2007-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE

May/June 2007

Sierra Sacramento Valley

Medicine

We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication.

PRESIDENT’S MESSAGE Your Future New Tax Bill

A Solo Physician’s View on a CalPERS Data Bill

Richard Jones, MD

Lee Snook, MD

LETTER TO THE EDITOR The Right to Sell Organs

Gaseous Planet — The Paris Hilton Rules

The “Omes” Are Coming!

Harrison Chow, MD, MS

David J. Gibson, MD

Board Briefs

“Sacramento’s Best Docs”

F. James Rybka, MD

BOOK REVIEW A QOD, QTD, Q?D Diet

Posit: The Right to Profit and Health Care

Ted Fourkas

Missed Diagnosis

Working as Ship’s Doctor on an Antarctic Icebreaker

Nathan Hitzeman, MD

John Loofbourow, MD

Voices of Medicine

Del Meyer, MD

SSVMS Can Now Accredit CME Programs

WINNING STUDENT ESSAY A Healthy Solution

Kristine Wallach

New Applicants

Gabe Schamberg

To Be or Not To Be... Pregnant, that is

Classified Ads

Ruth Haskins, MD

inside back cover A Trip to Antarctica

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

SSV Medicine is online at www.ssvms.org/magazine.asp

Ophthalmologist Dr. Barbara Arnold painted this watercolor of the Alcázar of Toledo, Spain, in September 2003. She sketched it from a hillside used by renowned artists in the past; the Tajo River is in the foreground. She tried to capture the important features of the landscape; one result was an intensification of colors, and omission of many homes at the scene. The original watercolor is 14 by 20 inches, on 140-pound cold press Arches cotton rag.

Volume 58/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

The Alcázar of Toledo was a Roman palace in the 3rd century. It was the site of a battle between Spanish Nationalist and Republican forces in 1936, and became an important symbol for the Nationalists. bjarnold@ucdavis.edu

May/June 2007

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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. 2007 Officers & Board of Directors Richard Jones, MD President Margaret Parsons, MD President-Elect Kuldip Sandhu, MD, Immediate Past President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Charles McDonnell, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD 2007 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Barbara Arnold, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Tom Ormiston, MD At-Large Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Margaret Parsons, MD Charles McDonnell, MD Robert Midgley, MD Janet O’Brien, MD Richard Pan, MD Earl Washburn, MD

District 4 Ulrich Hacker, MD District 5 Eduardo Bermudez, MD David Herbert, MD Elisabeth Mathew, MD Stephen Melcher, MD District 6 Marcia Gollober, MD Alternate-Delegates District 1 Robert Kahle, MD District 2 Samuel Ciricillo, MD District 3 Ken Ozawa, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Craighton Chin, MD At-Large Alicia Abels, MD Christopher Chong, MD Marcia Gollober, MD Robert Jacoby, MD Anthony Russell, MD Kuldip Sandhu, MD Jeff Suplica, MD

CMA Trustees 11th District Joanne Berkowitz, MD Dean Hadley, MD Solo/Small Group Practice Forum Lee T. Snook, MD Very Large Group Forum Paul R. Phinney, MD Council on Scientific Affairs Allan Siefkin, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor David Gibson, MD, Vice Chair William Peniston, MD Robert LaPerriere, MD Eleanor Rodgerson, MD Gordon Love, MD F. James Rybka, MD John McCarthy, MD Gilbert Wright, MD Del Meyer, MD Lydia Wytrzes, MD George Meyer, MD John Ostrich, MD Medical Students Robin Telerant

Tasha Marenbach

Managing Editor Webmaster Graphic Design

Ted Fourkas Melissa Darling Kelly Davis

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

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President’s Message

Your Future New Tax Bill By Richard Jones, MD I had reconciled my fears of getting a root canal by mentally chanting the mantra of “it won’t hurt a bit.” But April might not have been a good month to visit my dentist… The morning I showed up was the day after my dentist had been to the accountant. Understandably, he was still fuming at expenses and deductions that had not saved him from an unexpected tax bill. Given the mouthful of buzzing, grinding, lasering and stinging instruments that could have been inserted in a fit of trembling rage with in my tender oral cavity, I used my most sympathetic and calming tones, stating that I felt his pain! Since my accountant’s visit wasn’t much more pleasant, then, too, I could have used some novocain for the 1040. Only a short time ago, we all had to sit down and undergo the punishing process of doing our taxes. We struggle to find mortgage deductions, investment credits, equipment purchase, car leases, “business meals” and dependents to be itemized — all in a valiant effort to defervesce the tax burden. It is an annual rite of passage that we face the IRS (our personal internal revenue reducing service) and the State Board of Equalization (appropriately named because after paying out the tax rate of 10 percent, our income seems greatly equalized closer to zero). While we do live in a nation and state that is worth paying to support, it is ironic that although overall health care GDP expenses are increasing and the tax rates creep upward, the rates we receive as physicians in inflationadjusted reimbursement are but 40 percent of what they were 10 years ago. Additionally, Medi-Cal reimbursements are the lowest in the nation and the prospects of further Medicare and Medi-Cal cutbacks for the

future are very real. If unchallenged by organized medicine’s efforts, rates will decrease 30 percent for Medicare (the de facto standard to which all Medi-Cal and commercial rates are pegged). So as we are accustomed to receiving our annual governmental tax solicitations for some rather meager return of service, let’s consider what it would be like if you had another tax statement — one sent out by the California Medical Association (CMA). Perhaps it would read like the table on the next page. Even for an Enron accountant or those of us who don’t balance their checkbook regularly, it is easy to see the value. The benefits earned by the CMA and SSVMS to our patients, society and our own well-being far outweigh the meager cost and represent a phenomenal return on investment! Hedge funds, real estate, and even corporate HMO executives stock options pale in comparison. Ask your non-member colleagues about how they feel about their state and federal taxes. After the expletives cease and you have wiped the spittle away, remind your non-member colleagues of the taxes they have not paid this April. Clip the table out and present it to them. Then let them know about this potential tax bill that the CMA and our county medical society and YOU have prevented them from receiving! Then ask them to join and do their part. Make your colleagues understand that without the support of the nation-leading CMA and SSVMS they would otherwise be faced with an annual medical tax bill like this and a far more dysfunctional medical community poorly serving our patients. Without the ongoing defense of CMA

May/June 2007

and SSVMS, come some April, physicians in California would be faced with a 39 percent federal tax bracket, a 10 percent state tax and this future Medical Tax. Undoubtedly, with this scenario April would be a very ill-tempered month for physicians. My dentistâ&#x20AC;&#x2122;s reaction to his taxes was bad

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enough now; but in that future April or May, I would much rather then visit my dentist than my proctologist! Support CMA/SSVMS for a pain-free future. It wonâ&#x20AC;&#x2122;t hurt a bit. rajones@sbcglobal.net

Letter to the Editor The Right to Sell Organs The notion of owning one’s own body seems odd to some, but if we don’t own it ourselves, who does? Historically, after death, bodies were the property of the deceased’s relatives, like the rest of the deceased’s estate or as part of a family’s right to bury their dead. Inherent in this traditional approach is the notion of ownership, either by the deceased or the family. But that isn’t how the government sees it. The President’s Council on Bioethics, the U.S. Dept. of Health and Human Services, and the New York State Legislature are discussing presumed consent as a possible solution to the organ shortage. Presumed consent really is no consent at all. Presumed consent is a form of “conscription.” Unless individuals make their contrary wishes clearly known, the government will take possession of their organs and use them as they see fit. It seems rather undemocratic for the government to presume anything regarding my wishes, let alone the notion that the government has the authority to presume what I want to do with my body while alive or after death. If not conscription, perhaps the proper analogy is eminent domain, in which case, fair compensation is due. Either way, the government is taking something of value from one set of citizens without their consent to benefit others, and those benefiting are not just the recipients dying on the organ donor waiting list. Doctors aren’t expected to harvest or implant organs for free. Hospitals aren’t expected to provide their surgical facilities and recovery rooms for free. Organs aren’t transported from one facility to another for free. Organ and tissue banks all make nice size profits, as do the companies that use donated bone and tissue to manufacture all sorts of medical products used in surgery. It is revealing that everyone is making money except for the people who provide the raw material. No wonder some patients feel cheated when what they give for altruistic reasons is used to make others millions.

The solution to the organ shortage is to allow a free market in all aspects of organ and tissue procurement. Let the market do what it does best – match those with goods and services with those who need them. It would be nice if altruistic motives were enough to provide all the organs and tissues needed, but why, in a society where the exchange of money for goods and services is the norm, should people be limited to the two options of giving their bodies away or having the government take them without asking? The organ shortage kills more than just the people who die waiting on the organ donor list. Transplant surgeons argue that organs should be harvested earlier by reverting back to heart/lung indications for death instead of waiting for brain death; people get sick because organs are harvested without full medical screening; selling organs on the black market has caused multiple cases where people became ill due to contaminated bone and tissue transplants; and funeral homes steal and sell organs and other body parts on the black market. To make a real dent in the organ shortage, states don’t need more laws, more police investigations, more active recruitment of donors, or more aggressive tactics to get families to donate; what they need is a legitimate market. Let people sell their kidneys while they are alive (most people have two), and let people stipulate in their wills that they want to sell their organs, bone and other tissues at death. Insurance companies can create real incentives — financial incentives — to get people to donate. Incentives such as a partial reduction in premiums when someone signs up as a donor and the payment of funeral expenses once the organs are harvested. The real way to stop the transplant nightmare is staring us in the face. Just let people do what they naturally do — exchange money for goods and services.

It is revealing that everyone is making money except for the people who provide the raw material. No wonder some patients feel cheated when what they give for altruistic reasons is used to make others millions.

Sigrid Fry-Revere, J.D., Ph.D. Director of Bioethics Studies, Cato Institute

May/June 2007

The “Omes” Are Coming! The Ome era will demand real bench based scientists, not the clinical study stamp collecting that masquerades as scientific training in our medical schools today.

By David J. Gibson, MD I have an enduring interest in the way disrupting technology changes the course of history. Accordingly, I have been reading Roy Adkins’ masterpiece “Nelson’s Trafalgar.” On Monday, October 21, 1805, the French battleship Fougueux fired the first shot shortly after noon at the nearest British ship, the Royal Sovereign. The battle of Trafalgar was on! The shots from this broadside all fell short. Trafalgar was the beginning of the end of the Napoleonic era. Since Trafalgar there has been an uninterrupted decline in the influence and authority of the French. Trafalgar represented the zenith in the technology of sailing ships. However, these vessels could not point higher than 80-degrees off the wind; they were slow and took an inordinate amount of time to tack. Trafalgar was the last great naval battle using sailing vessels. Within 60 years, the first iron battle ship with steam engines was introduced to the fleet.

