, and recently accepted a position on the Sacramento County Public Health Advisory Board.

For more information and health policy commentary, visit Mr. Dougherty’s blog at www.adammd.org.

Adam Dougherty, left, receives award from AMA President Dr. Peter Carmel.

May/June 2012

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Vaccine Protection Counseling Parents About Vaccines Protects our Communities

By Assemblymember Richard Pan, MD, MPH

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

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ONE OF THE MOST STRIKING ITEMS in our society’s medical history museum is the iron lung. The iron lung reminds us of the horror and terror polio brought to our communities as children became struck with paralysis each summer until polio vaccination became widespread. Thanks to the success of universal vaccination, polio and many other vaccinepreventable diseases such as measles and whooping cough now seem to be distant memories. Except for smallpox, however, these diseases are not gone, and when vaccine rates decline, diseases are reemerging in our communities.

In California, unvaccinated children can enter school if their parents sign a two-sentence exemption statement. Despite the risk unvaccinated children may pose to students, teachers, and other people at school and in their community, there is currently no requirement that these parents receive information about the potential consequences of their decision.

Thus, I have authored AB2109, which requires a parent or guardian seeking a personal belief exemption to send their child to school without meeting school entry vaccine requirements to present a document, signed by themselves and a licensed health care practitioner, that states the practitioner has informed the parent or guardian of the benefits and risks of immunizations and the health risks of the diseases that a child can contract and spread. This bill preserves a parent’s option to exempt their child from immunizations.

2010 data showed that about 11,500 California kindergarteners had a personal belief exemption, representing a 25 percent increase in two years. Studies of vaccine refusal by parents

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have shown that these parents believe their children have low susceptibility to the disease, that the disease severity is low, and that vaccines are unsafe based on information from the internet and groups opposed to immunizations.

With the success of immunizations, few parents have first-hand experience with vaccinepreventable disease. However, the internet contains discredited research linking autism and the measles vaccine, testimonials by anti-vaccine celebrities, and various vaccine conspiracy theories. It is not surprising that many parents are uncertain about immunizations.

In my own pediatric practice, I witnessed how confused parents may become while searching the internet. I cared for the children of a family who decided to refuse vaccinations based on what they read on the internet. Thus I was surprised when, in 2002, they came to my office demanding the smallpox vaccine for their children. While I explained that smallpox was eradicated and the vaccine was not given to the general public, I learned that an internet smallpox terrorism scare after 9/11 prompted this demand.

Counseling by a health care professional has an overall positive impact on parents’ decisions about vaccination. Perceptions about vaccine safety are more informed, and parents often seek information relevant to their specific concerns from the health care professional.

One of the reasons for the past success of immunizations is herd immunity, which requires 85-90 percent of the population to be immunized to stop transmission of the disease in the community. Herd immunity protects people who cannot be immunized including young infants, people with compromised

immunity, such as those on chemotherapy for Diego County was infected in Switzerland and cancer or HIV patients, and people with vaccine on return caused 12 children to be infected with allergies. In addition, a small percentage of measles including three infants too young to be children who are vaccinated have an insufficient vaccinated. response and remain susceptible to infection Parents want to do what is best for their when exposed. Over 30 percent of California children. As parents, my wife and I had our counties have exemption rates of greater than children fully immunized. The decision five percent with Nevada County at nearly 18 to vaccinate or not vaccinate has significant percent. High exemption rate communities are consequences not only for our children, but for more likely to have disease outbreaks. People in other children in their school and community. these counties are at risk for disease spreading Ensuring that parents receive information from a throughout their community. licensed health care professional about the risks In medical school, I learned about measles and benefits of immunizations before children but was told that because of the measles vaccine, enter school helps protect our community.

I would probably not see a case in my career.

I believe that with this information, parents However, in my senior year, I did a rotation will make an informed choice for their child in a community clinic in Philadelphia when a and their community. Please support passage of measles outbreak occurred, primarily among AB2109 to empower parents with information members of two churches who did not accept from a health professional when deciding about vaccination. I saw measles first-hand and heard immunizations. Let us keep vaccine-preventable about children dying, including two out of three diseases in the history books and not in today’s children in one family. By the conclusion of the news. outbreak, 938 cases and six deaths occurred.

Together, we can build a healthier California.

Unfortunately, children continue to become ill and die of vaccine-preventable illnesses.

Richard.Pan@asm.ca.gov In 2010, 10 infants died of pertussis and over 600 people were hospitalized ANNE E. FERGUSON with it in California.

A PROFESSIONAL LAW CORPORATION Expanding pertussis immunization to all ado  Physician IPA & health plan contracts lescents for school entry P r o v i d i n g legal has resulted in no deaths  Medical group organizations, operations & s e r v i c e s to other business matters from pertussis in 2011, the physicians & first time in more than 20 medical groups for  Practice management, governance & buymore than 20 years sell agreements years.

In 2011, measles  Physician employment agreements cases reached a 15-year Anne E. Ferguson  Practice sales, acquisitions & mergers 655 University Avenue high in the United States.

Suite 110  Medical director, hospital-physician, International travel raises Sacramento, CA 95825 recruitment, call-coverage & other the risk of infection at Telephone: (916) 488‐5388 contracts Facsimile: (916) 488‐5387 home. In 2011, there were  Medical Records, HIPAA & EHRs

more than 30,000 cases website:  Regulatory compliance, compliance www.fergusonlawcorp.com of measles in Europe, programs, Stark and Anti-Kickback

including eight deaths, due

 Medical office leases, ASC investments & This is attorney advertising. to falling immunization other business matters rates in European countries.

In 2008, a child from San

May/June 2012

15

“Is There a Doctor on the Plane?”

By Marion Leff, 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.

LET IT BE KNOWN FROM THE START that, as a family physician, the variety of patient presentations I see and my tolerance of uncertainty are trademarks and skills of my specialty. As such, I confess to enjoying the adrenaline kick of running to a hospital Code Blue or responding to the call, “Is there a doctor in the house?”

In today’s world of frequent travel, these calls are not rare.1 My first such experience was straightforward and easy to handle when the woman sitting directly behind me with her teenage daughter — trying to make it home to Sacramento after a cancelled flight five hours earlier — began to hyperventilate and develop a full-blown panic attack before take off.

The flight crew confronted her with an ultimatum to disembark if she could not handle the trip. A little brown bag (in this case “barf bag”) therapy and a calm talk-down did the trick. She thanked me profusely afterwards.

My husband, Stan, a former emergency department doctor and now a family physician, has a theory that there are two kinds of doctors: those who, like me, will jump over the lap of their spouse to respond to an emergency call, and those who will sink down lower in their seat to allow others to go first. I’d like to think that we make a good team.

On not one — but two — separate occasions, Stan has followed me through the theater to check on folks seizing, stimulated by the strobe lighting effects in Moulin Rouge and Spider-Man. You would think that someone in a wheelchair and protective helmet would know better than to choose such a movie!

So we come to our transatlantic flight 6250 on Iberia heading to a much-awaited vacation

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in Israel. The plane lights were off and most passengers were under the influence of vino tinto, vino blanco, or perhaps Ambien, my husband’s hypnotic of choice.

An ominous announcement interrupted our quiet repose at 30,000 feet, “Is there a doctor on the plane who can offer assistance?”

