2007-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE

July/August 2007

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Dispatch #4 Physician Mission Grim Possible

2007 Ship Doc 2: Inside Passage to Alaska

Richard Jones, MD

John Loofbourow, MD

LETTER TO THE EDITOR Taking Issue with Dr. Snook

IN MEMORIAM Glenn Emmett Millar, Sr., MD

Why Health Care Reform is Failing — Again

BOOK REVIEW The Coronary Care Scandal at Redding Medical Center

David J. Gibson, MD

George Meyer, MD

Posit: on Plan B

Board Briefs

UC Davis Medical Students Run Five Inner-City Clinics

Charles Casey

New Applicants

Classified Ads

inside back cover art work by Amanda Bouillé and Terri Sacré

Voices of Medicine

Del Meyer, MD

WINNING STUDENT ESSAY Helping the Healing Process

Darren Salmi, MSII

Preventing the Cascade

Timothy J. Aspinwall, Esq.

Demystifying Defibrillators

Kent M. Perryman, PhD

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

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

This is the fourth in a series of covers by ophthalmologist Barbara Arnold, MD. This watercolor was completed in California after a visit in September 2004 to the home of Claude Monet, in Giverny, France. Monet’s colorful home is now a museum and a tourist attraction.

Volume 58/Number 4

For Dr. Arnold, the painting brings back “wonderful memories of the bright pink stucco home with ruffled curtains, windows framed in brightly enameled green shutters, and an overgrowth of morning glories.”

5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Official publication of the Sierra Sacramento Valley Medical Society

Her original is 18 by 24 inches on French Arches 140 pound cold press cotton rag. bjarnold@ucdavis.edu

July/August 2007

Sierra Sacramento Valley

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

Dispatch #4 Physician Mission Grim Possible Our agent 007 meets the Medical Menace in War of the Whirled Healthcare

By Richard Jones, MD California faces a new fiscal medical access and insurance crisis encompassing a constellation of problems resulting from, procrastination, inaction, regulations, litigation and other demographic and societal changes representing a new paradigm of …ZZZZZZ Stop! ‘Tis summer and time for a holiday from my impending tendentious, serious and lugubrious editorial on health care… Who’s in favor of some campy, pulp non-fiction? It was a dark and stormy night. The thudding and wheezing reverberated closer and more forbiddingly. As air raid sirens wailed and spotlights prowled the skies, the apocalyptic atmosphere was staccatoed by the chopping rotors of Department of Health Services helicopters, their loudspeakers blaring out warnings and threats to the approaching Leviathan. The capitol shuddered with the impact of each quickening step of the monstrosity steadily lurching forward. Legislators, litigators and lobbyists frantically scurried in the Capitol warrens to build barricades with their reams of legislative bills. The statutory books of health care regulations piled into the corridors were at least 5 feet thick; they whirled in the gusts of the gathering tempest. “Bring me more bills, there are gaps in the coverage!” yelled one frenzied legislator. He packed more reams of Department of Health Services bulletins and CMS manuals into the bulwark. “I don’t know how we can take it... These regulations are not going to hold it back!

Spiritual Nonecumenical Being, help us!” “Call in the attorneys,” cried another. “Maybe we can still sue! Someone! Anyone!” a staffer pleaded. “No! No! It is too late for that,” a grizzled state senator squawked in reply. “Look! The tort lawyers have been stampeded. They are now in alliance with this demon! The tentacles of the monster have meshed with them and they are symbiotic! See, their subpoenas are flaccid!” In the corner of the governor’s quaking cigar-butt strewn HQ tent fidgeted a sultry brunette. She flicked her long-stemmed Virginia Slims ash on the barbells next to the governor’s Lazyboy. Her demeanor could make a scientist guy cosine away his hypotenuse and integrate his differential to a new inflection point. Wisps of smoke curled languidly upward as she pouted and asked. “Well, what about the other politicians? Can’t they help?” The governor shook his head and stammered “Our healthcare budget may be terminated and, and I may not be back. I am afraid we have only one last hope! The reports are that LA and SF and all the major cities in California are under similar assault. We have got to call upon the physicians of the state. Maybe they can save us from judgment day!” He winced as he saw the flood of impoverished sickly citizens fleeing up L Street, past the shuttered businesses of a growing economic exodus. Their pockets were empty, their obese

July/August 2007

A gelatinous, sero sanguineous, poorly differentiated mass of health care expenditure crisis oozed forward. It was the Iniquitous Health care budget, Economy, Inequity and Inefficiency Incarnate. IHEIII !!