The Imperative to Change Dislocating technology occurred in Pearl Harbor. Until then, the battleship was the cornerstone of the U.S. Navy. The advanced deployment of aircraft using a carrier base ended the battleship era forever. Dislocating technology also has played a major role in medicine. Antibiotics were introduced during World War II and medicine changed for the better. In 1955, Jonas E. Salk began immunizing children at Pittsburgh’s Arsenal Elementary School. The rest is history. Dislocating technology is defined as being so manifestly better that the prior generation of technology cannot possibly compete. You would have

to be troglodytic to miss the power of disruptive technology as a change agent in history. A dramatic new example is about to unfold. The Omes are coming! Omes collectively represent the genome, proteome, epigenome, transcriptome and metabolome.1 In aggregate, the “omes” define an individual’s biology at the gene, protein and metabolic level. In the near future, Ome technology will redefine how we finance health care, how we define the role of the physician and the business model for how we manufacture pharmaceuticals. Our health care system during the antibiotic era has been structured around “blockbuster” therapy. During this era, most physicians treated most similarly diagnosed patients with drugs and devices without any knowledge of which patient would benefit. Physicians now rely on evidence-based protocols to make therapeutic decisions. We construct complex threedimensional grids based on the consensus of hundreds of barely conclusive studies to define truth. We then populate these hundreds of resulting cells to determine the appropriate “best practice” therapy for complex diseases like metabolic syndrome. 2 We have known the reliability of these protocols is flimsy at best, as has been demonstrated in the case of stents used to treat coronary artery disease, but grid-based protocols have been the best tools available. In the Ome era, treatment grids based on clinical trials will be remembered as hopelessly primitive. Clinical trial-based decision-making will be remembered as a quaint relic, similar to the use of leeches.

May/June 2007

Few of our patients know there is a concept called “numbers needed to treat,” or NNT. 3 This is an estimate of how many patients use a drug or treatment compared to how many benefit from it. For treatments considered “effective,” the NNT is typically between 30 and 80. That is, 30 to 80 people have to use a specific drug or device before one person will actually benefit. Doctors and researchers simply do not know which individuals will respond to what. Therefore, we treat as many people as possible in an attempt to benefit as many people as possible. This has generated monumental inefficiencies within the industry. 4 The implantable cardioverter defibrillator is a classic example. This device senses a lifethreatening abnormality in the heart’s electrical rhythm and rapidly delivers a shock to restore

Doctors and researchers simply do not know which individuals will respond to what. Therefore, we treat as many people as possible in an attempt to benefit as many people as possible. This has generated monumental inefficiencies within the industry. normal rhythm. The problem — out of every 100 patients who get this device permanently implanted, only 12 to 15 ever need it and receive the appropriate electrical discharge. The remaining 85 percent or more have a device that costs more than $50,000 to implant, carries a risk of infection and may “fire” inappropriately. More than 200,000 such devices are implanted in this country every year. On the pharmaceutical side, statins are among the world’s top-selling blockbuster drugs, with more than $15 billion per year in prescriptions. However, for every 100 patients who take a statin, only 8 to 10 derive any real benefit in terms of reducing the risk of heart attack, stroke or death. The remaining 90 percent or so are taking an expensive medicine — at a cost of $3 to $4 per day — with potential side effects. They gain the psychological comfort of a reduced cholesterol level but no real health value. The second most commonly prescribed medicine in our country is Plavix, taken to avoid

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blood clots. About 30 percent of patients do not respond to the common dosage and as a result are left vulnerable to developing potentially lethal blood clots. These outcomes are both rational and predictable. We do not test medicines in the same way that we prescribe them. Most medicines in common use have never been tested in the elderly population, whose metabolism and kidney function is dramatically reduced with age. In addition, most clinical drug trials are performed in low-risk populations that do not reflect the real world, where patients often have multiple co-morbidities and drug clearance compromised. This is where the Ome disruptive technology will be transformative. Medicine and the American economy simply cannot tolerate the inefficiency that our collective ignorance has generated to the present. We are now at the brink of an exciting discovery phase for biomedical research — one that will radically reboot medicine with new software. In the years ahead, we will tailor a specific therapy or prevention to a particular biologic vulnerability or need, one human being at a time. With the introduction of the Ome era in medicine, what will be the dislocating effect on the current financing and delivery system within health care? There are implications for health insurance companies, physicians and pharmaceutical corporations.

Health Insurance Companies Health insurance is based upon not knowing basic facts about the insured. Thus, large numbers of people not likely to generate medical cost are grouped with those who will. Those without chronic conditions or even the genetic predisposition for disease may have a catastrophic event that will require financial support from a third party, but most of the coverage they purchase today is a waste of their money. Thus, buying only high deductible coverage is economically rational for most people. As we move into the Ome era where the ignorance on which health insurance relies has been displaced, the current group model is not likely to

survive. We will need to rethink the entire concept of financing health care in the future.

The Physician Paradigm In 1906, following the proprietary drug scandals chronicled by Harpers Magazine, the development of the Division of Chemistry followed by the Bureau of Chemistry gave birth to the modern era of the Food and Drug Administration. With passage of the Federal Food and Drugs Act, physicians were entrusted with the sole franchise to diagnose and treat disease. Prior to this time, many health care practitioners, including pharmacists, filled this role. This paradigm, in which the physician is at the apex of decision-making in health care, is about to disappear. Diagnosing and treating individual patients in the Ome era will require a much broader and better trained group of professionals. This team will include geneticists, statisticians, physical chemists, biochemists, physicists and specialty pharmacists to name only a few. In short, the Ome era will demand real bench-based scientists, not the clinical study stamp collecting that masquerades as scientific training in our medical schools today.

Pharmaceutical Manufacturing The pharmaceutical industry is hopelessly wedded to the blockbuster-based business model. When Pfizer announced that it was halting clinical testing of its new cholesterol drug, torcetrapib, the company’s market value fell by $21 billion overnight; 10,000 job cuts followed. The ongoing promise of nearly $3 billion in annual sales vanished when Merck pulled Vioxx (rofecoxib) from the shelves, and the company’s market value fell by $25 billion. For decades, blockbuster drugs have nourished big pharma. That era is over. The Ome era demands orphan drugs manufactured for individual patients. The pharmaceutical manufacturing industry has demonstrated a complete inability to deliver to the market biopharmaceutical based drugs. These drugs are but a way station on the way to the orphan agents the Ome era will demand. I doubt any of the current manufacturers will survive the coming transition to the Ome

era. We will need new companies with radically different business models that are divorced from current investor expectations in the future. It is easier to lead a parade than turn it around. No group or industry has ever been able to impede disruptive technology. WWII battle ship admirals tried and failed. Physicians who denied the germ theory of disease tried and failed. A recent example involves the music industry. From 2001 to 2003 the industry pursued the single dumbest strategy possible in the digital age. It tried to stop the progress of technology and deny users access to a new download technology (peer-to-peer file sharing). The industry attacked and crushed Napster, which officially had more than 26 million users, but may in fact have had twice that many. This was accomplished by criminalizing the industry’s own customers. From our current vantage point, this effort failed. The question we face in the health care industry is how will we adapt to the Ome era? Resisting or even inhibiting the transformative

In short, the Ome era will demand real bench-based scientists, not the clinical study stamp collecting that masquerades as scientific training in our medical schools today effect of this technology is not an option. The CMA’s annual political warfare before the legislature each year over scope of practice is about to become a quaint historic relic. DJGibson@winfirst.com 1 The genome is the full set of chromosomes; all the inheritable traits of an organism. The proteome is the set of proteins expressed by the genetic material of an organism under a given set of environmental conditions. The epigenome controls the differential expression of genes in specific cells. The transcriptome is the set of all messenger RNA (mRNA) molecules, or “transcripts”, produced in one or a population of cells. Metabolome refers to the complete set of small-molecule metabolites (such as metabolic intermediates, hormones and other signaling molecules, and secondary metabolites) to be found within a biological sample, such as a single organism. 2 Int J Clin Pract Suppl. 2003 Mar;(134):3-9. 3 http://www.shef.ac.uk/scharr/ir/nnt.html 4 Some of the following data is excerpted from Dr. Eric J. Topol’s Op-Ed article, “A medical treatment all your own,” in the Los Angeles Times on 03-28-07.

May/June 2007

”Sacramento’s Best Docs” You’ve come a long way, baby. See you in court?

By F. James Rybka, MD In 1970, when I entered practice as a plastic surgeon, there were tight restrictions on physician advertising. You could send out announcement cards listing your address, phone numbers, medical and specialty training, and languages spoken. Period. These rules had been imposed for over a century by the Sacramento Medical Society (see box), but they generally were the same statewide — in fact, nationwide. Today, some specialists entering the area have probably budgeted a line of credit of $100,000 to “prime the pump” in advertising themselves. It began with the Yellow Pages but it now blankets every conceivable public medium. What caused this radical change was a US Supreme Court decision in 1977, Bates vs. State Bar of Arizona, which held that attorney advertising was protected by the right to free speech. After that, it wasn’t long before controversy occurred as younger, less experienced doctors tried to propel their practices in a conservative environment based on “word of mouth” for referrals. The area’s ophthalmologists, for example, had been a very traditional group until, “Ivan, the Eye Van,” suddenly hit town and, using clever ads, he offered a novel outpatient convenience that changed the practices of many. As advertising progressed, some of it became tacky and undignified. Years ago, I recall discussing it with friends from San Francisco, when the wife agreed saying, “Why, the other day, I had lunch at a restaurant near Union Square, and some plastic surgeon had posted his ad about breast implants right in the toilet stall of the

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ladies room!” Another thing that occurred about this same time was the demonstration that many surgical procedures could be done, just as safely, on an outpatient basis, saving the patient larger hospital costs. Sensing a loophole here, some minimally trained surgeons, or even non-surgeons, marketed themselves as “plastic surgeons,” or “cosmetic surgeons,” and set up well-advertised shops outside the scrutiny of any hospital credential committee. To their credit, plastic surgical societies instigated some laws prohibiting false and misleading advertising, and other rules that beefed-up the licensing of outpatient facilities. Still, too many loopholes exist. Although it nearly all seems bad, there was one minor providential effect of advertising in Sacramento: it reduced a smugness and snobbery that had begun to afflict a few wellestablished, central area doctors who, because of seniority and location alone, were benefiting disproportionately from “word of mouth.” Although most of the seniors were welcoming of younger colleagues who brought in fresh ideas, a few grumbled, and denigrated the newcomers as “marginal” doctors. Although “word from a trusted mouth” is still about the finest way to choose a physician, advertising made it no longer the only way. Unfortunately, many well-trained, advertising subspecialists now practice outside the hospital, and have dropped out of the medical society. I wish there was a way to attract them back in, because there is a wealth of talent out there. Their input would be valuable indeed as we attempt to solve the more important issues that will affect the future of American medicine. If even a small fraction of the money now spent

on advertising were redirected to the medical society, and used imaginatively for community health improvement, the benefits could be enormous. And it is not just the doctors now huckstering. Hospitals and drug companies are spending huge amounts of taxpayers’ money on advertising, driving up healthcare costs with no medical benefit. A physician relishing publicity might take notice how, apparently, some nebulous point exists where public accolades and self promotion can alter his status before a court of law. This past February, a decision in Sacramento by the Third District Court of Appeal looked into when an advertising physician advances to where he becomes “a limited public figure.” The arguments went something like this: Does the doctor issue such statements about his experience and expertise on a website, on TV or in a book that “injects him into the public debate?” If so, then he has “placed himself into the spotlight” and he “invites public attention and comments” regarding his practice. The case involved a distinguished, very welltrained colleague who, unfortunately, had a disgruntled and vengeful female patient. She established a counter website very critical of him. Calling some of her statements “false,” he understandably went to court to shut it down. But the court refused. It said her website was protected free speech because he was a