Just five seats behind us sat 61-year-old Will and his wife who were on their way to a Mediterranean cruise. As the first on the scene (yes, climbing over my sleeping spouse), I found my patient was diaphoretic, clammy and almost non-responsive. Oh man! What am I doing here and where are all those vacationing cardiologists when you need them?

Stan was quickly with me, and a wonderful PA from New York completed our medical team. It is highly anxiety-provoking to recognize a serious medical situation potentially occurring in a cramped space with limited resources.

While Will’s wife stepped aside, we got the plane’s emergency kit and tried to take a history as rapidly as possible while checking some vital signs.

Our patient was hypotensive, sitting in a coach seat with thready slow pulse and poorly responsive. We learned in bits and pieces that our patient was not diabetic and had not taken any sleepers with wine, but he was on an ARB-diuretic combination for hypertension.

His wife felt he was pretty healthy, maybe a little stressed and — oh, by the way, he carries an Epi-Pen for severe allergic symptoms to shellfish, but she was sure he did not touch the shrimp appetizer that came with dinner. Thank God, our patient is an English speaker or the ability to render help would be even harder.

First aid in the form of a cold washcloth was minimally helpful, and Will seemed to be able to answer “yes” and “no” questions, but continued to be confused, and those vital signs were still crappy.

“Are you having pain, chest pain?”

“No.“ “Are you feeling short of breath?”

“No.” “Leg pain?”

“No.” Going through our minds, our differential diagnoses ranged from vasovagal event, (but hey, while sleeping?) to major life-threatening diagnoses like PE, MI, arrhythmia, and I favored orthostatic hypotension secondary to medications with inadequate hydration.

While we checked out the emergency equipment — lots of drugs, needles, but no IV equipment — Damn! — the co-pilot appeared.

My anxiety growing, I asked how far we were to Madrid or the nearest airport. Were we still over the ocean? Can we do CPR in the narrow walkway? It seemed clear we needed to get our patient supine, but moving him from the window seat where he had trouble sitting up was an uncertain challenge.

The flight attendants had bumped a business class passenger at bulkhead, where there is more leg room, if we could move Will. Slowly, Stan and our burly PA teammate got him up and into the roomy business class area and our care consisted of reclining back, holding his legs up and monitoring his vitals. No oxygen, no Epi-Pen, no emergency landing.

Gradually his vitals improved and our patient claimed he felt better, and drank some fluids. He told us he had just gotten a clean bill of health after a treadmill test (but why had that been ordered?). The flight attendant shared her hypothesis, having witnessed frequent such events: “It’s the air on board.”

But what of the disposition, the

hand-off of care? What would you have done?

Because we had a long layover before our connection to Tel Aviv, we chose to stay with our patient and see him off, more or less, to his next destination. We repeatedly admonished him and his wife to abandon the trip for a visit to the local ED if he still felt ill.

A wheelchair was provided at the plane gate to take him to the next gate, since he did not seem to require immediate emergency medical care. The cruise ship would also have medical resources, and happily Will’s wife said for the first time ever that she took out travel insurance!

Except for the loss of their cell phone when moving from coach to business class, all seemed to end well. While we did not get a business upgrade ourselves, we did later receive an invitation to join the Iberia frequent flyer club and have immediate miles added to our account as a ”Thank You.” leffm@sutterhealth.org

May/June 2012

1 Gibson, DJ. A Doctor’s view of in-flight medical emergencies.

SSVM, July/ August 2006. http:// www.ssvms.org/ ssv_medicine/ archives/2006/04/ articles/0604-gibson. pdf

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Spitting,Today and Yesterday

By Irma West, MD, MPH

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

THE DISCOVERY OF MYCOBACTERIUM tuberculosis in 1882 by the German physician, Robert Koch, led to anti-spitting campaigns and local ordinances in this country and beyond. It was assumed by medical authorities that spit was transmitting tuberculosis, the leading cause of death.

New York City enacted the first ordinance in May of 1896, imposing a fine of $500 and a year in jail for spitting in public places, such as on sidewalks, in ferry boats, railroad and street cars and on their platforms. “No spitting” signs were posted.

Sacramento was not far behind when the Board of Trustees approved Ordinance 444 on December 5, 1896. Spitting on sidewalks, in public buildings or public conveyances risked a fine of $5.00 and two days in jail. When enforcement was lax, such as at the Forester’s Hall Dances, patrons complained. Hackmen, awaiting passengers at the entranceway, left puddles of tobacco spit causing the ladies to raise their skirts! Police Chief Dywer gave instructions to enforce the law at all places of amusement. (Sacramento Union, February 20, 1898).

This law remains on the books. In 2010 a high school student was cited for spitting on a patrol car and fined $35 plus $158 court costs. (Sacramento Bee, 5-2410). An Occupy Sacramento protester was cited for spitting in the face of another protester.

(Sacramento Bee 11-22-11).

Apart from the anti-spitting ordinances, spitting on a person is battery, a misdemeanor or worse if the intent is to transmit disease. Spitting at someone but missing is assault.

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Today the Centers For Disease Control and other public health authorities do not consider spitting on the ground a common method of transmitting tuberculosis or other infectious diseases, although there have been no studies to address the subject.

In the early 1900s, tobacco chewing and spitting were popular. Spittoons (cuspidors) were found wherever men congregated. Some chewers had personal spittoons. Former President Teddy Roosevelt’s brass spittoon, circa 1906, is on display at the Panama Canal Museum at Seminole, FL. As cigarettes became fashionable and widely advertised as good for you, the ashtray replaced the spittoon.

Chewing tobacco and spitting have persisted in certain sports. Baseball players chew to relieve stress and dry mouth. In1990, Major League Baseball reported on the hazards of smokeless tobacco and discouraged its use.

Today, chewing tobacco by players during games is permitted in big league baseball but not in the minor leagues.

The spitball was banned by Major League Baseball following the death of a Cleveland Indian batter, Ray Chapman. His skull was fractured by a dirty spitball pitched at him during a game in New York City, August 16, 1920. Spit on baseballs makes them dirty, hard to see and they can slide off the bat.

Golfers are less tolerant of spitters. Tiger Woods was fined for spitting on the green.

(Sacramento Bee, 2-16-11).

Wrestlers spit into buckets before weighing in if they need to lose weight to qualify in a desired category. Marathon runners spit because they cannot

swallow their saliva while breathing hard.

Young men carrying spit bottles and chewing sunflower seeds is a recent trend.

Seed packages may proclaim, “eat, spit and be happy” and include instructions on how to be a cool “seeder.” Carrying spit bottles and chewing sunflower seeds or tobacco is a common substitute for smoking cigarettes among wildland firefighters and marines in combat in Iraq and Afghanistan. The firefighters must drink large quantities of fluid which produce excess saliva.

California’s robust wine industry is responsible for producing volumes of spit during wine tasting. Wineries offer customers spittoons, sometimes colorful, next to their glasses.

Spitting contests are popular worldwide. Participants spit local products such as watermelon and sunflower seeds, cherry pits and peanuts. In Spain, it is olives. Tribes in Africa compete using Kudu antelope dung; their current record is 15.56 meters. At Purdue University’s annual Bug Bowl in Lafayette, IA, a recent record for spitting dead crickets is 32 feet 1/2 inches. At the San Diego County Fair in June, 2011, an 11-year-old boy won his division title by hawking a watermelon seed more than 14 feet. His mother won the adult competition at 25 feet. Fatalities are on record when spitters choke on what they were spitting.