forms silhouetted by the glowing embers of cigarettes. Michael Moore, clutching a supersized French Fry bag, lurched in the lead of the pack, his rolls of “Sicko” spent film dangling like a ghastly train of celluloid entrails from his paunch. Already the regulatory bills were being whipped into a vortex whirling and fluttering into the maws of the monster. The governor commanded, “Get me the Physician Transmission! Call the CMA. Sound the general alarm!” Shrieks and screams were punctuated with the thudding, whooshing cacophony as it turned the corner. Bursts of borborygmi bellicosity issued from the mass: ”Feed me more money! Feed me more resources. Screw your uninsured, your tired and your poor, your huddled masses at the ER door. I want more!” It belched. Statewide the physicians’ pagers beeped and buzzed in unison as the SOS beacon beamed throughout the state. Jamie Bonda, MD (Medical Board of California 007), glanced at his Motorola. He shuddered as he read the message. “Medical Crisis. It is coming closer — the horror, the humanity, the budget, the jobs, the taxes, and the uninsured…arrrrgghh!!!…” The words flatlined and the screen went black. Dr. Bonda had dreaded the message’s inevitable arrival. For years, just this eventuality had been forewarned and prognosticated. Health Care Expenditure and Budget Situation had reached DEFCON 4. The CMA agents and physicians were now prepared to fully mobilize and take control. They had trained and been cultivated with the best of the CMA Academy. They had written, testified, protested, and tried to convince politicians, regulators and others of what was looming. Their efforts and pleas had been ignored by the influence of special interests and the pervasive condition of a political pathology clinically known as cephalic intrasigmoidus. Bonda reached into his lab coat pocket and grasped his weapon. The rumbling of the creature was closer and the night was getting darker and stormier. He was thankful that Q at the IMQ, special branch of CMA, had prepared him.

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He stepped outside his office. He could already see other MDs dashing out of their offices, sheathed in their white coats – pockets bulging with their special ammunition. He gasped as he beheld the abominable behemoth. A gelatinous, sero sanguineous, poorly differentiated mass of health care expenditure crisis oozed forward. It was the Iniquitous Health care budget, Economy, Inequity and Inefficiency Incarnate. IHEIII !! Sloth, greed, selfishness, personal financial and healthcare irresponsibility, waste, fraud and ignorance had made this seething beast. It sucked in money, state resources, and jobs like a surgical Gomco on steroids, oozing out pustular streams of executive stock options and gaping vacuoles of inefficiency in return. The miasma was of sickness, disease, avarice, and inattention, equivalent to enchiladas left in the call room cabinet by a drug rep a month before… Steadfastly and slicker than a KY’d catheter, Dr. Bonda bimanually whipped out his weapons. He raised his pen and took aim at his prescription pad. “Now my colleagues,” he cried, “Fire one!“ The first salvo of doctors scribbling on pads started. They wrote: “Generic drugs! Cut pharmacy costs! Enhance drug company competition and send more money to research and development! Cut direct-to-consumer drug advertising! The healthcare expenditure monster groaned and burbled. The doctors’ flashed pens like swords, and prescription pads as shields. “Fire two!” Dr. Bonda charged forward. The scribbling on the RX pads continued. “Educate and effectively persuade our patients in healthy lifestyles. Hold them accountable to lose weight, stop smoking, exercise more, and improve nutrition! Health Savings Accounts!” The monster belched, quivered and started to shrivel. The sucking and whirling decreased. “Fire three!” Dr. Jaime Bonda shouted. “Medical malpractice and liability reform. Stop defensive medicine. Order only lab and diagnostic tests that are reasonable. Prevent fraud. Reform practices of bad doctors, clinics, and hospitals.” Though it wasn’t easy to decipher the doctors’

writing, it seemed effective! The monster’s mass deflated and deturgessed further. A voice rang from the crowd. “It’s shrinking!” Cheers erupted from the besieged Capitol. Treos trilled and Blackberrys blipped out the news, reporting similar dissipations of the menace throughout the state. The stunned and hunted patients swarmed around Bonda and his colleagues from the CMA. Legislators who had been slinging bills and books at the health care expenditure monster stood with jaws agape, wordless for the first time. The tort attorneys shuffled and cleaned the depositions from their pants; the monster was an abating blob coalescing into pools of melted golden insurance executives, carbonizing deflating hospital bills, and an effervescence of wastefulness. The governor pumped his fists into the air. “You did it! You terminated it!“ The beguiling brunette, menthol cigarette dangling from her lips, sashayed up to Jamie Bonda, MD, and cooed, “Dr. Bonda, how did you do it? How is it all the legislators, lobbyists’ attorneys and actors with all their formidable firepower couldn’t stop this health care monster? What magic is it that you have? What is it, Doctor, you know?” “It simple”, shrugged Bonda, “We doctors of the CMA know the solution to healthcare problems really begins with us. We can cut the costs by choosing medication, testing, and procedures wisely and prudently; we can convince our patients to change bad health habits that

can cost millions, we can persuade our representatives that tort and regulation reform can dramatically cut costs and enhance efficiency. We can advocate that a pluralistic universal basic coverage is a good investment and saves lives and money and maintains economic vitality. We know we can work together when called.” Bonda continued. “Do you remember H.G. Wells’ War of the Worlds? Humanity was under assault by Martians, like we were under assault by a medical insurance protean problem monster. We humble, but powerful providers and directors of healthcare are like tiny organisms that doomed H.G. Wells’ Martians. Against our many small and individual efforts to provide quality, cost effective and humane care, the monster created by regulation, litigation, over libation and gustatation had no immunity.” “Oh doctor!” she sighed. “How can we thank you!“ Jamie Bonda MD’s hand gently reached for her as the clouds parted and a golden ray of sunlight caressed her countenance. He grabbed her cigarette and with a flourish crushed it on the pavement. “That’s how! And start exercising more! Here’s looking at you, kid.” He winked. “Now if you’ll excuse, me I have some more work to do.” Holstering pen and prescription pad in pocket, he paused, whirled, and then sauntered away with his white coat fluttering like a cape.