“limited public figure” who had cited how he had appeared on TV, written books, etc., about the particular surgery. Therefore, he was held to a higher standard. Even if her statements were false, he would need to show that they were made with malice. “Malice” is a much tougher standard because it means he would have to prove that she knew her statements were false when she issued them. Finally, a thought about the title of this article. Who are the best doctors in the city? I certainly don’t know. Do you know who they are? Who is in a position to know? It’s probably a lot easier to find out who the worst docs are. I am not sure how Sacramento Magazine determines this. I recall that they describe some survey that they do. Even so, the validity of this is immediately questionable. I do not know about Sacramento, but for some other city magazines, the “best“ may be big advertisers who are fed to the publishers by public relations agents. Even if that is not the case here, it raises an interesting question: When the magazine cites who is “the best,” is it pushing this particular physician across that legal line to the status of a “limited public figure?” If so, enter one vindictive patient and this honor could create a potential risk that the physician did not intend to take on. jimrybka@hotmail.com

The Historic View of Physician Advertising This text is from two sections of the Articles of Incorporation for the Sacramento Medical Society,1855 SECTION III.

It is derogatory to the dignity of the profession, to resort to public advertisements or private cards or hand-bills, inviting the attention of individuals affected with particular diseases… or promising radical cures; or to publish cases and operations in the daily prints, or suffer such publications to be made; to invite laymen to be present at (a public demonstration) of skill and success, or to perform any other similar acts. These are the ordinary practices of empirics, and are highly reprehendsible in a regular Physician.

SECTION IV.

Equally derogatory to professional character is it, for a Physician to hold a patent for any surgical instrument, or medicine; or to dispense a secret nostrum, whether it be the composition or exclusive property of himself, or of others. For, if such, nostrum be of real efficacy, any concealment regarding it is inconsistent with beneficence and professional liberality; and if mystery alone give it value and importance, such craft implies either disgraceful ignorance, or fraudulent avarice. It is also reprehensible for Physicians to give certificates attesting the efficacy of patent or secret medicines, or in any way to promote the use of them.

May/June 2007

Posit: The Right to Profit and Health Care “If health care is a ‘right,’ like life, liberty, and the pursuit of happiness, it follows inevitably that a free and competitive market — or unregulated profit — is inconsistent with that right.”

“Other than those serving in the military, those in prisons, and those at the extremes of life without any relatives to care for them, few others have any entitlement, or ’right’ to free healthcare....”

Summary: Some readers objected that the e-posit could be viewed two ways, so that to agree was to disagree; there is some merit to that position. The statement could have been better. Even so, there were diverse, and cogent, comments, so voluminous that we are forced to edit significantly. Unedited comments can be viewed at ssvms.org. “The US cannot afford 16 percent of the GNP to have inferior and inequitable care.” — Thomas March, MD “Any right must be earned, planned, and protected. Anything earned is appreciated and valued. Competition improves the product. Reward increases the endeavor to produce the product.” — Bryant Sheehy, MD “The basics of health care should be available to all citizens of the state. It is an implied contract between the citizen and the state that they care for one another. It is imperative upon the state to maintain the well-being of its citizens as its very existence is dependent on them. Competition in the provision of health care is not untenable in this light. Private medical attention can be bought and paid for by those who care for it. This should not interfere with everyone having health care available to them.” — Jose Ma C. Leuterio, MD “It isn’t the ‘free market’ that’s the problem. That would be fine on the level of the community physician. It’s the corporate predatory free market, which allows corporate clout, backroom political shenanigans, and high priced propaganda to distort the reality of healthcare needs in the name of profits.” — John McCarthty, MD

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“This sounds like jibberish. If you want an opinion, do not speak in cliché, or trite phrases, ask what you want to know.” — Gerald Upcraft, MD “Basically, the government is only obliged to protect its citizens against public health risks (epidemics, floods, enemy attacks). Other than those serving in the military, those in prisons, and those at the extremes of life without any relatives to care for them, few others have any entitlement, or ’right’ to free healthcare.... Those unable to pay, by tradition, have been cared for by religious and other organizations that embraced charity. In manning the charity hospitals, the government can demand that all new physicians must serve for a few years at a state salary before they break out into private medicine. Congress made a big mistake when Medicare was born by mandating upscale benefits, like a semi-private room — no more wards. Its over-regulation has produced massive administrative costs, all of which drain money away from the actual health delivery. Rather than a right to health care, the citizens have a right to expect the government to keep insurance rates affordable but, if no low cost insurance is available, then the government should provide a ‘bare-bones’ policy at charity hospitals. This will resurrect a two-level system of care, but at least everyone will receive some basic care.” — Jim Rybka, MD “I am in favor of a competitive market though I do not favor unregulated profit. My concern is who is responsible for ’regulating profit.’ If physician professional organizations are responsible for ’regulating profit,’ I would

certainly prefer this than having the government acting as the regulator…. Unfortunately, I am unaware of investigations…which address the question of assessing physicians’ ability to regulate profit based on factors such as certification, Continuing Medical Education, practice standard, etc.” — Scotte Doggett, MD “A free and competitive market to deliver health services provides no incentive for guaranteeing that there will be comprehensive care delivered at a basic level for all. Ensuring everyone a certain level of care requires more of a socialized approach (ahem, Canada). On the other hand, a free market provides very strong incentive for pharmaceutical companies to constantly strive to produce the next best drug, and for practitioners to strive to improve procedures that will not necessarily be practical or affordable for everyone. This topic is understandably a great point for debate.” — Abigail Kopecke, MD “Like most posits, this one is both controversial and overbroad in its description…. I live in Italy six months of the year and volunteer at a local clinic. I am impressed with the level of care provided, including diagnostics studies and the availability of specialty consultants, both for outpatient and inpatient care. As a permanent resident, I also am eligible for health care and receive this benefit at no cost to me. All Italian citizens and permanent residents receive this benefit. Italy spends 9 percent of its GNP on health care and all 60 million of its citizens/permanent residents are covered. These numbers are also applicable to France, Germany, Switzerland and the Benelux countries. The United States spends 14 of its GNP on health care and we have 46 million Americans who have no health care coverage. The difference that I see is that there is no concept of ’profit’ among the health care providers in Italy, who earn good incomes. “If health care is a ’right,’ then we as a nation are doing something ’wrong’ in our ability to provide care to our citizens. It would appear that the time is ripe for National Health Care, which appears to be a major platform issue for the Democratic Party. I do not have all the data, but would suspect that the cumulative salaries paid

to support the multiple layers of administrative costs of the nation’s health plans would be more than adequate to operate a National Health Plan. I am aware of the studies citing successes in some of the provinces of Canada; however, I am concerned that without some type of change the 46 million Americans without health care coverage will never ’profit’ from the current status quo.”— Michael Klein, MD “I can’t even believe that there is a question whether there should be a free market. Health care is not a ’right,’ it is a good that people purchase and make personal choices on where to get it and where to forego.” — James Sly, MD “It is inconsistent only if that market is the only available way to get health care. If there is an alternative ’free’ system, then the co-existence of a free market is not inconsistent with the right to health care.” — Evalyn Horowitz, MD “In order to address disparities in health related outcomes, health care must be available and accessible, both financially and geographically, to all those who live and work in California.” — Caroline Peck, MD “I believe that life, liberty, and the pursuit of happiness and health are rights. And that along with rights come some responsibilities; some individual and some societal. Pursuit of health and care of illness…are both societal and individual responsibilities.” — W. Hudson, MD “Healthcare is not a right, like those referenced in the US Constitution. Like education, healthcare is a resource for which a wise society will ensure that its citizens have basic access. However, as medical interventions become more sophisticated (and expensive), there must be a rationing of services in order to control costs, and the more sophisticated interventions should be provided to those who make secure the economic resources to pay for them. This is an important incentive for individuals to participate in purchasing healthcare insurance. In order to ensure a high level of insured individuals, a single payer national healthcare insurance should be established to cover catastrophic care.” — Adam Quest, MD “Non-free and non-competitive systems

May/June 2007

“If health care is a ’right,’ then we as a nation are doing something ’wrong’ in our ability to provide care to our citizens.”

“I don’t know if it is a ’right,’ but it is something that an advanced society should assure its members. What would our society be like if police, firefighters, and military were set up as competitive, for– profit businesses?”

cannot deliver services. This seems to be a lesson we must relearn and relearn. It is like living through a health policy ’Ground Hogs Day.’” — David Gibson, MD “Whether or not we choose to define it as a ’right,’ is it a service that we believe in and want to provide for our citizens? Would our society be safer, healthier and more prosperous if we decided to find a mechanism to ensure that our population has access to a reasonable level of basic health care, and eliminate this as a major source (the largest source) of personal bankruptcies? We have already essentially made that choice for our seniors — Medicare. It does not eliminate the private competitive market, witness all the Medicare supplement policies/HMOs, but that is really not the essential point. For people over 65, it guarantees a foot in the door — access to at least some basic health care without having to go through the most overburdened and dysfunctional part of our dysfunctional ’system,’ the Emergency Room. Every other developed nation has made this decision, but the wealthiest nation on earth — in the history of the earth — has not. I don’t know what we are waiting for.” — Francisco Prieto, MD “…In my view basic health care is a right and should be paid for with a garnish on every dollar earned by any U.S. worker anytime anywhere. Top drawer health care like any commodity is a luxury that not all can expect to have but must pay for.” — David Harrison, MD “I don’t know if it is a ’right,’ but it is something that an advanced society should assure its members. What would our society be like if police, firefighters, and military were set up as competitive, for–profit businesses?” — Felix Battisella, MD “Who says it’s a right? But, following such thinking, who is required to grant that ’right’? How about hot and cold running water? Is there anything we should take care of for ourselves? Should we prepare for rainy days, buy insurance, save for college, avoid driving while drinking or is it the government’s responsibility to grant us cradle-to-grave ‘rights’? To the contrary, I take care of the government by paying taxes aplenty. It depends on me; it has a ’right,’ encoded in