For centuries the betel nut, (actually the seed of the areca palm) wrapped in betel leaves with various additives has been chewed and spit by Pacific Islanders, Chinese, East Indians, Indonesians and many others. The seed contains arecoline, a stimulant which is

mildly addictive. Immigrants have brought the habit to this country, but it has not been popular with their children. They prefer the white teeth seen on television to the black stains on the teeth of their parents.

At Father Damien’s church in Molokai, HI, holes were drilled in the floor next to the kneeling benches for leprosy victims to spit in.

Stone Age tribal beer making exists today among Amazon Indians. Women sit in a circle, chew grain and spit it into pots to form a fermenting mass. Ambient yeast adds to the brew which is saved for ceremonial and religious festivals.

Putting a “spit shine” on shoes has been a time-honored custom as has spitting on a handkerchief and wiping a child’s face. The origin of the expression “spitting image” is foggy. Perhaps it came from 17th century England where it was said that someone was

May/June 2012

Left page: St. Philomena Church on Molokai offered fluid holes in the floor for leprosy victims to discreetly spit out phlegm. Above: The author’s daughter-in-law, Mary Piowaty, photographed this sign in her travels. Below: David brand sunflower seeds suggests the “proper” way to enjoy their product!

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so like another that he/she must have been spit from the other’s mouth.

Camels, cobras, chimpanzees, and the octopus are among the best animal spitters. The mythical fire-spitting dragon gave a name to the Spitfire, a fighter plane credited with winning the Battle of Britain in 1940, and holding Hitler at bay until the United States entered WWII. imariewest@aol.com References: Center for Sacramento History, 551 Sequoia Blvd, Smokeless Tobacco and baseball: a Short History, quitnet.com/library Eames, Alan. Secret Life of Beer, Storey Publishing LLC 1995 hotelclub.com/spitting-as-a-sport 11-21-08 mountainroseherbs.com/betelnut 2-6-12 Municipal Archives, New York City, City Hall Library, 31 Chambers St., New York City, 10007 Personal communication: Zak Basch, spokesman, Sacramento River Cats.

Dr. Bob LaPierriere, Kirk Campbell and Kenny Meyer.

Grandchildren, Heidi, Michael, Mason, Molly, and their mother, Mary. phrases.org,uk/meanings 2-3-12 signonsandiego.com/news 6-24-11 (spitting contests)

Intolerance

By Robert Kahle, MD WHEN DID WE FIRST HAVE AN indication? An inkling? Was it already apparent to us when we were developing in the womb? Some inherent transmission, some genetic transfer that let us know? Something that we could feel even in that wonderfully-cozy yet isolated place?

Did it first become apparent in the initial moments after birth, with the first breaths we took? With the first sights and sounds of life around us? Was it apparent in the initial reactions of those present as we burst forth?

Was it something that was nurtured in us over time? Something we took in as we suckled at the breast? Was it in the first independent steps we took, declaring our separateness, our otherness?

During our infancy, while fully dependent on others, was it just a by-product of our social environment? How others dealt with us or how we perceived others?

During childhood, was it learned in lessons in the

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classroom or during our play at recess? From parents?

From teachers? From ministers? From our peers?

When was it that our own individuality, our own unique character, those things that make us who we are, our own self-worth … when was that first judged?

When did we come to find out we were different?

When did we first encounter intolerance, prejudice, discrimination, or bigotry? And in that, when did we have and express those same thoughts and emotions?

When did we become so different as to not easily tolerate each other? Are we so different after all? And aren’t those things that make us unique worth consideration? Even celebration?

Must our intolerance grow ever larger and pass from generation to generation or can we throw off this yoke and learn to accept each other in love and patience? In consideration and celebration? As our world grows smaller, our survival may very much depend on just that. robert.kahle@dignityhealth.org

A Posit on SugarSweetened Beverages “Sugar-sweetened beverages should be taxed to offset the public health costs of their consumption.”

BACKGROUND: Last year, 15 states discussed proposals to tax sugar-sweetened beverages.

None passed. Authors of a January 2012 study published in Health Affairs estimate that Americans consume “approximately 45 gallons per capita annually of soda, fruit punch, sweetened tea, sports drinks, and all other beverages with added caloric sweeteners.” They estimate that a nationwide penny-per-ounce excise tax on sugar-sweetened beverages would reduce consumption of these beverages among adults ages 25-64 by 15 percent. They argue that this, in turn, would prevent 2.4 million diabetes person-years, 95,000 coronary heart events, 8,000 strokes, and 26,000 premature deaths.

Results: Agree, 53; Disagree, 31. Some edited comments follow: Over the past generation we have raised taxes on cigarettes — an even more unhealthy habit — and engaged in a steady education campaign to educate people about their hazards, and we have gone from a society where over 50 percent of adults smoked to one where fewer than 25 percent do. Financial disincentives are among the most powerful ones we have, and we need to use every tool at our disposal. The federal government’s subsidies for corn producers since the late 1960s made high fructose corn syrup an incredibly cheap sweetener, amounting to a subsidy for the industry and making possible the huge portions of cheap sweetened beverages that are feeding our obesity and diabetes epidemics.

It is time we removed those subsidies, and started applying the reverse incentive for the sake of all our health. —Francisco Prieto, MD Hasn’t worked for tobacco, and seems like

not so clear a connection that this one thing is to blame. The connection is clear with tobacco and seat belts, but this appears misdirected. Why don’t they tax sugar in any form, any use? (I’m being facetious here!) —Brian Wippermann, MD We tax sillier things than that already.

Childhood obesity is in large part due to consumption of non-nutritive beverages. We all pay as a society for the poor health of the obese.

If the funds could be used for further research, prevention and education on healthy diets, I am all for it. —Joanne Berkowitz, MD (Disagreeing) [I] would agree if that money actually went back to health care, etc. “Sin taxes” rarely seem to do that; it also penalizes poor/uneducated more. —Jason Flamm, MD (Disagreeing) The taxing of tobacco products has not decreased their consumption, nor has it offset the health costs from tobacco use. —Reinhardt Hilzinger, MD A one-cent tax may help a little in health care costs, but will do nothing to curb consumption.

Look at how little heavy taxation has done to stop cigarette smoking. The answer lies in education, which will be extremely difficult in the face of what the manufacturers have been and will continue telling the public. —Clifford Marr, MD (Agreeing) I would suggest taxing all non-necessary foods including my favorite snacks like chips, Fritos, etc. —George Meyer, MD There is scant scientific data to prove that the effect of taxes on sugar-sweetened beverages will substantially reduce their consumption or prevent disease and death. However, taxes May/June 2012

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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This should not be a sin tax. Would sugar or salt be next?