The monster was an abating blob coalescing into pools of melted golden insurance executives, carbonizing deflating hospital bills, and an effervescence of wastefulness.

rajones@sbcglobal.net

AMA Adopts a Local Resolution on Emergency Contraception The 2007 meeting of the American Medical Association House of Delegates has adopted a resolution on emergency contraception from the California Medical Association’s 11th District — made of medical societies east of the Coast Range, and stretching from the Yolo and Sacramento areas the Oregon border. The resolution by Dr. Larry Ozeram of the Yuba-SutterColusa Medical Society, calls for the AMA to: (1) work in collaboration with other stakeholders (such as American College of Obstetricians and Gynecologists, American Academy of Pediatrics, and American College of Preventive

Medicine) to communicate with the National Association of Chain Drug Stores and the National Community Pharmacists Association, and request that pharmacies use their web site or other means to signify whether they stock and dispense emergency contraception, and if not, where it can be obtained in their region, either with or without a prescription; and (2) urge that established emergency contraception regimens be approved for over-the-counter access to women of reproductive age, as recommended by the relevant medical specialty societies and the US Food and Drug Administration’s own expert panel.

July/August 2007

Letter to the Editor Taking Issue with Dr. Snook I read Dr. Snook’s article in the May/June SSV Medicine with great interest. Several of his observations merit comment. He cited a class action lawsuit against Blue Shield of California alleging unlawful, unfair and fraudulent business practices. Blue Shield is a not-for-profit entity — a mutual company whose shareholders are the subscribers they cover for health care services. I discovered the lawsuit was filed after Blue Shield made a variety of changes to its Individual and Family Plans. Like life insurance, Blue Shield has multiple risk tiers for this product. Applicants, when they first enroll, are assigned to a tier based on multiple factors. Blue Shield has been on a mission to make health care coverage more affordable for Californians. In keeping with this, one change was to create a new, lowest risk tier — into which the company moved the lowest risk members. The class action lawsuit was filed on behalf of remaining members in the upper tiers, who claimed this raised their rates and was not in keeping with existing subscriber agreements. Blue Shield settled without admitting guilt and, indeed, felt the charges were defensible. The plaintiff felt its legal assertions had merit. Both sides agreed to settle rather than to go through the time and expense of legal proceedings. I looked up Blue Shield’s Annual Report for 2006. Its administrative expense as a percentage of revenues was 11.8% — not the 15–20% cited by Dr. Snook. Approximately one third of this goes to insurance brokers, the people we turn to when we purchase insurance products. About 2–4% of the premium goes toward the cost of sending out membership cards, membership information and processing claims. Blue Shield also contributed $30 million from profits to its Foundation for community support. Grants were awarded from this pool to help fund the Healthy Family Program, free clinics and domestic violence programs

Dr. Snook states that doctor charges do not increase costs of health care. In general, he is correct. However, our behavior does indeed affect costs. Unnecessary testing certainly plays a role. As an example, abdominal CT scans are typically ordered before a surgeon sees a patient, even when there is a strong clinical suspicion of appendicitis. This test carries a false negative rate of upwards of 25%. There are recent reports that the resultant delay in providing surgical management results in a subset of patients experiencing a ruptured appendix. (Indeed, some old timers feel many younger physicians have lost their diagnostic acumen, failing to rely on history and physical examination skills, and instead using advanced radiographic imaging as an extension of the physical exam.) While the treating physician may not receive more money, there are certainly increased costs and payments to other parts of the delivery system — costs ultimately borne by employers and all consumers. Where services are performed also can be significant. I recently had a trans-esophageal echocardiogram, done on an outpatient basis at Mercy General Hospital. I was shocked to see the charge for the technical component was over $2,000. The allowed amount was 90% of the gross charge. I looked up the CMS allowance for the procedure and found it was in the range of $270. I paid more with my co-insurance than if the procedure were performed in a non-hospital-owned free-standing facility, and if I paid for 100% of the technical component — even at 180% of the CMS allowance! Finally, if we believe that we don’t directly contribute to the cost of care, I suggest reading “Coronary, A True Story of Medicine Gone Awry”, by Stephen Klaidman. It is a book outlining what took place in a hospital system in Northern California several years ago. (Editor’s note: See page 30 for a review of the book.) — Frank Apgar, MD July/August 2007