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law and culture, to be supported by me! Hey, you guys; have we lost our way?” — William Cushard, MD “The public will never get good health insurance coverage from a ’for-profit health insurance company.’ That should be the first thing to go.” — E. T. Rulison, MD “A right to health care is implied in the ’right to life,’ because one may need health care in order to continue one’s life. Similarly, a right to education is implied in the ’right to...the pursuit of happiness,’ as it is hard to be happy if one cannot constructively contribute to the economy and the society. For mysterious historical reasons, there is widespread acceptance of tax-supported education for everyone (at least through secondary school), but not for taxsupported health care for everyone.” — Patrick Romano, MD “Consistent with such a ’right’ is that healthrelated goods and services must be available to everyone at no cost. Those goods and services must therefore be provided by unpaid slaves, or otherwise paid for by resources confiscated from innocent victims. We have observed (failed or failing) political systems built upon similar ’principles.’ Many people claim that communism, socialism, or collectivism by any name, has just not been afforded a fair trial; and that we must continue to employ it in some fashion. I have yet to learn from those ’progressives’ or ’centrists’ what dose of socialist poison is most beneficial to an otherwise free society. Can anyone offer an explanation? An analysis of the world’s nations demonstrates that those with the greatest amount of individual and economic freedom — entirely consistent with unfettered free markets and capitalism — are the most prosperous. A narrative description of those findings is at www.freedomworks.org/informed/issues_ template.php?issue_id=2706 — ‘Who is the freest of all? — A look at the 2006 Annual Economic Report of the World,’ by Richard W. Rahn.” — Lee Welter, MD “I don’t see how ‘it follows inevitably that a free and competitive market is inconsistent with that right.’” — Jose Cueto, MD “In every competitive area, there are winners

and losers. In health care, the winners are the drug companies whose profits are many times greater than comparable corporations in other industries and the extremely highly compensated officers of insurance companies. Our biggest losers are the 50,000,000 uninsured in our country. Our other losers are our domestic companies that can’t compete with foreign companies having lower health costs. Inevitably, employers will lower wages as they try to keep up with soaring health care premiums. Then, all but a few of us will be free to be losers.” — Gil Simon, MD “None of our other rights, such as life, liberty, pursuit of happiness, right to bear arms, require the government to provide this service. All of our other rights require that the government leave us alone. This is where the ’right’ to healthcare, provided at government expense, becomes problematic. Maybe the government should also pass out arms with unlimited access to munitions.” — William Lewis, MD “…I don’t like the idea of physician income being regulated by the government or insurance companies but on the other hand, in today’s economic climate and with today’s physician’s use of ads that include more than just type of practice and qualifications, I’m not sure that we as a profession can manage physician costs to patients very well. In addition, there are all the costs, necessary or inflated by profit motive, of medications, medical equipment and facilities which are not necessarily controlled by our profession, either. Thus, I come to agree with the statement.” — Marlene Mirassou, MD “While I agree that competition often improves the product, I strongly believe that every person should have access to basic services. Leave the unregulated profit part to…those who want more than the basics, like we do our (public and private) school systems.” — Bette Hinton, MD “Health care is a privilege and not a right…. Rights are things that should not be taken from us. Privileges are things extended to us. Viewing health care as a privilege allows society to decide what basic services it will and will not provide as part of this privilege. Individuals can then

Missed Diagnosis

By Nathan Hitzeman, MD

You lurked on the ocean floor, plotting and grinning, And breached when the time was right, In the mid-day sun, For all to see. For all to see. So obvious, how could I have doubted your existence. You came as a Trojan Horse. I let you in, entertained you in fact, And when the time was right, And my defenses down, You unleashed mayhem, And infested my fortress. You inhabit the silences of my day. You are the letter I have yet to open. The uncomfortable conversation with colleagues I have yet to have. The face in the supermarket I loathe to see. You threaten my livelihood, my family’s future, my legacy, My satisfaction at the end of the day. And yet I cannot blame you for any of it. I can only blame myself.

make up any shortcomings they identify through personal health insurance or paying directly for those services. “I think we should extend vaccinations and well child care services as privileges to all Americans because these benefit society at large. From there, you extend privileges until the money runs out. Certain very expensive items, such as transplantation and artificial hearts, would probably not be on the menu.” — Bill Lewis, MD

May/June 2007

Voices of Medicine Not-so-humble physicians, thoughts of a 1,999-year-old, and problems in the ER.

By Del Meyer, MD

Vanity, thy Name is… MD? The Harvard Medical Alumni Bulletin has published “The Seven Deadly Sins.” This is from one of them, called “Vanity Fair,” by Peter Klass, MD. It appeared in the California Society of Anesthesiologists’ CSA Bulletin, Winter 2007. See www.csahq.org/pdf/bulletin/issue_15/Klass_064.pdf for the entire article. “Tell physicians you’re writing an essay about doctors and pride, and they immediately start to snicker. One doctor friend launched into his favorite joke: How many medical students does it take to change a lightbulb? One — to stand there and wait for the world to revolve around him. Several others offered anecdotes — the arrogance of a physician who doesn’t bother to learn the names of non doctor colleagues, the rudeness of a doctor who never returns calls, the boorishness of a doctor who leaves his dirty dishes in the conference room. “I protested, a little weakly, that character is more complicated than that. Those doctors may simply be plagued with a weak memory, or poor social skills, or bad manners; it wasn’t fair to interpret everything as just more evidence of the massive medical ego. But these were all doctors telling the stories, and, truth be told, they were more than a little self-satisfied in the telling — they were, each and every one of them, profoundly proud of having a keen eye for overly arrogant colleagues. “The issue of pride — and the perception of pride — permeates medical practice. You could call it doctors’ besetting sin. It’s part of almost every cliché about our behavior — and misbehavior. I can think of two jokes right this minute

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about doctors and our overweening pride — one is completely unprintable, while the other opens with a fellow making it up to heaven. While the recently deceased is standing at the Pearly Gates, St. Peter points out a bearded gentleman strolling by in a long white coat. ‘Look!’ St. Peter says. ‘There goes God. Sometimes he just likes to play doctor…’”

And Now for Something Entirely Different The same CSA Bulletin contains a spoof called “Laughing Gas: The 2,000-Year-Old Anesthesiologist,” by Kenneth Y. Pauker, M.D., Chair, Division of Legislative and Practice Affairs, Associate Editor. “With apologies to Mel Brooks and Carl Reiner. “Recently I was privileged to interview with Dr. Methuselah Z. Heffenweisser, an ancient man of healing, who is here in Southern California to promote his book, ‘How To Be Weiss Without Really Trying.’ Reported to be 2,000 years old, Dr. Heffenweisser also claims in his book to be the one to give the first general anesthesia. “KP: Dr. Heffenweisser, welcome to Orange County. It is a great honor for me to meet you after hearing for so many years of your exploits around the world. “MZH: Thank you so much, sonny. It’s just great for me after all my travels all over the world to make it to your California Riviera, although I must say that I have often layed out in da true Riviera, and diss, my son, is no Riviera. And where are the oranges? “KP: Oh, the oranges … Well, doctor, Orange County has changed. You’ll have to go to Florida now for oranges, but I’d like to ask you a few questions about your amazing life. So if I may,

I’d like to ask the question that is foremost on everyone’s mind. How could you possibly be 2,000 years old? “MZH: Two thousand years old? What are you talking about? I don’t know who told you that. NO, NO, NO, and NO! I’m not 2,000 years old!! “KP: You’re not? “MZH: Two thousand years old?! Look at me, sonny. Do I look 2,000? Come on! I’m not going to be 2,000 until next summer! “KP: So you are 1,999 years old? “MZH: In years, dat is correct, but inside beats da heart of a 28-year-old man. “KP: OK, then. Everyone would like to know how you have lived so long. Would you say that to stay young, you must be young at heart? “MZH: A young heart, yes! “KP: So it’s really about one’s attitude and one’s enthusiasm? “MZH: Who knows? Who cares? I had a heart transplant two years ago, and dey put in da heart of a 28-year-old man. Actually I had it done in India. Very economical. No waiting on lists. Done right in my hotel room, very convenient…” To read the entire spoof, please go to www. csahq.org/pdf/bulletin/issue_15/laughgas_064.pdf.

The Trouble with ERs Mohammed Arain, MD, discusses “EMR, ER Calls and Reimbursement” in his President’s Message, in the April issue of Vital Signs, published by the Fresno-Madera Medical Society. It is at www.fmms.org/pdf/Apr07_VS_FINAL.pdf. “There is talk all over about emergency room coverage by physicians and specialists. Increasingly, a number of hospitals have had to reinvent methods to keep their ERs open. Some hospitals have tried to close their ER, but due to loss in revenues from government-funded programs, they are forced to keep them open. “Emergency room patients used to be a source of support to new physicians to help them build up their practice. This has now become more of a liability. Patients who come to the ER are either using them as a free walk-in clinic or they are noncompliant and seek care only when their illness becomes serious. There

are patients who are acutely ill and need help, but ER patients are no longer a stabilizing source for physicians’ practices. “Taking the ER calls puts more strain on physicians’ already limited income and time. Many hospitals have recognized the need to work with the physicians and accommodate their needs, but even in this day and age, some hospitals have no guidelines for taking ER call. Some require staff to take ER call, irrespective of their age or health condition and they refuse to relocate some budgets and work with physicians. There are no other professions where one is forced to provide free service. One has to have some returns to survive. “Health insurance companies like any other businesses, have always kept up with the profits. The best buildings in any city are either banks or insurance companies. They keep increasing insurance premiums, keep cutting the benefits and keep on reducing the reimbursement to physicians. Since the rise of HMOs, the standard of payment has been Medicare or MediCal. BCCMP and healthy family programs pay even less than Medi-Cal. Even PPO insurance compares their payments with Medicare and Medi-Cal. “Office overhead is increasing every day due to increased paper work, more calls and more requirements by insurance carriers. Patients demand prescriptions and procedures which require pre-authorizations. Just to get authorization for needed procedures takes hours of calls. A full-time secretary is needed to have this done with no returns. Malpractice insurance carriers keep increasing their premiums and do not hesitate to drop clients depending on their own discretion. “All insurance carriers want electronic billing. The cost to set up can be up to $100,000, and the system can become obsolete the moment it is installed. The New York Medical Society is helping to fund physicians to set up an electronic system. Our California Medical Association is also seeking funding sources, including insurance companies, to assist California physicians in setting up their system.”

“Health insurance companies like any other businesses, have always kept up with the profits. The best buildings in any city are either banks or insurance companies.”

DelMeyer@HealthCareCom.net May/June 2007

Winning Student Essay

A Healthy Solution This is the winning high school entry in our first student essay contest. The winning college entry will be published in the next issue.