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must be collected from some source and sugarsweetened beverages may be as good a target as alcohol or tobacco, and arguably to be preferred over increases in our income tax. We should also tax drinks flavored with artificial sweeteners. Scientific research indicates that ingestion of artificial sweeteners promotes substantial weight gain. (See, e.g., Nonnutritive Sweetener Consumption in Humans: Effects on Appetite and Food Intake and Their Putative Mechanisms. Am J Clin Nutr 2009 Jan; 89(1) 1–14.) —Bruce Barnett, MD As well intentioned as this effort may be, neither the state, nor the federal government has the constitutional authority for this degree of intrusion in the lives of its citizens. —Michael Patmas, MD (Disagreeing) Next would be a tax on stupidity in general. —Pat Hardy, MD (Disagreeing) Enjoy reading this fascinating article: The Evolution of Obesity: Insights From the Mid-Miocene, w w w. n c b i . n l m . n i h . g o v / p m c / a r t i c l e s / PMC2917125/pdf/tacca121000295.pdf. —Lee Welter, MD (Disagreeing) Nanny taxes to effect behavior are oppressive. Educate people about the risks of doing what they are, then let them be responsible for their own actions with the attendant consequences. —Richard Gray, Jr., MD (Agreeing) This is a no brainer. One would think that taxing sugar would be just as rational and just as easy as taxing alcohol and tobacco.

In fact, I believe that increases in tobacco taxes have been followed by significant reductions in tobacco use. The harm of the high-sugar diet is evident all around us, and the benefits of lower sugar consumption should be very impressive. (Yet I’m empted to) assume that the money funneled by lobbyists to our legislators by industries that benefit from sugar consumption far exceeds any money from those who have a stake in “health.” —Alfredo Czerwinski, MD While the posit, as stated, simply suggests taxing sugars in order to raise money for health costs, the authors of the quoted Health Policy article claim health benefits will result. They make broad assumptions about behaviors of

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Americans and develop a computer model based on these assumptions. I suggest that is the worst basis for making public policy, even when it falls from the lips of those associated with highlyregarded institutions. Why have proposals like this been rejected by 15 states? First, Big Money is behind high profit-margin food. Second, too many people realize the proposal is just one more abusive tax. Third, social-cultural pressure can change behavior — call it education if you like — but legislation or taxation? Never. Fourth, this is an extremely regressive tax — like that on cigarettes — aimed at the poorest and least educated among us. Fifth, and most significantly, the evidence is lacking that a tax would reduce either consumption of sugar, obesity, or related disease. —John Loofbourow, MD (Likely disagreeing) Stupid. —Michael Burman, MD The costs of health insurance should be tiered depending on several factors including BMI. —Terry Zimmerman, MD This should not be a sin tax. Would sugar or salt be next? Julita Fong, MD I think all non-essential food should be taxed — candy; sugar-added beverages including teas, fruit drinks with sugar added, etc; alcohol; popcorn; cakes; donuts; cookies; ice cream; etc. I think it is horrid we are in a depression, but folks can spend their $$ on junk without having the state pick up some profit from these non-essentials. Yes, there can be some “question,” so [I] would allow what I don’t recommend such as white bread, non-wheat pasta, etc., but the dessert stuff and above lists are clearly “extras.” However, I do not think this will stop or decrease obesity, diabetes, CAD, CVAs, etc. —Evalyn Horowitz, MD This is a classic case of externalities imposed by producers and consumers on society. To capture those externalities, and foster reengineering of hazardous products, taxation is an appropriate policy tool. —Patrick Romano, MD Added sugars, like tobacco products, are key drivers of health morbidity. We need to draw from the anti-tobacco playbook in our efforts to curb obesity. —John Struthers, MD Oh please, will you commies get out of our

lives. —Paulette Jenison, MD Only in a nanny government. —Wayne Matthews, MD (Agreeing) It does seem intrusive for government to be making these decisions; [I] would prefer that culture, parents, or individuals would educate and change.

However, we all pay for the other guys’ chronic disease and dysfunction, whether it is directly through government-paid insurance or private insurance, and disability coverage. In addition, the jury really is “In” on the deleterious effects of such chronic drink intakes, without counterbalancing benefits. —Nancy Gilbert, MD Sugar does not cause diabetes, stroke, coronary heart disease, premature death or, for that matter, obesity. Only over-consumption is associated with health problems. Sugar substitutes have been shown to encourage overconsumption of calories as the sweetness is no longer associated with satiation and overall caloric intake increases. It is more logical to

tax sugar substitutes. If more tax money is needed, why not tax nonscientific proposals such as this? Fifteen states would have benefited already. —Richard Park MD A soda tax may or may not reduce consumption, but we have to try something.

Tobacco consumption has declined, and no one can prove whether it was taxation or marketing that was responsible. People who criticize this type of tax as over-intrusive and nannyism, ignore the fact that other types of taxes and “fees” currently pay for the health consequences of over-indulgence. Also known as income taxes and insurance premiums, they spread the cost out over all of us, whether we consume or not. I would prefer that the overconsumer pay the tax on his/her folly, rather than it come out of my taxes and premiums.

What if taxation doesn’t do the trick and we need education? Great, but who will pay for that, if it isn’t taxed like tobacco? —Ann Gerhardt, MD

Your care makes all the difference.

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

www.bloodsource.org

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not-for-profit since 1948

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.

May/June 2012

23

“My premium savings was over $1,900! What a great member benefit. All Society members with employees should get a quote. It was so easy to do.”

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The SPIRIT Program Stories of our Local Volunteer Doctors

By Elizabeth Zima, Staff Writer at the California Medical Association MITCHELL SHIPEK, 32, FEARED THAT his hernia would jeopardize his dream of graduating from California State University in Sacramento with a degree in geography. To pay his way through school, Shipek had driven commercial trucks. He worked his way up from a junior college. In the summer of 2011 he needed employment to finance his schooling that fall. When he divulged a hernia during a job interview at Gordon Trucking, he was denied employment. Shipek was crushed.

“The company said I had to get it taken care of before they could consider me, so I went to my doctor and paid out of pocket and asked her to sign a release, but she wouldn’t,” said Shipek.

Instead she referred him to John Young, MD, a general surgeon with the Mercy Medical Group in Sacramento.

When Dr. Young expressed reluctance to clear him for work because of the hernia, Shipek panicked. “Most of my life, I have been without health insurance,” said Shipek. “I did not have the money for a hernia repair.” But what Shipek didn’t know was that he wouldn’t have to pay out of pocket − and that Dr. Young was part of the SPIRIT program, which could provide the service free of charge!

The Sacramento Physicians Initiative to Reach Out, Innovate, and Teach, or SPIRIT project, was started by the Sierra Sacramento Valley Medical Society with $300,000 in grant money from the Robert Wood Johnson Foundation. Now, the program has grown to include over 40 physician volunteers in the Sacramento area who provide care for 1,228 patients a year doing everything from basic family medical care within public clinics to eye surgery and hernia repairs.

Shipek was skeptical. “At first when he told me about the program, ‘I was like, yeah, but I will have to fight for it,’” he said. “Instead, everything was done for me. I just showed up at the appointed time for tests and the surgery and it was all free. It was all very easy.”

It was also easy for Dr. Young to do as well.

With 14 years of performing hernia repair for the SPIRIT program (close to 140 surgeries), he and his partners, Christian A. Swanson, MD, and Wen Long, MD, see approximately one to two patients a month. “The program screens the patients,” Dr. Young said, to make sure they meet the requirements. Then, “the patients come into the office for a workup and examination, and we discuss with them what we will do.”

In addition to placing volunteer physicians, SPIRIT provides case management for all surgeries and communicates directly with patients to ensure that they complete pre- and post-op care.