Why Health Care Reform is Failing — Again By David J. Gibson, MD Despite all the carbon dioxide generated by the tyronic bloviators under the Capitol dome, health care reform is failing once again. At its inception, this round of high-minded reform had many political fathers. There was the Arnold Schwarzenegger Plan, which had no sponsor in the Legislature. Then Speaker Fabian Núñez’s plan appeared at trumpeted news conferences. Not to be outdone, Senate President pro Tem Don Perata trotted out his own plan. Each used apocalyptic arguments and attempted to foment an atmosphere of hysteria to support their proposals. A couple of proposals are still technically alive, but appear to be in a persistent vegetative state. Reform had many fathers, but just as in the past, it will be buried an orphan. Perhaps this time we can learn some important lessons. There are nine major contributors to the failure of reform. The focus was on reforming financing rather than the flawed health care system. Changing the financing system is not reforming health care. America’s health care system is a World War II era construct. Then, surgery in hospitals represented the leading edge of medical technology. Our health care system still performs relatively well when addressing acute episodes of care. But it is ill equipped to address chronic conditions, which now dominate as the baby boomers age. The result is unsustainable costs related to preventable complications. Redesigning the underwriting system without first redesigning the delivery system is a waste of time and

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resources. Treating chronic disease on an acuity basis has generated increasing per capita health care spending over the past half century at a rate two to three times faster than per capita gross domestic product (GDP). At its current growth rate, health care spending will consume almost 80 percent of GDP by 2075. As a result, Medicare now has an unfunded liability six times the size of Social Security.1 Furthermore, we are trying to develop financing for yesterday’s health care system. All of the financing reforms sought to preferentially fund yesterday’s acuity/invasive/custodial delivery paradigm. These proposals did not account for the transition now taking place. In the dawning genomic era, diagnostic and therapeutic technology will focus on the cellular level. This technology will prioritize the proactive prevention of disease rather than invasively treating the predictable consequences of the disease process in a custodial environment. Increased public investing in health care will not reduce the level of the uninsured. In America, health care spending conforms to the laws of gas in thermodynamics. The system will infinitely expand to accommodate increased funding. Unfortunately, no measurable outcome improvement has ever been demonstrated. For example, state and local government spending on health care delivery increased from $115.9 billion in 1995 to $170.2 billion in 2005.2 That was a 46.9 percent jump, compared to inflation registering 22.4 percent (as measured by the GDP price deflator) over the same period. Total federal health-related spending — including health services, research, Medicare and veteran’s

health care — during this same period increased from $291.7 billion in 1995 to $577.9 billion in 2005, a 98 percent increase. Did the number of uninsured decline with this increase in public spending? No, the raw numbers of uninsured increased — from 40.6 million in 1995 to 46.5 million in 2005. As a share of the population, 15.4 percent were uninsured in 1995 versus 15.9 percent in 2005. Government at all levels is bankrupt. At the federal level, a recently released report3 demonstrates that our government has already promised $63.675 trillion more in benefits than it will collect in taxes. That figure exceeds the gross value of all assets within the United States by $20 trillion dollars. Just paying for these already promised benefits would require an immediate 14.4 percent tax on all payrolls. America’s voluntary based tax system will not survive such an increase. The economy would be driven underground. The bad news does not stop there. At the state level, we really do not know the extent of current entitlement liabilities. However, conservative estimates indicate the national total could be $1 trillion. Here in California, State Controller John Chiang has estimated the cost of promised health care benefits to state employees over the next three decades. The tab is $47.9 billion. Chiang’s estimate is unrealistically optimistic.4 Using more accepted standards, the Legislative Analyst’s Office last year estimated the liability at $70 billion. This covers only state employees. Cities, school districts and community colleges face an additional estimated $90 billion in unfunded health care obligations. Liabilities of these magnitudes at all levels of government make a new, publicly funded, health care entitlement an unattainable option. At all levels, there is no ability to raise taxes to pay for an expansive new entitlement. At the federal level, the policy priority is to address the Alternative Minimum Tax (AMT) issue, not create an expansive new entitlement. Without legislation this year, the number of Americans who pay the AMT will rise as much as six-fold to 23 million. Families with just $60,000 in combined income will begin paying the AMT