By Gabe Schamberg Despite many attempts to fix the problem, the cost of health care continues to be an issue throughout California and other states all over the country. As the cost rises at a rapid pace, more and more families are becoming uninsured, but we do not have the funds to provide unlimited health care for all citizens in California. This not only damages the process of health care, but it is affecting business profits, as well as family budgets. Over fifty percent of all bankruptcies are a result of health expenses. Over five million people all over California are currently without health insurance. Many of the uninsured use the emergency room instead of preventative measures, but the cost of visiting the emergency room is one of the most expensive aspects of health care. Money is not the only issue at hand, however, for some insurance providers will not cover people with risky occupations or certain prescription medications. This is a burning problem that needs to be fixed. The best way to solve the health care crisis in California is to have a tax-funded health care program in which health insurance is not required but all expenses are shared among citizens in a statewide tax. With any strategy that is used to fix the issue at hand, it is clear that a large amount of money will be spent. The decision that needs to be made is how the money will reach the hospitals, doctors, and health care providers. In a system in which no health insurance is required to get the necessary health care a person needs, a large amount of money will be saved. Currently,

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when a person buys insurance from a given agency, a portion of the money he pays is going to the office workers, advertising, other agency expenses, and profit. The taxes that would be collected would be the same amount of money minus all those extra business expenses. A taxfunded health care system would save time and effort by eliminating all the steps associated with buying a policy, making a claim, and arguing with insurance companies. Funding the system would require generating tax income to replace funds already paid to private insurers and other State government sources. A tax on business payrolls would actually be less expensive for the companies that had previously been providing coverage for employees while it would just be a small amount of money for companies that did not provide health care benefits. An exemption or deduction of these taxes could be applied to small businesses. Also, Federal funds that already go to California could be redirected into the taxfunded health care system. Ideally, our Governor and representatives to Congress would also be encouraging the Federal government to redirect some of the funds currently going toward the war in Iraq to the health care system. The remaining taxes would then be paid by the taxpayers of California, who are now without the burden of insurance and other health care expenses. The total amount generated for the tax-funded health care system should be much less than the current system, allowing businesses and individuals to save money by paying these taxes rather than buying health insurance. This system does, however, bring up a few

problems. As it is likely that more people would seek health care, it may be more difficult to get an appointment when many more people are going to the same doctor than before. There is a concern about how expensive procedures would be rationed and whether some procedures would be provided at all. These problems can be solved. This plan does not completely rid the state of health insurance. If people would like better coverage than they receive through paying the tax, then they are free to buy it. It is very much like the school system. While everybody pays for public schools through taxes, the option to send children to private schools is still available. Similarly, should people want to buy health

insurance, or if they have it covered through work, then they still have that ability, but people who choose not to buy additional coverage get basic health care funded by a statewide tax. A tax-funded health care system would cost-effectively provide basic health care for all Californians. Providing optional insurance for additional coverage would address the politics of profit for the insurance companies and the concerns of citizens regarding expensive health procedures and operations. The less frequent emergency room visits, the savings provided by preventive care for those currently not utilizing medical services, and reduced non-medical costs for insurance companies would mean an overall savings for all citizens.

A taxfunded health care system would costeffectively provide basic health care for all Californians.

More About our Winner and the Essay Contest Gabe Schamberg of Cool, California, is the winner of the first SSV Medicine Essay Contest for high school juniors and seniors. He is a student in Honors English 3 at Golden Sierra High School. Gabe is interested in engineering, his favorite subject is math, and his hobby is drums. He has lived in Cool since age five. His English teacher, Liz Ketelle, has been there since 1982 except for two years at the American School of Bucharest in Romania. She is also a credentialed school librarian. In addition to Honors English and running the library, she teaches a class for struggling readers. USA Today selected Ms. Katelle to be on the USA Today Teacher Team. Their March 1, 2007 article quotes her in part as follows: “These are my kids. I take their papers home to grade. My life and my work are seamless. The kids here work at the local market. They see what I buy. I went to a small high school, and that’s all I have ever been interested in doing: teaching in small schools. Luckily, I found this one early in my career, and it was just a perfect fit for me. I haven’t ever wanted to go anywhere else.” Her student Gabe is evidence that she is in the right place.

Essays were judged on their relevancy to the essay topic, grasp of health related information, and how well the ideas or proposals were expressed. They were not judged by, and do not necessarily reflect, positions taken by the Editorial Committee, SSVMS Board members, or SSV Medicine. The process of judging was thorough. Essays were first apportioned among Committee members. According to their evaluations, the five best essays were then distributed by email to all Committee members for a second round of assessment. The winner was selected based on the accumulated scores received. In 2006, a proposal for this essay contest was made to the Editorial Committee. The motivation for sponsoring it included: encouraging students to think about important health issues; reconfirming organized medicine’s interest in, and communication with, our communities; promoting student awareness and consideration of medical careers. David Gibson and Bill Sandberg met with local school administrators, who felt that the idea was practical. The SSVMS Board approved and funded the high school contest. Announcements were placed in SSV Medicine, and sent to all high schools in our three-county area. — J.L.

May/June 2007

To Be or Not To Be… Pregnant, that is By Ruth Haskins, MD Now women have a choice when there has been a contraceptive failure. Surprisingly, over half of pregnancies in this country are unintended, and of those, fully half represent contraceptive mishap. In these instances in prior years, women would just have to be fearful and wait for nature to take its course. Now they have a choice: emergency contraception. Emergency contraception, often referred to as “the morning after pill,” Plan B, or ECP, is widely available, highly effective, very safe and simply under-utilized. Only 3 to 4 percent of women who are candidates for its use are aware of its availability. It is important for all physicians caring for fertile women to inform patients of emergency contraception. For maximal effectiveness, every woman should be offered an “advance prescription” for this product at her yearly health screening evaluation. Providing this prescription to minors does not require parental consent and is not prohibited by any law. Although ECP is now available in California for women of all ages without a prescription, it is sometimes difficult to find a pharmacy which has it in stock, and which has a pharmacist specially trained to dispense it as such. Without a prescription this product can cost as much as $50. A patient with an advance prescription can have it filled at a wider range of pharmacies and just pay her usual insurance copay for the product. To find a local pharmacy that provides this product, a patient can enter her zip code into

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a data base at www.not-2-late.com or at www.echelp.org, or can call 1-800-NOT-2-LATE. Emergency contraception works best if taken within the first 24 hours after unprotected intercourse, so getting the product in a timely fashion is critical to its successful use. It reduces the chance of pregnancy by up to 95 percent, with only 1 percent of women becoming pregnant (instead of the expected 8 percent without ECP use). It can be taken up to five days after such an event (though at 60 hours, the effectiveness drops to 60 percent). It consists of a two-dose regimen of oral contraceptive. The first is taken immediately, the second dose 12 hours later. ECP can be dispensed as the dedicated product, “Plan B,” which is a prepackaged set of two pills, each containing 0.75 mg of levonorgestrel. It is more effective and has fewer side effects than the alternative — a standard combination birth control pill taken at a more concentrated interval. (Go to www.not-2-late.com for comprehensive details of options.) Emergency contraception works primarily by preventing ovulation. It also alters the uterine environment to inhibit a sperm from getting to the egg if ovulation has already occurred. This change in the endometrial environment would also inhibit a fertilized egg from implanting — if the pills are taken after conception has occurred. This latter mechanism of action, thought to occur rarely, makes those who define life as beginning at conception label this product an abortifacient. Medical science defines pregnancy as beginning at implantation. Once implanted, this product does not disrupt an ongoing pregnancy.

All women can take ECP — even those who cannot take birth control pills. There are no contraindications to its use, and no serious side effects have been reported. Emergency contraception would not disrupt an existing pregnancy and no untoward effect on the fetus would be expected. It is extremely unusual for women to use this product as a form of regular contraception (mainly due to its expense and aggravation). Its availability has not been shown to alter the sexual behavior or regular contraceptive use of our youth or their partners. Susceptible patients must be advised that use of emergency contraception does not protect against sexually transmitted diseases, and is not

as effective at preventing pregnancy as is regular use of contraception. One out of every two women aged 15 to 44 in the US has experienced at least one unintended pregnancy. The cost to society in terms of medical care dollars and the psychological costs to women with unplanned pregnancies is considerable. Making emergency contraception more widely available is very important to help women reduce their risk of unintended pregnancy and the consequent need for abortion “To be or not to be…” pregnant: Let’s provide our patients affordable, attainable options when unexpectedly faced with such a question. ruth.haskins@ucdmc.ucdavis.edu

— By Will Nakashima, MD

May/June 2007

A Solo Physician’s View on a CalPERS Data Bill I can save you the cost of this legislation, which will solve nothing, and in fact further obfuscates the obvious; we doctors are not the cause of rising costs of health care.

By Lee Snook, MD Following is a transcript of a presentation by Dr. Snook before the California Medical Association’s Council on Legislation, on March 28 of this year. He had been asked to counter a CalPERS presentation on AB 1296, which would have required providers to provide CalPERS with cost, utilization and claims payment information for its members. We are indeed pleased that CalPERS is concerned about the Causes of Rising Health Care Costs. As a practicing solo physician, who is responsible for my business, its costs, liabilities, and performance, I have a few observations and a few suggestions. For starters, the analysis is flawed. It presumes that by getting information from the health plans about individual providers that this information will “enable staff to more effectively analyze benefit plan designs, validate the true cost of health care, and reliably determine health program effectiveness during the health plan annual rate negotiation process.” One may infer that the staff will then be able to better negotiate a lower rate, and this somehow will improve quality medical care. There are a few false assumptions: (1) that the “plan” will provide accurate, reliable, and verifiable “provider” information. (2) that the “provider” is a source for future savings. (3) that doctors are responsible for the rising