It’s very satisfying to perform the surgeries, Dr. Young said, because “hernias fall through the cracks.” Public health centers do not cover them, and according to SPIRIT’s program director, Kris Wallach, about 66 percent of SPIRIT patients with hernias can go back to work. “This makes a big difference quickly,” she said.

Over the lifetime of the SPIRIT program, which began in 1995, some $8 million in services have been donated treating some 37,000 patients. On any given day of the week, a SPIRIT volunteer is working in the community providing care for those in need without insurance.

After his surgery, Shipek was hired by Gordon Trucking and drives the I-5 corridor

May/June 2012

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.

25

delivering products for ConAgra and Kraft foods. He hopes to return to college shortly to complete his schooling, become a geophysical surveyor and put truck driving behind him.

Regular Tuesday morning care

David Kissinger, MD, has provided hernia repair since 1999.

Providing health care to people who cannot afford it can be very satisfying. In some instances, it can cause a total transformation.

Andrew Hudnut, MD, a family physician with the Sutter Medical Group in Elk Grove and a member of SSVMS, finds that his work with the SPIRIT program brings him in contact with people who are given the time to think about

their lives.

On Tuesday mornings you will find Dr. Hudnut at the Interim Care Project housed by the Sacramento Salvation Army. The 18-bed facility provides care for homeless patients who have been hospitalized and need a safe place to be released. SPIRIT provides the doctors who work there.

Dr. Hudnut cares for patients who need wounds dressed, have emphysema or pneumonia, have suffered accidents in cars or while walking the streets, and who suffer from addiction and mental illness. He finds the opportunity to care for the people in the program “wonderfully satisfying and a rewarding way to spend my time and use my knowledge. This is why I went into medicine,” he said.

“Because the facility is an interim stop in the patient’s life, giving respite from homelessness − a lifestyle that can be fraught with danger and chaos − many patients here are able to rest and think about their lives,” Dr. Hudnut said. “Some patients are able to break the cycle of homelessness, substance abuse and mental illness. I have seen patients who have made profound changes in their lives here,” he said.

“It is a very spiritual practice to care for these people,” he said. “It renews my enjoyment of being a family care doctor.”

Who once was blind but now can see Many people find themselves suffering from illness and diseases that rob them of their ability to function from day to day.

“We see a lot of advanced ocular disease in this population,” said Edward Denz, OD, for Kaiser Permanente. As a part of SPIRIT Vision, Dr. Denz works with his colleagues, Ovidiv Statescu, OD, and Kaiser Chief of Ophthalmology, W. Clinton McClanahan, MD, to see uninsured patients identified by the SPIRIT program who have vision problems and who need eye screening for diabetic retinopathy, glaucoma screening, refraction for glasses and even cataract surgery.

“One Monday a month, we conduct a group screening in Rancho Cordova to provide refraction and free glasses. These groups are

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made up of about 30 people,” said Dr. Denz, who has treated a total of 573 patients as of the end of 2011.

On Friday afternoons after his regular clinic hours at Kaiser Permanente, he conducts “one-on-one individual exams. We stay late and see a handful of patients” who have cataracts or diabetic retinopathy (these patients are referred out). “I am fortunate that Kaiser allows us to do this. These people really need care. It is very satisfying to give it,” he said. “Last week we saw two people with cataracts in both eyes that rendered them legally blind. We were able to take care of these disabling cataracts and helped these patients regain their sight.”

“These patients really need our care!”

hernia repair and talks about the appreciation of the patients. “To a patient, they are all grateful. It is rare to have someone not be demonstrative.”

Have you been moved by the SPIRIT? To volunteer for the program or to make a tax-deductible charitable contribution to the SPIRIT program, please contact Kris Wallach, SPIRIT Program Director, Sierra Sacramento Valley Medical Society, by phone 916-453-0254 or email kwallach@ssvms.org.

Why I chose to be a doctor Students going into the practice of medicine routinely express the desire to care for people, no matter what. And while the business of medicine seems to swallow up this original intent, it still exists for many. David Kissinger, MD, is one Kaiser surgeon who goes the extra mile to care for people.

“It’s hard to go to a foreign country (to provide health care) when you have a family, but this is in our backyard,” said Dr. Kissinger.

He has provided hernia repair since 1999, when he found out about the program. He has since performed almost 100 surgeries for patients in the SPIRIT program.

“These are the neediest people and this is the purest act of giving,” he said. “We can return (many of these patients) to work. It fulfills all my personal goals.”

Dr. Kissinger has performed so many of these surgeries over the years that he has it down to a science. “We perform one surgery after the surgical suite is closed for the day at 5 pm on Friday,” he said. “I pick dates when I can do the surgery.” These are submitted to the OR and the OR posts the proposed times, asking for volunteers to sign up, he said. The SPIRIT program coordinates the time and pre-op tests with the patient. “Everything is taken care of by volunteers,” says Dr. Kissinger.

He is excited to be coming up on his 100th

Ed Denz, OD, above left, conducts an eye exam.

Below right, Drew Hudnut, MD, consults with a patient.

May/June 2012

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“Huffing” Freon: A Risky Youth Behavior

By Marcelina Jasmine Silva, MS IV Marcelina Jasmine Silva is a fourth-year student graduating from Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. She will begin a residency in family medicine in Northern California this fall.

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.

IN RECENT YEARS, SPORADIC CASES of death have been reported nationally due to recreational inhalation of Freon from backyard air conditioning units. While the Centers for Disease Control and Prevention (CDC) and medical literature have long addressed the dangers of “huffing” aerosols, glues, paints, or other solvents, the specific abuse of Freon remains critically underreported.

Of the agencies entrusted to inform the public of this behavior — such as the CDC, the National Institute on Drug Abuse, and the American Association of Poison Control Centers — only the California Mechanical Code has recognized the seriousness of the problem and currently recommends all refrigerant service ports be fitted with locking-type, tamperresistant caps to prevent “huffing “ of Freon gas.1 However, this is rarely enforced. While the Environmental Protection Agency does restrict the sale of large storage containers of Freon due to its ozone-depleting properties, it does not restrict the sale of smaller containers which are often abused.

As a medical student interested in the circumstances of how people came to “huff,” I visited a voluntary adult outpatient treatment center in San Bernardino County which provides group counseling for current and former substance abusers. What I learned about the culture of recreational Freon inhalation from

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air conditioning units was both astounding and disturbing.

Over the course of several visits, I interviewed 42 people. Of those people, 19 had either engaged in Freon huffing from air conditioning units themselves, or had witnessed someone doing it first-hand. The interviewees described inhaling Freon from, or meant for, air-conditioning appliances. They accessed the Freon directly from the appliance service port, or by using a hose or bag as a conduit. Many reported finding easy access to Freon through unlocked household air-conditioning units in neighbor’s yards. However, others pointed out that auto parts stores and major retailers have smaller containers of Freon for sale to the general public. Some reported stealing both the smaller automotive and larger regulated Freon canisters from retailers.