in California. The Democrats who run Congress know they risk a tax revolt in 2008 without some kind of AMT patch. The Democrats’ goal is to exempt families with earnings under $250,000 a year from AMT. Democrats on the House Ways and Means Committee released a draft of their tax plan that would raise the highest income tax rate by 4.3 percentage points to 39.3 percent immediately. Without an extension of existing tax structure, the highest income tax rate would rise to the neighborhood of 44 percent after 2010. Moreover, for families with incomes from $250,000 – $500,000, the “marginal” tax rate on the next dollar of earned income will increase to 80 percent, or in some cases even above 100 percent. All of the above will be required to keep the federal tax revenue neutral. It does not pay for any additional new programs with additional revenue. Every health reform proposal at both the state and the federal level incorporate a progressive tax to pay for providing health insurance for the poor. Of course, the same argument is made for reforming education, maintaining infrastructure and paying for existing entitlements. At the state level, Prop 13 requires a twothirds vote in the Legislature before new taxes can be levied. That restriction has prevented enactment of new taxes in the past and will likely prevent new taxes to pay for an expansive entitlement in the future. Outside of new taxes, no one is willing to pay for reform. Californians who have health insurance — and who vote — currently pay the lion’s share of taxes. They have not bought the argument that they should pay more taxes for coverage of the uninsured. The increasing dissociation between tax payments and benefits received exacerbates the difficulty in selling more taxes. A recently published study5 found that America’s lowest-earning one-fifth of households received roughly $8.21 in government spending for each dollar of taxes paid in 2004. Households with middle incomes received $1.30 per tax dollar, and America’s highest-earning households received $0.41. Government spending targeted at the lowest-earning 60 percent of

July/August 2007

Californians who have health insurance — and who vote — currently pay the lion’s share of taxes. They have not bought the argument that they should pay more taxes for coverage of the uninsured.

Turning over a vital service such as health care to government strikes most voters as a naïve or, worse, a utopian idea. Government at all levels is not only insolvent — it is incompetent.

U.S. households is larger than what they paid in federal, state and local taxes. In 2004, between $1.03 trillion and $1.53 trillion was redistributed downward from the two highest income quintiles to the three lowest income quintiles. Making the case that an ever-decreasing number of taxpayers should pay for their nontaxed brethren is even more difficult in a steeply progressive tax system state like California The Schwarzenegger proposal incorporates a dubious end run on Prop 13. Five percent “fees” would have been charged to doctors and hospitals. For the health care system, this was a non-starter at its inception. The health care system does not want reform. The health care industry wants more money pumped into the existing financing system by third parties. What stakeholders in the industry do not want is fundamental reform and redesign of the system itself. Without new outside funding, the industry opts for the status quo. The health care industry in California generally gets what it wants. At over $200 billion in revenue per year, the health care sector is the largest industry in the state’s economy. Health care is now the leading employer in most communities across California. The industry freely spends on lobbying the government. According to a report released in June of 2006 by California Secretary of State Bruce McPherson’s office, the health care industry spent $24,431,294 in lobbying the state government in 2005. This is the highest spending figure for any single industry in California’s economy outside of government itself. Reform of the health care system will not occur through the state’s public policy arena. The health care industry bought and holds the deed for California’s politicians a long time ago. The philosophical gulf between a pro business governor and a redistributionist Legislature is too broad to bridge. Both the Fabian Núñez (Assembly Bill 8) and the Perata (Senate Bill 48) plans were passed by the Legislature. The Senate even passed Senator Shiela Kuehl’s single payer bill. The first two called exclusively for employer funding,

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the third called for steep tax increases. All are philosophically unacceptable to the pro-business governor and, therefore, had no chance of enactment. Californians do not trust their government to manage the health care system. At the national level, the inattention to competent management is a long and growing list. These include border security, hurricane Katrina, Iraq, medical care for returning service members — the list stretches on. On the state level, California has been unable to maintain its infrastructure, manage the prison system (which boasts the highest per inmate cost in the nation), educate our children and balance its budget. Taxpayers long ago concluded their government does not govern. It has become a massive social redistribution organization that is inadequately managed, outrageously expensive and never held accountable for objective outcomes. Consequently, proposals like Senator Kuehl’s single payer bill, which could actually restructure the health care system, are not taken seriously. Turning over a vital service such as health care to government strikes most voters as a naïve or, worse, a utopian idea. Government at all levels is not only insolvent — it is incompetent. Any one of the nine obstacles would doom health care reform. Their cumulative effect means reform had no chance of succeeding. So why have California’s politicians raised expectations once again with no real chance for success? I believe the answer lies in a broader issue of paradigm change in the public policy arena. For most of America’s history, politicians have trod a well-defined path to electoral success. They enter politics at the local level by ingratiating themselves to special interests that, in turn, fund their campaigns. Once in office, these newlyelected officials make every effort to become careerists. They remain in office and advance to higher office by returning taxpayer money to their constituents and the special interests that have funded their previous campaigns. This makes democracy an inherently unstable form of government. The system begins to fail once voters discover they can vote themselves largesse from the public treasury and

require payment from “others” or from future generations through debt financing. From that moment on, the majority of voters will generally select candidates promising them entitlements for which they do not have to pay. All of our current political class came into office within this “activist” government paradigm. An old political saw is, “Don’t tax me. Don’t tax thee. Tax that feller behind the tree.” If the republic is to survive, politics in the future will be about taking away entitlements, not increasing them. Thus, the only current option is to talk about delivering new programs without actually succeeding in doing so. About the only option politicians will be able to deliver to their constituents will be unfunded mandates imposed on the private sector. Thus, this entire episode has been about bloviating. Reforming health care is beyond the ability of the public policy makers. This discussion gave politicians the appearance of respond-