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cost of health care. CalPERS staff recommends that the Board sponsor legislation that will require contracting health plans to provide actual provider claims payment information for all member health care services rendered at the individual level, including the provider contract allowance amounts. We would like to believe that CalPERS would not breach patient confidentiality and would also like to believe that they would not use patient and physician medical information against them. Unfortunately, this has been the case with other entities. I can save you the cost of this legislation, which will solve nothing, and in fact further obfuscates the obvious; we doctors are not the cause of rising costs of health care. How about paying me, the physician, directly? That way you have direct and tangible data. You receive a bill from me, electronically if you prefer, at the point of service. You then pay me, electronically if you prefer, within a reasonable time frame you and I have agreed to. This is the best format for Pay for Performance. I perform and you pay… without the high cost of the middle-man plan administrator. I have my payment and you have your data: reliable, accurate, verifiable and immediately available. Do not be deluded into thinking that the insurance plan will divulge their rapacious profiteering. Why should they? Think of the savings that CalPERS can reap. You have immediately saved at least 15–20

percent on plan administration right off the top. You have saved on an endless stream of middle managers and a variety of other entities that extract money from the system without any value or benefit to your constituents, which are our patients. By taking this action you have done a great service to restore the doctor patient relationship and direct communication with the payer, you. No longer do you have to seek costly legislation to procure data that you can immediately obtain with existent technology that you already own. No increased cost for proprietary software, no increased overhead to collect and verify data. It is there for you to look at, already as your staff wishes a “detailed provider claims payment data for each member.” The solution to your problem is already at your hands. Your Board has a fiduciary responsibility to its constituents, our patients. You propose legislation that will compel health plans to provide you accurate insider industry information. You specifically mention Blue Shield, the State’s third largest health plan. Let’s look at the track record so far. It took a class action lawsuit against Blue Shield alleging unlawful, unfair and fraudulent business practices to get their attention. They agreed on a settlement of $6.5 million dollars on behalf of former and current Blue Shield subscribers residing in California, which received overwhelming support from the class members. Final approval of the settlement was granted by the Honorable James L. Warren in March of 2006. The DMHC recently fined Blue Cross in a relatively rare act of enforcement for a trivial amount of one million dollars. This is on the heels of a September 2006 fine of $200,000 dollars. Why? Because “Blue Cross’s practices irreparably harm the consumer,” to quote the DMHC press release of March 22, 2007. Quite simply, the plan’s behavior has become so egregious that it mandates an action from an entity that has historically been a pro insurance industry arm of the government. You can understand why we are concerned about CalPERS’ desire to access confidential medical information. If you read the papers, you must be aware that the health plans are extraordinarily profit-

able. A million dollars is chump change as a percentage of their profit. It doesn’t even qualify as a wrist slap. Where does this “profit” money come from? Isn’t this money that should be directed to health care? Do you pay the carriers to siphon money out of health care delivery all the while complaining of rising costs of health care? Please define health care. To me the simple definition is the care rendered by a physician to his or her patient. That is health care in its simplest form. CalPERS staff talks about “health care costs” continuing to climb in California. It isn’t because of our charges. Both Blue Cross and Blue Shield pay us a percentage of Medicare rates, which are nothing like our usual and customary charges. We doctors cannot control the rising cost of compliance with ever-increasing regulations. We cannot control the costs of prescribed pharmaceuticals. We cannot control the increased costs of responding to an endless stream of insurance industry denials, requests for authorizations, resubmitting of faxed documents, peer review rebuttals, peer review phone calls, paying for staff to be put on hold, and trying to navigate the obstacle course placed between the doctor and the patient, etc., etc., etc. We went to medical school to practice our art. Our experience with the current “system” is that the emphasis from the carrier is to delay care, deny care, avoid payment, and to minimize and weaken the clinical decision making of the treating physician. It has very little to do with “quality care.” What they mean by Quality Care is really cost savings. I read 1984 and recognize Orwellian double-speak, too. We also have a fiduciary relationship with your members, our patients. They trust us to follow our sacred oath on their behalf. We want to honor that trust. If you are acting as a fiduciary, a responsibility based on trust to your members, then you should care about this as much as we do. We doctors in the trenches actually seeing patients and keeping track of our business have seen a steady decline in our payment for services rendered year after year, for at least the last 20 years — for as long as I have been keeping

May/June 2007

Our experience with the current “system” is that the emphasis from the carrier is to delay care, deny care, avoid payment, and to minimize and weaken the clinical decision making of the treating physician. It has very little to do with “quality care.”

track. We know that the money you pay in good faith to provide health care to your members is being skimmed off the top by money handlers and the whole insurance industrial complex. You certainly must be aware that the increased “cost of care” has little or nothing to do with our charges. If you would like us solo doctors to prove this, we would be more than happy to provide you with our EOBs. Your good faith attempt to collect more data to wrestle more money out of the 21 percent of the “health care dollar” going to doctors will not help you at all. You simply cannot squeeze us more than you already have. And by the way, what is wrong with 21 percent of the health care dollar going to the physician? There simply is no better value to your constituent, our patient, than the doctor-patient relationship. What are you thinking? The robber barons of the insurance

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industry have had their way with you. I suggest you spend your energies on the real driver of “rising health care costs,” the insurance industry and their addiction to profit and capital greed. We physicians continue to hang on and provide care at the same rates we charged over 15 years ago. Only, we get substantially much less payment for services rendered for a much greater overhead and extraordinary hassle. We do so because our primary directive is to care for our patients. I recommend you abandon your proposed legislative action. lsnook@pain-mpmc.com Note: The COL rejected the proposal to support AB 1296. The bill was amended on April 19 to apply only to hospitals. — Ed.

Capital Reflections The nationâ&#x20AC;&#x2122;s Capitol and the Washington Monument are captured in the reflecting pool of the Lincoln Memorial, The photo is by Jason Kamras, a public school teacher and avid photographer in Washington, DC. He grew up in Sacramento and is the son of Marvin Kamras, MD, an obstetrician gynecologist. This photo and others can be viewed, or purchased, at www.kamrasphotography.com.

May/June 2007

Gaseous Planet — The Paris Hilton Rules By Harrison Chow,M.D., M.S. This article is reprinted from the “Laughing Gas” feature in the California Society of Anesthesiologists’ CSA Bulletin, Winter 2006. A novel health care reform activist group is the curiously-named ”Free Healthcare for All Coalition” based in Marin, California. I met with the group’s founder and director, Diana Tiffany, to discuss FHAC and their plan to introduce the health care spending reform bill AB $0.00 for 2006. HC: Ms. Tiffany, so tell me about the founding of FHAC and its goals. DT: Why, certainly! FHAC was founded to provide accessible and free healthcare in America. Free, zero, nada — not a single red cent. We’re in the process of submitting AB $0.00 to the California Assembly as a pilot; if successful, we plan to spread this concept across country. It would be, you know, another “California-leading-the-nation” thing. HC: Many health care plans have failed because of underfunding concerns. How is AB $0.00 any different? DT: The zeros in AB $0.00 stand not only for what the patients pay but also the balance in your trust fund account. HC: Excuse me. I don’t have a trust fund. I actually work for a living. DT: Obviously, you would not be a candidate for joining FHAC or affected by AB $0.00. There is a minimum requirement of a $10 million dollar trust fund in order to be a FHAC member.

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HC: I have to say, this is a truly new approach — bankrupting the trust funds of the idle rich to pay for the health care of the less fortunate. Usually these health care financing proposals focus on raising funds from working people. DT: I founded FHAC after working many years as a nanny for the super rich — the Rockefellers, Gettys and Hiltons. Whenever they had a problem brat child, I was there to the rescue. HC: So, how did you move from nanny to health care activist? DT: As a nanny, I kept seeing the troubling cycle of obligatory radicalism in ‘”my’” kids. So many of my kids would grow up ignored by their parents, and despite their wealth, they become communists in sandals before falling back to wearing Gucci shoes again. I thought I would channel their rebellious energy to real reform. HC: I don’t see the connection. DT: Ignored in childhood, these kids would yearn to fill their emotional emptiness by joining the latest Socialist movement at their Ivy League — or Stanford or Berkeley — campuses in an attempt to be ”one with the people.” HC: So you mean it’s like the John Lennon verse ”All you need is love.” DT: Exactly. They don’t get love as children, so instead, they look to society. Sad, really. HC: So why FHAC? DT: Well, I knew so many super rich kids who were interested in the health care financ-

ing crisis that I thought we could get together and propose real reform. HC: How do you get Ivy League-caliber rich kids together? DT: Well, we had our initial three-day organizational symposium at the Ritz-Carlton in St. Croix, but I have to admit that we were a little unfocused and too idealistic. Reform proposals ranged from ”Enslavement of Physicians for the Betterment of the Masses” to ”Teaching SelfSurgical Techniques to Urban Children.” HC: Wow, pretty much all over the place. Any favorites? DT: Yes, I found the kids’ presentations of ”Genetic Cloning: the Resurrection of Dr. Che Guevara? and ”Relativity: Use of Nebula Wormholes to Finance Health Care” as particularly creative and inspiring. HC: So how did AB $0.00 come about? DT: Well, the kids decided that we needed to take responsibility. That and also that we were inspired by Paris Hilton. I raised Paris, you know? HC: Wow, no, I didn’t! To the best of my knowledge, Paris Hilton has been pretty quiet about health care reform. DT: She’s quiet because she sticks to what she knows. You don’t see her prancing and howling on stage with U2 promoting AIDS relief for Sudanese macadamia nut farmers like some of my other kids, do you? HC: So, just how does Paris Hilton help health care reform? DT: Well, we have four rules that are in FHAC’s charter. First rule: Look in the mirror, and love yourself. Don’t look for social causes to love you. Second rule: Don’t talk about things you can’t possibly understand — such as food stamps and Toyotas. Third rule: Don’t attempt to represent people you spend your existence trying to avoid — for example, actual working people and public school graduates. HC: I wonder how many mirrors Paris Hilton uses. And, anyway, how does AB $0.00 fit into these FHAC rules and objectives?

DT: Well, we all decided that rather than trying to improve health care by getting the working class to foot the bill, the trust fund kids could contribute their money rather than their ethereal ideas to the problem. HC: Do you think your kids will support AB $0.00? Without their trust funds, they might have to actually find a job and work. DT: We’ll soon find out. The FHAC kids took off in their jets to Barbados last week to have another symposium. I understand AB $0.00 is the second item on the agenda, behind ”Promoting Diversity: Cross-breeding Harvard and Stanford Alumni.” HC: Paris Hilton as a role model for the rich — I need to get used to the concept. And, as I recall, you said there were four rules. What is the fourth? DT: Oh, yes, thank you for reminding me. The fourth rule: Never, ever be seen in public without a ”killer” tan. Dr. Harrison Chow is an anesthesiologist practicing in San Jose and is still looking for the keys to his trust fund. He can be reached at hchow@ stanfordalumni.org.

May/June 2007

Board Briefs March 12, 2007 The Board: Approved the un-audited financial statements ending December 31, 2006 and ratified the actions of the Executive Committee regarding the Smith Barney investments. Approved the Revised Investment Policy for the General, Building Scholarship and Community Service, Education and Research Fund (CSERF), which consolidates individual investment policies for all funds into one document. Approved the Membership Report: For Active Membership — Jerry P. Arnold, MD; Antony R. Boody, MD; Marc K. Chinn, MD; Richard N. Gray, Jr., MD; Erin Kong, MD; Susan S. Lin, MD; Matthew J. Sekera, MD. For a Change in Membership Status from Resident to Active — Michael T. Sim, MD For a Change in Membership Status from Retired to Active

Wilke Fleury ad p/u Jan/Feb 07

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65/20 — Michael S. Parr, MD For Retired Membership — Frederick R. Burrell, MD; Katherine K. Cheng, MD; David F. Dozier, Jr., MD; Nancy A. Gilbert, MD; Cary S. Hart, MD; Stephen L. Mandaro, MD; Alfred L. Stump MD. For Illness Leave of Absence — Douglas R. Schuch, MD For Annual Renewal of Special Leave of Absence — Stephen K. Parkinson, MD For Resignation — Nitin P. Bhosale, MD (moved to Illinois); Christopher J. Gapen, MD (moved to Washington); Shawn E. Gurtcheff, MD (moved to Utah); Sun I.K. Kim, MD (moved to Fontana, CA); Kim-Oanh T. Ly, MD (moved to Stockton); Richard R. Maguire, MD (moved to Georgia); Samrina Marshall, MD; Jennifer Pawlowski, MD (moved to San Francisco); Anuj A. Shah, MD (moved to Maryland); Stanley W. Stead, MD (moved to Encino).