Dangerous Effects The documented dangerous effects of huffing Freon fall along a spectrum: epidermal burns and blistering,2 headache, dizziness, nausea, numbness, dysesthesia, muscular weakness, tinnitus, sore throat, shortness of breath, heart palpations, ophthalmic keratitis,3 bradycardia,4 mucosal hemorrhages in the small intestine,5 and death from acute respiratory arrest, pulmonary edema, ventricular fibrillation,6 and cerebral edema.7 I was interested in the ages most users began experimenting with huffing Freon. My interviews revealed a 15-19 year-old age range for peak huffing behavior. With the exception of one interviewee for whom Freon remained his drug of choice (he had schizophrenia and

he felt it best quieted the voices he heard), all described the behavior as more prevalent among adolescents and young adults. When asked why they stopped huffing Freon when they continued other substance-abuse behaviors into adulthood, interviewees expressed that it was something they grew out of. They described Freon huffing as “immature” and even “childish.”

Abundantly Available When I pressed them further on why teenagers huff, a consistent theme emerged: Teenagers often lack the finances to obtain the more elusive, “sexy” drugs. As a corollary, one interviewee observed increased huffing with the worsening economy. It is abundantly available and simple to procure at little to no cost.

Interviewees also shared information about the experience itself. The act of huffing Freon was commonly described by proper name, but was also referred to as doing “speed,” “nitro,” “tanks,” “air blasts,” “air heads,” and “getting hot.” (These terms were used interchangeably to also describe the act of huffing nitrous oxide.)

The compelling reasons given for usage included easy access, affordability, fast administration, a pleasurable “rush” similar to asphyxiation, long lasting effects (compared to aerosols), effects similar to mescaline, and claims that it does not cause a “hung over” feeling or uncomfortable “come-down.”

Barriers to accessing the gas were rarely reported beyond confronting gated private property. Only one interviewee reported encountering a locking cap over a Freon air conditioning service port on his second visit to a fire station. None of the interviewees had ever seen educational materials about the dangers of Freon huffing. All had been introduced to the behavior by friends or family members.

While the type of data I gathered through my informal interviews is qualitative, these trends can be corroborated by the CDC’s 2009 Youth Risk Behavior Surveillance System (YRBSS).

Nationally, the prevalence of huffing spray cans, inhaling paints, and sniffing glue is 11.7 percent of the youth surveyed. Even more disconcerting

is that huffing peaked nationally for 9th graders, the youngest population surveyed, at 13.0 percent. In the San Bernardino district, 18.9 percent of the youth surveyed in the YRBSS had huffed, with peak prevalence in the 9th grade population of a staggering 24.8 percent.8 Focus on the Freon huffing issue should now be shifting from problem identification to strategic intervention. As individual physicians, we can broaden our questioning during wellteen checks and educate and warn parents to watch for unlocked Freon valves in their neighborhood or other easily accessible canisters. With a few simple actions, we can work to combat this unaddressed threat to our nation’s youth. msilva@westernu.edu 1 Office of Statewide Health Planning and Development, California Mechanical Code, Title 24, Part 4, 2009 Uniform Mechanical Code Section 1106.3.1.

2 Kurbat S, Pollack C. Facial injury and airway threat from inhalant abuse: a case report. The Journal of Emergency Medicine.

1998;16(2):167-169.

3 Kubota T, Akimasa M. Acute Inhalational Exposure to Chlorodifluoromethane (Freon-22): A Report of 43 Cases. Clinical Toxicology. 2005;43:305–308.

4 Edling C, Ohlson CG, Ljungkvist G, Oliv A, Soderholm B. Cardiac arrhythmia in refrigerator repairmen exposed to fluorocarbons.

British Journal of Industrial Medicine. 1990;47:207-212.

5 Koreeda A, Kosei Y, Sohtarou M, Yuki O, Shigeyuki T. An accidental death due to Freon 22 (monochlorodifluoromethane) inhalation in a fishing vessel. Forensic Science International.

2007;168:208–211.

6 Fitzgerald RL, Fishel CE, Bush LLE. Fatality Due to Recreational Use of Chlorodifluoromethane and Chloropentafluoroethane.

Journal of Forensic Sciences, JFSCA. 1993;38(2):476-482.

7 Phatak DR, Walterscheid J. Huffing Air Conditioner Fluid: A Cool Way to Die? Am J Forensic Med Pathol. 2010 Apr 19.

8 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2009. Surveillance Summaries, June 4, 2010. MMWR Vol 59, 2010.

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May/June 2012

29

What’s Hot and What’s Not Early Electro-Thermotherapy for Musculoskeletal and Other Ailments

By Kent M. Perryman, PhD IF ONE LOOKS AROUND THE Sierra Sacramento Valley Medical Society’s Medical History Museum, they can’t help but notice the variety of clinical heating devices that Dr. Bob LaPerriere, our curator, has collected.

Heat therapy has been promoted since the time of the ancient Greek and Roman civilizations to treat sore muscles and injuries.

Heat treatments were thought to increase blood flow for tissue healing and to decrease pain.

Prior to the advent of pharmacotherapy and antibiotics, heat therapy was applied directly to the body for pain relief. Traditionally, this took the form of hot water. Thermal spas built near natural volcanic vents diverted water to pools for public baths. The ancient Roman baths were renowned for this. Even today, spas and hot tubs are still marketed for their hydrotherapeutic benefits.

Here I report on the early 20th century development of electrical devices to generate superficial and deep tissue heat.

Nikola Tesla and the Tesla Coil1

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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Sierra Sacramento Valley Medicine

Following shortly after the invention of Edison’s incandescent light in 1891, Nikola Tesla introduced his Tesla coil. The circuit consisted of coil instead of iron core transformers, capacitors and a spark gap that could produce much higher voltage than that produced by conventional transformers. These coils were primarily incorporated into radio transmitters.

Tesla, an electrical engineer, had left employment with Edison after Edison’s insulting offer for a raise. Tesla displayed his coils at the 1893 Chicago World’s Fair along with some of his early Violet Ray machines.

Violet Ray2, 3, 4 Tesla believed his coils could be used to generate deep tissue heat for therapeutic purposes. Our society’s medical museum has a number of early hand-held and larger cabinetsize electro-thermotheraputic devices known as “Violet Ray Instruments” that utilize the Tesla coil for their operation.

One common misconception about these instruments is that they emit ultra-violet radiation: This is not true. The violet light given off by the soda glass wands (electrodes) is due to the ionization of oxygen molecules in a partial vacuum. The amount of the vacuum determines the color spectrum of light emitted.

Some of the early glass wands manufactured in Europe were filled with neon that emitted an orange glow. The glass wands used as vacuum condenser electrodes were introduced in 1897

by Dr. Frederick Finch Strong. These electrodes permitted high-frequency currents to penetrate tissue without burning the skin. Dr. Strong went on to develop various configurations of these glass wands to accommodate bodily orifices.

A booming electro-therapy market existed in the United States in 1910 (see “The Popularity of Early Electrotherapeutic Hokum” in the July/ August 2008 SSVM issue). Around that time, a Violet Ray device with the Tesla mechanism appeared which was capable of being screwed into a light socket (if the homeowner was fortunate enough to have light switches and

sockets).

Some of these Violet Ray instruments could operate on direct current from a battery, as well as alternating household current.

Some of the Violet Ray devices were equipped with additional metal electrodes for cauterizing small growths such as warts and moles, or even wound bleeding. These early “cauterizers” may well have been the predecessors to Bovie cautery or electrocautery.