ing to a need. It was never envisioned that a reform effort would succeed. Health care reform is needed and will come. It will either follow a collapse of the current financing system or come through proactive leadership from within the health care industry. The smart money is on the former. DJGibson@winfirst.com 1 Source: Andrew J. Rettenmaier and Thomas R. Saving, “Medicare: Past, Present and Future,” National Center for Policy Analysis, Policy Report No. 299, June 2007. 2 Source: U.S. Census Bureau 3 Do the Markets Care about the $2.4 Trillion U.S. Deficit?; Financial Analysts Journal; Jagadeesh Gokhale and Kent Smetters; March/April 2007, Vol. 63, No. 2: 37-47 (doi: 10.2469/ faj.v63.n2.4527) 4 Chiang assumes that the current steep rise in health care costs will ease over time, from 10 percent this year to 4.5 percent 10 years from now. 5 Andrew Chamberlain, Gerald Prante and Scott A. Hodge; “Who Pays America’s Tax Burden, and Who Gets the Most Government Spending?”; The Tax Foundation; Special Report No. 151; http://www.taxfoundation.org/files/sr151.pdf

EXAQ ad (camera ready)

July/August 2007

Posit: on “Plan B” “Primary care physicians have an ethical and professional obligation to inform women of childbearing age about ‘Plan B’ (the Morning After Pill), and to offer the prescription to be filled in an emergency.”

“Obligation is a pretty strong word. What if we think the pill is ethically wrong?”

A majority agreed with the posit, which was based on Dr. Ruth Haskin’s essay in the May issue of Sierra Sacramento Valley Medicine. (Agree–92; Disagree–24; No opinion–2; comments–24.) Readers should keep in mind that posits are not valid surveys or polls. They are strident statements intended to promote dialogue among members, and do not reflect the views of the Board of Directors, Officers, or the Editorial Committee. Comments reflect a broad range of opinion, and we present them without interjecting our own. Edited comments appear below, while unedited commentary is viewable on line. As these remarks were being prepared for publication, the American Medical Association adopted a Northern California resolution to ease access to emergency contraception. See page 5 for more details. “Since we all would like to limit the need for abortions, this is a very ethical approach for all physicians.” — Anthony Russell, MD “A person whose personal ethics will interfere with the patient’s rights — THE PATIENT’S RIGHTS — should consider a more appropriate specialty such as ophthalmology or podiatry. Perhaps even a career in chiropractics?” — Andrew Last, MD “What about our own moral obligations to ourselves?” — Kevin Mackey, MD “This is not a religious or abortion issue!” — E.T. Rulison, MD “The basis of the medical profession is serving the patient’s needs, not your own agenda.” — David Gibson, MD “I wouldn’t call this the ’morning after pill.’ This is not the RU-486 pill and does not cause an abortion if already pregnant. Using this label Sierra Sacramento Valley Medicine

also is irresponsible and feeds into public fears. Call it Plan B or the Emergency Contraceptive Pill. As a pediatrician, I would like to think that my colleagues also agree with the above statement.” — Sean Cooke, MD “I am a pro choice person. The morningafter-pill, preventing even the fertilization of an egg, is better than abortion, a poor replacement for birth control. …people can see that even this egg is not yet a ’living’ being.” — George Meyer, MD “Obligation is a pretty strong word. What if we think the pill is ethically wrong? There are already so many ways to prevent unwanted pregnancy that doctors should not be ’required’ to inform or prescribe the morning after pill. It’s about time we as a group start to ask the patients to take some responsibility for their actions.” — Esther Kim, MD “Some physicians have moral and ethical objections to providing contraceptives or abortifacients. They should not be forced to choose between career and conscience.” — Steve McCurdy, MD “It seems that the questions in these surveys aren’t structured very well. This is really two questions. Is there a moral obligation to inform; the answer to that is sometimes. “The second question, which is very different, is there an obligation to prescribe if requested; the answer to that question is yes.” — Thom Atkins, MD “Agree they should fill prescription in an emergency but not that informing patients about the availability of the morning after pill is an obligation.” — David Wisner, MD “Physicians should not withhold medical information that may help a patient make a

reasoned decision. Since this is now available over the counter, a prescription may not be needed. “If a physician is not comfortable prescribing Plan B, the patient should be informed of that fact and given information on how to get it elsewhere.” — Joanne Berkowitz, MD “There is an ethical and professional obligation to educate and inform patients of the availability of ’the morning after pill.’ This may include referring patients to other facilities or colleagues that offer such services. However, a physician should not himself be ethically bounded to condone, offer, or administer intervention and fill this prescription in an emergency. The act of offering and administration of the intervention or in this case prescribe the drug may be contrary to the physician’s own sense of morals and ethical beliefs of life and abortion.” — Mark Pham, MD “Once again, you have done it. You have asked people to agree or disagree with a poorly worded statement. The direct corollary of this statement is that any primary care physician who fails [to] inform any of their patients of child bearing age about PLAN B is both unethical and unprofessional. Most would agree that one of the important tasks of primary care physicians is to inform interested patients about family planning and contraceptive options, and that one such option is ’Plan B.’ “That being said, I would hope that physicians would think twice, and then disagree with the statement and its inherent implications.” — Gerald Upcraft, MD “Particularly if a patient inquires about it. Not sure that we need to bring it up proactively with all women patients of childbearing age, though.” — Jason Flamm, MD “Physicians have a duty to educate their patients.” — Kent Hart, MD “There is no obligation for MD’s to offer circumcision for infants even though there is nothing morally wrong to perform circumcisions. There is no obligation for physicians to perform abortions…. One of the effects of Plan B is to prevent implantation of a fertilized ovum. Therefore, preventing implantation is exactly the