Book Review

A QOD, QTD, Q?D Diet By Ted Fourkas The QOD Diet, Eating Well Every Other Day, by John T. Daugirdas, MD, White Swan Publishing, Willowbrook, IL, ISBN-10-97746140-8, 147 pages, $18.95 This is a short book. About a third of it is appendices — including a log of the author’s trial of the diet. Some text is filler, such as a chapter on fasting by different religions. It is short because it promotes a simple idea: You can lose weight by a semi-fast every other day. Dr. Daugirdas, a retired kidney specialist, would probably not recommend treatment not verified by controlled studies. But he has written a book for hundreds or thousands of readers absent any controlled study. So he trots out caveats: don’t try this diet if you’re a child or over age 60, if you have heart problems, if you’re diabetic, if you have to restrict sodium or potassium intake, if you’re a binge eater, if your blood pressure is too high or too low, or if you’re taking medications affected by food intake. Or if you don’t like vegetables. But if you’re a suitable candidate, cut back to about 400 calories (500 with exercise) every other day and gradually lose up to 25 pounds. The key to the diet? It avoids a change in metabolism — which dooms most diets by kicking into “starvation mode” after a few days. “Every day” in medical shorthand is q.d., from the Latin quaque die. “Every other day” in similar shorthand is q.o.d. — the same Latin separated by an English word, other. That’s where the book title comes from. (Latin for “every other day” is actually quaque altera die, or q.a.d., which apparently no one uses.) When I told the Editorial Committee I might review this book, I was met with skepticism bordering on derision. “Diets don’t work.” “You have to change your life style, and exercise.” And then committee members flat out chal

lenged me to try it out. So I did, even though I’m well over the 60-year limit. I’m reasonably healthy, and semi-fasting appeared to be benign. I adopted several of the author’s recommendations. A breakfast of egg whites (for protein) and tomato juice (for potassium and sodium). Vegetables for lunch and dinner. No bread. No alcohol. Coffee is ok, but it is a diuretic, so avoid caffeine in the afternoon. I actually used a fat-free egg product, microwaved to scrambled egg consistency and topped with chipotle tabasco sauce (better tasting and less spicy than the original tabasco sauce). Lunch was typically a package of spinach sprinkled with lemon juice. For dinner, I opted for smaller portions. I also made an important change for regular eating days: no more big seconds at dinner (though I sometimes have a “half second”). I discovered after a couple of semi-fasting, or “off” days, that q.o.d. did not work. Food was constantly on my mind. The solution was semifasting every third day (which neatly abbreviates to q.t.d. in both Latin and Engish). But in a few weeks I settled on a more convenient schedule — twice a week, typically Sunday and Thursday (for which there is no suitable abbreviation). The result: on the day I wrote this review, I had lost 15 pounds over 162 days. Not very impressive, but not painful, either. I don’t mind the “off” day, and often look forward to it. I have felt no side-effects, not even a lack of energy the author warns against. The biggest surprise: interrupting my usual evening highball a couple of times a week has lessened my desire or anticipation for an alcoholic drink. And I suspect I can maintain this q.?.d. diet for months to come — if only to claim it works. That is, quod erat demonstratum, q.e.d.

The key to the diet? It avoids a change in metabolism — which dooms most diets by kicking into “starvation mode” after a few days.

t4kas@comcast.net May/June 2007

Working as Ship’s Doctor on an Antarctic Icebreaker By John Loofbourow, MD See the inside back cover for photos of this trip, and the online version of Sierra Sacramento Valley Medicine for additional photos. A ship physician usually faces few major challenges; but when trouble comes it can be serious. Then we are in danger of being revealed as puny and inconsequential individuals feigning the ability to stand up to the hugeness of nature. Quintessential expedition E.D. doc Dave Graber encouraged me to fill that role on an Antarctic icebreaker. I had always wanted to make the journey, had learned to love and respect the sea during two shipboard years in the US Navy, and had worked as ship’s physician along the West coast of South America. For the Antarctic Ocean the application process was straightforward, but experience and emergency medicine qualifications were required. Although my checked baggage had been detoured to London, it arrived in Ushuaia Argentina, during a summer snowstorm, a day after my flight. At 7 a.m. on January 27, after emigration and screening, I found myself dragging my gear down a long, cold, rain-lashed dock to find my ship and relieve the returning docs.1 The Sarpik is a 90-passenger shallow draft, heavy hulled vessel, rather than a modern icebreaker,2 completely refurbished in Gdansk, Poland, in 1992. Quark Expeditions specializes in polar cruises, and leased the ship from a Danish owner; all signs were in English and/or

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Danish. The captain was a Finn whose English was afflicted by his very non Indo-European native tongue. The expedition staff consisted of eight naturalists of various stripes, two expedition leaders, a historian, a computer geek, and a physician. We were so culturally diverse that no two staff people spoke the same native language. Variously accented and mis-accented English was our common language. The crew were 5 able bodied seamen, a purser/manager, about 20 kitchen/cleaning staff, and the various engineers and senior officers. The ship has large fore and aft audiovisual observation rooms, and a library; all cabins are exterior, scattered over three decks. With a shallow draft and no stabilizer, she rolls in heavy seas. However, the advantages of this arrangement, and of side and down-looking sonar permitting close approach to land in shallow waters, and to icebergs, would later become very apparent. She carries two strange life boats like big orange watermelons, each holding about 70 people. They are self-propelled, entirely enclosed, and provide an ecologically shameful toilet that empties into the sea, food, water, communication equipment, and fuel. For the next four hours I did inventory, checked records and tried out equipment. Realizing the arrogance of assuming medical responsibility for people at sea, it’s best to try everything possible to prevent embarrassment or disillusion. Moreover, a small ship doc is usually the only person aboard without a physician, and is also the one person expected to

respond if a doc is needed. So there are four things I attend to when first going aboard. First, what medical gear is there and where is it? Second, who can I identify to help in the case of need? Third, who has what health problem? And fourth, what on board hazards are sailing with us? I started with the doctor’s office, or ”sick bay.” It was ample and well equipped, with toilet, shower over tub, desk with PC printer and CD drives, reference books, refrigerator, and a daunting cache of supplies and equipment. Some unfamiliar medications were from northern European countries. The Svornab defibrillator was straightforward enough, but the Gufengrod (OK, that’s fictional. But that’s the feeling I had.) repeat-action pump that shot sterile needles like a machine gun baffled me. Adjacent were two unadorned rooms, each with two beds, one of which I would use. All the portholes were still dogged tight after the infamous “Drake Crossing.” The passengers were not due to arrive until about 4 p.m., an hour before we weighed anchor. Accordingly, I spent the early afternoon going over staff, crew and passenger medical records. If a record indicates a significant medical risk, it is best to speak with the passenger before leaving port. On a previous trip this year, a man with a complicated set of medical problems left his medication behind. The ship had to return to port. Gratefully, I noted that among the passengers was an interpreter for each of two large ethnic/language groups: Japanese,

and French. In an astonishing coincidence,3 an ED nurse was expected aboard who works in the same ED as my daughter in Monterey County! Last, I looked over the kitchen, refrigeration, water system, bathrooms, supply of alcohol hand gel, the ladders, hatches and physical layout of the ship. I met the captain, first officer, and senior crew and expedition staff. I was instructed to attend all staff meetings, carry a two-way radio at all times, be in every first landing boat ashore and on the last boat to return to the ship, with gear for cardiopulmonary resuscitation and for treating injuries; some shore activities are strenuous. As we headed into the Straits of Magellan on day zero, I took my turn with the rest of the staff to introduce myself, welcome the passengers, and speak of hygiene, norovirus, safety, and the coming 1½ days when even the French might expect some non lethal mal de mer that can be minimized by rest, sleep, and possibly, medication. I had previously prepared a number of packets of four 25 mg tablets of phenergan and cloned the instructions on the printer. Many passengers had their own scopolamine patches as well. The Antarctic Circumpolar Current, the Arctic Convergence, and the Drake Passage are three physical features of the area that are so unearthly as to seem living mythic beings.

Moreover, a small ship doc is usually the only person aboard without a physician, and is also the one person expected to respond if a doc is needed.

May/June 2007

The net result is Weather. Satellite photos reveal that at any time

The world’s 4th largest continent4 sits at the south axis of the rotating earth. The earth spins Antarctica around itself, promoting wind from the West as well as inertial forces resulting in an ocean current 13,000 miles long that continuously circles Antarctica from East to West. It carries 34 billion gallons of water per second — 150 times the flow of all the Earth’s rivers. The current is thousands of feet deep and wide, narrowest and strongest at the Drake Passage between Cape Horn and the Antarctic Archipelago/Peninsula. Fresh water at near freezing converges with warmer seawater. The net result is Weather. Satellite photos reveal that at any time there are several hurricanes circling Antarctica. As we left the Straits of Magellan the captain announced that we would be privileged to make the crossing at the lead edge of one. He altered the planned course so that we could find shelter in a shallow bay on the east side the Shetland Islands. This year tens of thousands ”did Antarctica” on mega cruise ships, attracted by comparatively reasonable pricing. However, because of size and draft, big

there are several hurricanes circling Antarctica.