Companies such as A.S. Aloe, Remco, Master and H.G. Fischer manufactured these devices and marketed them for home use through mail-order catalogs, newspaper ads, medicine show promotionals, Sears & Roebuck Company, and Montgomery Wards. The “Violet Ray” eventually became known as the “Violet Ray Generator.”

By the 1930s, many of the Violet Rays were promoted in hair salons as beauty aids and to promote hair growth. Much of the marketing of Violet Ray Generators was based on pure quackery.

Each device included in its packaging a list of maladies that could be cured — “bladder disease,” “brain fag,” “diabetes,” “eczema,” “female troubles,” “flabby breast,” “cancer,” etc…! The FDA pulled the plug on most “medical” Violet Ray Generators in 1953 due to fraudulent marketing claims.

Diathermy (Electrically-Induced Heat) Diathermy, a cousin to the Violet Ray, was a spinoff of Tesla’s coil and spark gap. Diathermy generates more high-frequency energy to heat deep tissue. Dr. Franz Nagelschmidt came up with the term “diathermy” and first used it in 1907 in his medical practice in Berlin. Conventional longwave diathermy became illegal in 1954 because of its interference with radio transmissions. The FCC made exceptions for electrically-shielded machines that prevented waves from escaping beyond the building where it was used.

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Subsequently, short-wave diathermy (SWD) used shorter length radio waves to heat tissue by a rapidly-alternating electrical field. It was very popular in Europe during the 1920s to treat pneumonia. Surgical diathermy also became very popular at this time to cut, coagulate and fulgurate tissue. Unlike Violet Ray, which used “Ohmic” heating (passing an electric current through conductive tissue) to cauterize, diathermy employed dielectric heating, which is produced by the rotation of molecular dipoles in an alternating current field. Small electromagnetic fields are created within the tissue that raises the temperature.

Diathermy has had a more reputable therapeutic history than the Violet Ray treatments. Diathermy has been demonstrated to increase blood flow to treatment areas, assist in reducing inflammation, increase the extensibility of deep collagen, decrease joint stiffness and relieve deep muscle pain and spasm. There is considerable evidence, especially in the sports medicine and physical therapy literature, to support the application of SWD and pulsed SWD for soft tissue healing.5, 6, 7 Unlike the Violet Ray devices, diathermy machines were never marketed for home use.

Rather, the machines were used by health care practitioners in a controlled environment such as a private practice or a hospital. Early on, there were problems with significant burns

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from SWD, but by 1954 as long wave diathermy became illegal, improved circuits and electrodes made burns infrequent with SWD and it was a relatively safe modality.

Microwave diathermy made one last foray into the electro-thermotherapy field during the 1950s with the advent of the multi-cavity magnetron tube. The microwave energies could be more accurately focused on a tissue region using a feed horn antenna. However, the RF energy could not penetrate as deeply as SWD. With the introduction of pharmacological interventions in the 1950s to treat soft tissue injuries, the use of all forms of diathermy dwindled. It is interesting to consider these devices as precursors to common energy devices used today like the Bovie in surgery, laser, lithotripsy, and radiofrequency ablation for cancer or brain lesions.

The most common method of electrothermal heating used today is ultrasound. First used for medical purposes by another Berliner, Dr. Pohlman, in 1938, it is still used to treat tendonitis, bursitis, and degenerative arthritis.

Humankind has sought heat for relief of various ailments likely ever since they felt the warmth of the sun on their backs. Engineering and science continue to develop ways to improve the delivery of thermal energy for medical use. Both Violet Ray Generators and diathermy machines evolved from the Tesla coil when very little was known about the therapeutic effects of employing electrical energy to heat deep tissue.

Fortunately, not many people were seriously harmed in their development, but how many were helped is questionable. kperryman@suddenlink.net 1 http://en.wikipedia.org/wiki/Nikola_Tesla 2 McCoy, Bob. Quack!: Tales of Medical Fraud. Santa Monica Press. 2000.

3 Baar, Bruce. The Violet Ray Book. Baar Products. 1971.

4 http:/www.cayce.com/vray.htm 5 Introduction to Short Wave Diathermy: Nature, Clinical Indications, Therapeutic Technic; Illustrations. H.G. Fisher. H.G. Fisher & Co., 1937.

6 Downer’s Physical Therapy Procedures: Therapeutic Modalities.

R. E. Oestmann and A. H. Downer Charles C. Thomas Pub Ltd; 6th edition, 2003.

7 Continuous Short-Wave (radio-frequency) Diathermy. G. C. Goats. Br. J. Sports Med., 1989 23: 123-127. http://www.ncbi. nlm.nih.gov/pmc/ articles/PMC1478624/

Board Briefs March 18, 2012 The Board: Approved mailing the May/June issue of Sierra Sacramento Valley Medicine to all nonmembers with information regarding becoming a member.

Approved expending funds for the re-development of the SSVMS website that will include interactive features when SSVMS converts to its new database in June, and it will help facilitate usage by members and the community.

Approved the 2011 Fourth Quarter Financial Statements and End of Year Investment Reports.

Approved recommending to the CMA Political Action Committee (CALPAC) and the AMA Political Action Committee (AMPAC) their support of Ami Bera, MD, candidate for the Seventh Congressional District.

Approved readjusting the number of SSVMS Delegates and Alternates for the 2012 CMA House of Delegates in accordance with CMA 2011 end-of-year membership numbers.

Approved sending a letter of congratulations to Adam Dougherty, MPH, MS II, recipient of the American Medical

Association Foundation’s 2012 Leadership Award. The award provides medical students, residents/fellows and early career physicians from around the country with special training to develop their skills as future leaders in organized medicine and community affairs.

Approved the Membership Report: For Active Membership — Lori P. Burrey, MD; Kit Chang, MD; Christian P. Feinauer, MD; Mathew S. Foley, MD; Guruswami Giri, MD; Malathy Kapali, MD; John D. McCracken, MD; Billur C. Moghaddam, MD; David H. L. Ng, MD; Amrick S. Sandhu, MD; Michael J. Uhrik, MD; Eric R. Zacharias, MD. For Retired Membership — Jonathan R. Beck, MD; George A. Hahn, MD; Ernest E. Johnson, MD. For Resignation — Karen R. Gill, MD (transferred to San Francisco); Richard C. Graves, MD (moved to Chowchilla); Patricia M. Kopko, MD (transferred to San Diego); Vilasinee Morkjaroenpong, MD (moved to Pasadena); Jyoti Saxena, MD (transferred to Solano); Sailesh Shah, MD; Jason H. Solomon, MD.