same as an abortion (expelling a human fetus). Why should a physician be forced to prescribe Plan B and kill that fetus when other doctors are allowed to not perform abortions?” — Ku-Liang Yu, MD “Fertility and family planning/fertility management is…an integral part of Gyn/primary care practice. Medical Ethics and common courtesy mandate provision of effective and accepted therapy or, if the individual physician’s religious practice discourages this, prompt…referral to a viable prescribing source [is required.]” — Michael Goodman, MD “I believe [we]should give the option if pt comes in needing it, but not to inform them of it on a routine basis.” — Soni Nageswaran, MD “[I] do not believe a PCP, or for that matter a specialist, has an ethical and professional obligation to inform women about Plan B. If the physician chooses to, they can inform the patient but there is no obligation to do so.” — Jose Cueto, MD “Absolutely; women should be educated on this option.” — Karen Lo, MD “Question seems ambiguously worded. Does this imply that a visit is related to fear of pregnancy after a sexual exposure? Or a general announcement to all women patients of childbearing age?” — Michael McCloud, MD “As with any other treatment, patients need all the choices.” — Walter Malhoski, MD “Informing women is one thing, but being obligated to provide the Pill is quite another. We have a right to act in accord with our conscience and NOT prescribe drugs which have an abortifacient effect. We may refer to another physician who will provide it, but it is not fair to ask us to leave our own ethical concerns at the door.” — Stephanie Whittle, MD “Women of child bearing age may or may not know about the morning after pill option, and its availability.” — Rugmini Shah, MD “[You] don’t need a prescription for over age 18 in California.” — Barbara Hays Editor’s note: Dr Haskins’ article makes the point that even though a prescription is not required, there are significant practical advantages for the patient with Rx in hand in case of emergency.

July/August 2007

“Absolutely; women should be educated on this option.”

Voices of Medicine A complication of volleyball, when religion meets medicine, the draw of surgery centers.

By Del Meyer, MD

Broken Nose, Big Problem David Goldschmid, MD, the President of the San Mateo County Medical Society, writes about “When Doing The Right Thing Seems Wrong” in the society’s April Bulletin. “It is not always easy to do the right thing. Sometimes we know what the right thing is, but either choose not to do it or find ourselves in a position where we cannot. Sometimes we just do not know what the right thing is. “My daughter recently broke her nose playing soccer. She belongs to a Boston-based HMO associated with Harvard Medical School. She called her primary physician hoping to get a referral to a surgeon who is able to fix her nose. Instead, she was offered an appointment to see her primary care physician – in two weeks. “The medical director of the clinic explained that it was his policy to require that all referrals go through the primary care physicians, but there was a shortage of them, resulting in excessive delays. My daughter was advised that she should go to the ER if she thought she should be seen within two weeks. “Off she went to the ER, where the resident physician ordered a CT scan of her face. Apparently, having a nasal deformity is not sufficient for a diagnosis of a nasal fracture. She was told she needed an image to confirm the diagnosis in order to facilitate a referral to a surgeon. It was their custom to always get a CT (not just nasal bones), to make sure that “nothing was missed.” Worried about unnecessary radiation, she insisted that she only get plain nasal bone

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films if an image was required for a referral. This image showed a nasal fracture. “The primary care physician was contacted to get a referral, but he thought that repairing a nasal fracture might be denied, as it was probably ‘cosmetic.’ Eventually, she got her nose fixed, but her impression of physicians was less than stellar. Suffice it to say that this real scenario is peppered with people doing the wrong thing and is a good example of the chaos that results when we forget our true purpose and limit our goals to immediate ones. “The legitimate goal is to fix the broken nose. Her physicians forgot why they are there. The goal of the medical director is to limit cost, but his policies actually resulted in increased cost. The goal of the emergency resident is to protect himself from his colleagues’ criticisms and to be sure he does not miss anything. This results in unnecessary testing and exposure to radiation. Ultimately, this is a grand failure earning physicians loss of stature…” The entire article is at www.smcma.org/ Bulletin/BulletinIssues/April07issueFeaturedArticles April07.html