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ships cannot closely approach shore or icebergs. For 2,000 people to go ashore in small boats is a tedious, wearing experience, and carries the risk of sudden weather change. Better to pay the price or see more for less by going to Disneyland. Nearby, a large cruise ship carrying 1800 passengers had tried to escape the weather but went aground; another rode out the weather, sustaining much structural damage and 40 injuries, so it returned to Ushuaia: Advantage number one to smaller heavy hulled ships and state of the art sonar. Every day there were at least three lectures by staff naturalists directed at the day’s landings: topics included glaciology, geography, archeology, sea birds, geology, fossils, history, oceanography, whales, seals, penguins, and the teeming Antarctic ocean life. Global warming was not neglected. Al Gore’s movie was shown twice. His plodding pedantic style was easy for non-English speakers to understand. It seemed curious, however, that we were weeping and ranting over global warming while our expedition burned more fossil fuel in two weeks than some small countries! Appropriate nature films preceded lectures. Antarctica is the highest, driest, coldest, windiest continent. It is technically a desert, with less than 7 cm precipitation yearly, but it does rain on the Antarctic Peninsula and island archipelago where most of the life is found. During our visit it snowed twice, though it was never terribly cold. Landings were made in Zodiacs, 20-passenger motorized inflatable reinforced rubber rafts. They were offloaded by a crane next to a portside ramp when it was safe to do so. Usually we spent a few hours ashore with optional excursions; we occasionally made close approaches to whale pods and individuals, or explored shallow water where unusual ice formations or wildlife were to be found. Penguins were almost always present, waddling about on land with fin-like wings wide to keep cool, standing stoically on icebergs, or porpoising over the sea surface. They are unafraid of people5 and immature penguins are

irrepressibly curious. Rookeries sometimes were quite high on a ridge, requiring laborious trips by the parents with food from the sea. Seals were common as were the sound and flight of varied birds. We visited Argentine and Chilean ”research” stations6. A passport can be stamped at the stations which, frankly, are not devoted only to research but to keeping alive cherished claims to sovereignty. Passport stamps of the two stations are metaphoric for the idiosyncrasies of these two wonderful but very different cultures: The Chilean stamp is one color, austere, and precisely confined to the rectangle provided. The Argentine stamp is four-color, elaborate, and fills the entire page. A particularly welcome aspect of the trip was that the captain, confident in his reinforced hull and hi tech sonar, often took us into shallow water, and always tried to slide by within a few feet of huge floating icebergs that dwarfed the ship. As for physician duties, I was fortunate. There were no serious injuries; I confined one lady and her companion to their cabin for nearly two days, with vomiting and diarrhea, until I felt sure she did not have norovirus; it was probably a futile effort if she had, but the best choice. As usual, once the passengers and crew feel comfortable with the doctor they present litanies of aches and pains and curious or dubious requests; but that goes with the territory. The return crossing of the Drake was actually worse than the first, but by then we were all somewhat adapted and reasonably wise in the ways of seasickness. There are few more existential experiences than the feel and sound and fear of 40-foot seas. As a member of every landing, and a solo doc who was unable to resist the numerous lectures and activities, I was tired by the end of the trip. I wondered if it might have been better to have gone as a passenger. But I’m now over it. To offer a service as a physician in unusual circumstances, as I see it, is to be granted privileged access to humankind. I have always preferred work/travel to tourism because otherwise I tend to be reserved and

solitary. So maybe, just maybe, I’ll apply next year for a position on a larger icebreaker, one with helicopters and three way ice grinders. With one caveat: I’ll try to take a colleague. It is an experience simply too rewarding to pass up; or to keep all to myself! john@loofbourow.com 1 Two docs, or an ED doc-nurse team, is desirable; I replaced two E.D, physicians from Washington State. and was replaced by husband/wife physicians from Australia. 2 Newer icebreakers can chew through heavy ice, like that found at the North Pole. 3 Or is it coincidence? Such things seem to happen very often. I stayed in Argentina afterward to organize a tour for a travel agent friend. Alone at a tango gala in Buenos Aires, I sat next to a man who was also alone — an ED doc from Los Angeles, planning to move to Sacramento. 4 Most consider it the 5th largest continent. But who made Europe a continent when it is only a western appendage to Asia? I find it satisfying to contradict that grandiose claim; by that measure, India should be a continent also. Besides, my way all continents begin with A! 5 Some said that penguins are unafraid of humans because they had never had met a tort lawyer or politician. 6 Uruguayan joke about Argentineans: “How does an Argentino commit suicide?” Answer: “By leaping from the height of his own self importance.”

May/June 2007

SSVMS Can Now Accredit CME Programs By Kristine Wallach, CSERF Program Manager We are very pleased to announce that the Sierra Sacramento Valley Medical Society (SSVMS), in conjunction with the Community Service, Education, and Research Fund (CSERF) has been accredited by the Institute of Medical Quality of the California Medical Association to certify educational programs to provide physicians with AMA PRA Category 1 Creditâ&#x201E;˘. Initially we will focus on educational activities developed by Society committees such as Child and Adolescent Health Services, Emergency Care, and Public and Environmental Health that are already meeting regularly to address emerging issues and needs. We hope to eventually also offer joint sponsorship for non-accredited groups such as specialty societies.

We see our niche as providing

How did we get here?

the kind of activities not met by other providers.

In fall of 2005, the Child and Adolescent Health Services Committee of SSVMS gathered information from family practitioners and pediatricians about their patients with mental health problems. A survey was developed to determine interest and need in support of their proposed Pediatric Mental Health for Primary Care Physicians series. This series of six activities was accredited by Shriners. After the success of the first in this series, a proposal was made to the SSVMS Board of Directors in March 2006 to pursue our own accreditation. To do this the following steps were taken: survey the membership to determine interest in pursuing accreditation, develop a list of topics, develop a list of members interested in participating in the CME Committee; appoint a CME Committee (see below); conduct four CME activities under the guidance of a joint sponsor

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over the next 12 months; and apply for accreditation. In November 2006, our application to become accredited was submitted to the Institute of Medical Quality of the California Medical Association (IMQ/CMA). We had our site survey on January 15 and were accredited on February 7.

Our Mission The mission of the continuing medical education function of CSERF is to provide educational activities designed to meet the needs of member physicians to improve and enhance their medical knowledge and skills. We adhere to the guidelines and standards for continuing medical education set forth by both the IMQ/CMA and the ACCME Essentials and Standards. We also respond to CME policy statements issued by the FDA and AMA, and are guided by membership needs assessment surveys, member physicians, SSVMS committees, and evaluation results from previous activities. We will plan and implement CME activities that meet the needs of the audience for new and emerging medical information and guidelines for improving patient care. We see our niche as providing the kind of activities not met by other providers. We believe the Medical Society can offer a unique perspective in the local CME world because we are unaffiliated with any hospital or medical group. In addition, we already have committees such as Child and Adolescent Health services, Emergency Care, and Public and Environmental Health, that meet regularly to address emerging issues and needs. These SSVMS committees will be the start-

Meet the Applicants The following applications have been referred to the Membership Committee for review. Information pertinent to consideration of any applicant for membership should be communicated to the committee. — Charles H. McDonnell, III, MD, Secretary AMOLIK, Sharmila P, Internal Medicine, Grant Med Col, India 1992, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 ARELLANES, Rose E, Family Medicine, UC Davis 1997, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5200 AZZAM-CASO, Rita G, DO, Family Medicine, Chicago Col of Osteopathic 1999, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5000 CHAN, Emily Y, Endocrinology/Internal Med, Nat’ Univ Malaysia 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4903 CHEN, Anton, Otolaryngology, UC San Francisco 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 DICKSON, Troy S, Orthopedic Surgery, Loma Linda Univ 2000, Western Sierra Orthopaedic Ctr, 4300 Golden Center Dr #C, Placerville 95667 (530) 344-2070 FEIZ, Vahid, Ophthalmology/Cornea, External Dis & Refractive Surg, Washington Univ 1995, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6603 FERNANDEZ Y GARCIA, Bianca C, Pediatrics, Univ Southern Calif 2002, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060 FU, Audrey, Family Medicine, UC San Francisco 2003, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040 GASPAR, Kathy G, Family Medicine, Med Univ S. Carolina 2001, Calif State Univ, Sacramento, 6000 J St, Sacramento 95819 (916) 278-6029

HACKERT, Lynne A, Plastic Surgery/Hand & Microsurgery, Michigan State Univ 1997, The Plastic Surgery Center, 95 Scripps Dr, Sacramento 95825 (916) 929-1833

MIRZOYAN, Anna, Family Medicine, Yerevan State Med Univ, Russia 1986, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5243

HAHN, Yoav, Otolaryngology, Univ Missouri 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

MORALES, Joseph E, Emergency Medicine, UMDNJ 1975, Sutter Medical Group, 1014-W North Market Blvd., #20, Sacramento 95834 (916) 565-8600

HERINGER, Sarah J-K, DO, Emergency Medicine, Nova Southeastern Univ 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

NAGESWARAN, Soni, Family Medicine, The Univ Michigan 2001, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95757 (916) 478-5128

JACOBY, Russell F, Gastroenterology, New York Univ 1984, 3108 Gabbert Dr #230, Cameron Park 95682 KASIRYE, Olivia C, Preventive Medicine, Makerere Univ, Uganda 1988, Department of Health Services, 9333 Tech Center Dr #800, Sacramento 95826 (916) 875-4505 (Government) KHAN, Rakhshi, Family Medicine, Brody/East Carolina School of Med 2003, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 784-4050 KHANDHAR, Suketu M, Neurology/Movement Disorders, St. George’s Univ 2000, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6868 KHATRI, Rakhi, Internal/Preventive Medicine, MGM Med Col, India 1993, Sutter Medical Group, 2801 K St #520, Sacramento 95816 (916) 733-5044 KIM, Esther S-Y, Ophthalmology, UC Davis 1990, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6602

ing place for developing our CME activities. Although our accreditation gives us the opportunity to jointly sponsor CME activities with non-accredited organizations such as specialty societies, the CME Committee has decided that during our first year the focus of our fledgling CME program should be working with SSVMS committees to develop and implement activities.

Thank You A special thank you to CME Committee

OVADIA, Boaz, Pediatric Critical Care Med, Tel Aviv Univ/Sackler, Israel 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 RHODES, Michelle P, Pediatrics, Univ Colorado 2003, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-3944 ROXAS, Leah L, Internal Medicine, Univ Santo Tomas, Philippines 1999, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040 RIVERA, Ernesto S, Pediatric Cardiology, Univ of the Philippines 1987, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4989 TRIAS, Elman A.L, Pediatric Pulmonology, Univ of the Philippines 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7342 VANCE, W. Taylor, Orthopedic Surgery/Sports Medicine, Pennsylvania State Univ 1995, Western Sierra Orthopaedic Ctr, 4300 Golden Center Dr #C, Placerville 95667 (530) 344-2070

members Denise Satterfield, MD (chair), Satya Chatterjee, MD, Jose Cueto, MD, Alfredo Czerwinski, MD, Barbara Hays, MD, Maynard Johnston, Richard Jones, MD, Alexander Kelter, MD, Donald Lyman, MD, Charles Maas, MD, Lee Snook, MD, Lee Welter, MD, and Bill Sandberg. They expended much energy and overcame many obstacles to get this program up and running. If you have questions about our CME program, please contact Kristine Wallach at 453-0254. KWallach@ssvms.org

May/June 2007

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• • • • • • •

Daily Maintenance Detailing 3M Treatment Carpet Extractors Shampoo Carpets Tile Floor Care Window Cleaning

1-800-901-5830 Doctor’s Placement p/u Jan/Feb 07

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

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Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911 Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...

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All Members $100,000 Automatic Policy

Since 1973 • Max Uden, Owner • (916) 455-5880

• 31 years of medical experience • 1,600 Northern California physicians • 45 well-trained & professional operators • State of the art technology • Discounted rates for new SSVMS accounts • Spanish speaking operators during most shifts

Sierra Sacramento Valley Medicine

A Trip to Antarctica â&#x20AC;&#x201D; see page 30