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 Burrey, Lori P., Pediatrics, University of Texas, Galveston 2005, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-7334

Giri, Guruswami, Ophthalmology/Vitreo-Retinal, Stanley Medical College, India 1987, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015

Chang, Kit, Urology, Mount Sinai School of Medicine 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5355

Kapali, Malathy, Pathology/Cytopathology, University of Madras, India 1985, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Coates, Robert M, Jr., Psychiatry/Child & Adolescent Psychiatry, Wayne State University 2003, The Permanente Medical Group, 7300 Wyndham Wy, Sacramento 95823 (916) 525-6100

McCracken, John D., Gastroenterology, Loma Linda University 1985, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5380

Feinauer, Christian P., Emergency Medicine, University of Utah 2003, CEP/MedAmerica, Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 733-3003

Moghaddam, Billur C., Pediatrics/Clinical Genetics, University of Istanbul, Turkey 1989, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Foley, Mathew S., Emergency Medicine, George Washington University 2004, CEP/MedAmerica, Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 733-3003

Newman, Alison W., Psychiatry, Vanderbilt University 2006, The Permanente Medical Group, 7300 Wyndham Wy, Sacramento 95825 (916) 525-6100

Ng, David H., Nuclear Medicine, Loma Linda University 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7007 Sandhu, Amrick S., Internal Medicine, Kasturba Medical College, India 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Uhrik, Michael J., Internal Medicine, St. Louis University 1988, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5200 Wartell, Anthony E., Neonatal-Perinatal Medicine, University of Arizona 2004, Community Neonatology of Sacramento Medical Group, 6501 Coyle Ave, Carmichael 95608 (916) 537-5135 Young, Barry K., Anesthesiology, Tulane University 2000, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990 Zacharias, Eric R., Emergency Medicine, UC Davis 2005, CEP/MedAmerica, Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 733-3003

May/June 2012

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In Memoriam

James O. Farley, MD 1925–2012

JAMES O. FARLEY, MD, PASSED AWAY on March 5. He was born in Detroit, MI on June 18, 1925 to Sylvia Murray and William John Farley.

The family then moved about 60 miles north of Detroit to Davison, MI where his parents owned a restaurant and ice cream plant.

Jim went to school and graduated from Davison High School in 1942.

In the fall of that year, he enrolled in Albion College as a pre-med student.

It was during the war, so Jim joined the Navy V-12 Program. At the end of his first year, he was sent to Tufts College in Massachusetts and later to Midshipman’s School in Chicago. He received his Naval Commission in January 1945, and was transferred to James O. Farley, MD the Philippines to take command of a Landing Craft Tank.

After the war ended, Jim returned to Albion College where he met his bride to be, Marlyn A. Barnett. After finishing college, he enrolled in the Wayne University School of Medicine.

Jim completed his studies in June of 1952. He and Marlyn were married that same month and then traveled to Sacramento, CA where Jim completed his internship/residency program at the former Sacramento County Hospital.

While there he met and formed a partnership with William L. Hedges, MD. They practiced together for 22 years. Jim then joined the Kaiser organization in 1977 and was appointed Chief of Family Practice. He retired from Kaiser in 1989. While in practice, he was quite active in medical politics. He served on numerous SSVMS committees and was honored being elected president in 1969.

Kind postings to the online memorial guestbook include many touching remarks, such as: “He served the medical community with his professional skills and compassion. Jim 34

Sierra Sacramento Valley Medicine

was the consummate example of the qualities that a physician possesses. He has been an inspiration to me as what we should strive for, not only professionally, but personally bringing love to his family and support to his colleagues.” —Ralph Sett, MD

Marlyn Barnett Farley 1928–2012 Just two weeks after Jim’s death, his widow Marlyn passed away on March 19. Marlyn was born on July 4, 1928 in Detroit, MI to Esther Rask and Guy Barnett. She was raised in Detroit and graduated from Redford High School in 1946. She then attended both Albion College and the University of Michigan. She graduated from UM in 1950 receiving a Bachelors of Art in Latin American Studies. When Marlyn attended Albion College she met Jim, her future husband, while both were studying in the library.

After graduation, Marlyn worked in Chicago, IL for the Lions Organization publishing their international monthly magazine. After their wedding and move to Sacramento, she attended California State University, Sacramento to obtain a teaching credential. Marlyn enjoyed freelance writing and was published in both local and national publications.

Jim and Marlyn are survived by their four sons: James T. Farley, Thomas G. Farley, William C. Farley and David S. Farley; two daughters-inlaw, Nanette S. Farley and Shannon R. Farley; and two granddaughters, Lauren E. Farley and Catherine H. Farley.

Those wishing to make donations may select a charity of their choice or the William Dochterman Memorial Scholarship Fund at the Sierra Sacramento Valley Medical Society at 5380 Elvas Avenue #101, Sacramento, CA 95819.

In Memoriam

Edward A. Smeloff, MD 1925–2012

EDWARD SMELOFF PASSED AWAY March 23 at Sutter Memorial Hospital where he had spent his entire professional career as an innovative and courageous cardiac surgeon. The list of Ed’s achievements and “firsts” helped to make the Sutter Heart and Vascular Institute and Sutter Institute of Medical Research a standard in cardiovascular surgery here in the west. Ed’s goal was to have Sutter exceed the standards of university cardiac programs, and in this respect, he succeeded very well.

He married the love of his life, Jennie, and they remained inseparable for 49 years until Jennie lost her struggle with lung cancer in 1998. Ed is survived by his four children: Chris Lodge and her children, Quint and Eric; son, Ed Jr., wife Diana and their children, Alex and Maya; son, Jeffrey and his son Jarrett; and daughter, Elizabeth.

Ed was born and grew up in Allentown, PA of Russian parents. He was the second of three sons of Beatrice and Nicholas Smeloff. Ed loved Slavic humor and all of us smiled when he turned on the Russian accent! Ed graduated from Temple University in 1948, then moved to Pittsburgh for his surgery residency just as “open heart” was about to revolutionize care of heart disease. He devoted the rest of his life to this specialty.

Ed was drafted into the Air Force in 1953 and was stationed at Luke AFB where he met Milo Nittler, MD, who presciently introduced Ed and his young family to California. The Smeloff family drove from Pennsylvania to Sacramento in 1957. Ed chose Sutter Memorial Hospital to start this new heart surgery specialty, and personally spearheaded the development of an animal research laboratory in the basement of Sutter to organize a “team” and develop their own heart lung machine. On September 24, 1959, the first “open heart surgery” in central California was

completed successfully at Sutter Memorial.

Ed’s engineering background and curiosity led him to join hands with the Bio-Engineering Department of Sacramento State College, and he invented and produced a titanium heart valve which was the “state of the art” for many years. Ed was recognized internationally for the Smeloff-Cutter Valve, and he graciously donated the royalties from this invention to the Sutter Institute for Medical Research.

With the help and expertise of Malcolm McHenry, MD, and Glen Caylor, MD, the first ICUs with monitoring and specially-trained ICU nurses were set in place. Over 40,000 open heart surgeries have now been performed at Sutter Memorial with Edward A. Smeloff, MD exemplary survival statistics. The Sutter Heart and Vascular Institute continues at the forefront of cardio-thoracic surgery and delivers the region’s most comprehensive and advanced cardiac care.

Over 15 fully-trained cardiovascular surgeons have been recruited to join Ed here in Sacramento, and each has contributed their experience and talent to the Sutter heart team, providing pediatric and adult heart surgery, heart transplantation, ventricular assist device therapy, atrial fibrillation therapy and most recently, transcatheter aortic valve surgery. Dr. Smeloff was also the recipient of the SSVMS Golden Stethoscope Award in 1995.

From Ed Smeloff’s pioneering efforts, imagination and dedication, the citizens of California have received a widely-recognized center for the care of infant and adult heart disease that remains his finest memorial. Ed’s spirit and enthusiasm still guides us.

— Michael T. Ingram, MD, and Paul B. Kelly, MD

May/June 2012

35

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