The Minister’s Son The May 2007 issue of San Francisco Medicine focused on medicine and religion. The President’s Message of Stephen Follansbee, MD, was entitled, “A Prescription for Prayer?” “As the son of a Presbyterian minister, I am aware of how much I am my late father’s son, despite my different career path. My voice sounds like his. My hand gestures and mannerisms are like his. I think that at times, when talking with patients about life-threatening illness, death, and

dying, or advising them about how to talk with their families and friends, I must naturally rely on some of my father’s innate counseling skills. Is the practice of medicine that far from religion? As physicians, are we that different from clergy? The answer is a resounding ‘yes,’ even though a majority of hospitalized patients would like us to consider their spiritual needs… “As physicians, we are certainly aware of the conflict that can arise between religion and medicine. A 2005 study entitled ‘When Patients Choose Faith over Medicine: Physician Perspectives on Religiously Related Conflict in the Medical Encounter,’ by Curlin, Roach, GorawaraBhat, Lantos, and Chin, looked at this issue. The authors conducted one-to-one, in-depth, semistructured interviews with twenty-one physicians from a broad range of religious affiliations, specialties, and practice settings. Although admittedly based on a small study sample, their conclusions are interesting. The authors categorize the conflicts between medicine and religion into three overlapping domains: religious doctrine versus medicine, ethical controversy, and faith versus medicine. The refusal of Jehovah’s Witnesses to accept blood products is an example of religious doctrine. Lawsuits have been won by patients who have sued their physicians for battery after saving their lives with transfusions of red blood cells, against their expressed wishes. The courts are clear: A patient’s religious convictions must be respected, even if doing so conflicts with the doctor’s own judgment about appropriate medical care…” The entire article can be found at www. sfms.org/AM/Template.cfm?Section=SF_Medicine_ Magazine&Template=/CM/HTMLDisplay. cfm&ContentID=2316

Hospitals and Surgery Centers Phillip Goldberg, legal counsel for the California Society of Anesthesiologists, discusses “Hospitals vs. Surgery Centers” in the CSA Bulletin. “The proliferation of free-standing ambulatory surgery centers in recent years has sometimes created tension between these new facili-

ties and acute care hospitals. Most of these surgery centers are physician owned, in whole or in part, and physician investors are encouraged to steer patients to their surgery center for qualified procedures that might otherwise have been performed in the acute care hospital where the physician is on staff. “This is not just a matter of the surgeon’s financial self interest. Federal regulations actually encourage procedures at the surgery centers by providing fraud and abuse protection to a physician who performs enough procedures at the surgery center so it is considered an extension of the physician’s practice. (42 C.F.R. 1001.952(r).) Many surgery centers require their surgeon investors to perform enough cases to comply with the regulatory safe harbor as a condition of retaining their investment. Generally, to fit within the fraud and abuse safe harbor, the surgeon must perform at least one-third of his or her outpatient procedures at the surgery center. Although compliance with the safe harbor is not required to comply with the federal fraud and abuse statute, many surgery centers adopt the safe harbor as mandatory for their investors, with the result of increasing utilization at the facility. “By necessity, surgeons bring their healthier patients to the surgery center and leave their sicker patients at the hospital. By choice, the better reimbursing cases are often performed in the surgery center, and the lower paying cases are left at the hospital. As patients are leaving the hospital and moving to the surgery center, anesthesiologists are following them. It is not uncommon for some anesthesiologists to practice principally or exclusively at a surgery center. This exodus of patients and anesthesiologists has created problems for other anesthesiologists who continue to practice principally or exclusively at acute care hospitals…“ To read more, go to www.csahq.org/pageserver.cgi?tpl=internal.tpl&section=publications&na me=bulletin_view&idx=16 Click on legislative and practice affairs.

“By necessity, surgeons bring their healthier patients to the surgery center and leave their sicker patients at the hospital. By choice, the better reimbursing cases are often performed in the surgery center, and the lower paying cases are left at the hospital.

DelMeyer@HealthCareCom.net

July/August 2007

Winning Student Essay

Helping the Healing Process This is the winning college entry in our first student essay contest. The winning high school entry appeared in the last issue.

By Darren Salmi, MSII, UC Davis School of Medicine The winner of the 2007 SSV Medicine essay contest for medical students is Darren Salmi, in his second year at the UC Davis School of Medicine. He is a native Californian from the Bay Area. He became interested in oncology as an undergraduate at UC Santa Barbara, and is considering that as a future specialty. On the other hand, he has always enjoyed writing. So many well known writers have been physicians that perhaps he will keep that option open. â&#x20AC;&#x201D; J.L. Every year millions of children succumb to preventable deaths, mostly in the worldâ&#x20AC;&#x2122;s poorest countries. The methods of prevention are well-known and widely employed in many parts of the world. However, knowing how to do something and actually doing it are two very different things. Countries with high rates of infant/child death lack the appropriate resources, infrastructure, or stability to implement the necessary changes in water safety, food supply, and vaccine development and administration. As a result, such countries are dependent upon those willing to donate such services. For example, 4.3 million people in sub-Saharan Africa survive on food donated by the World Food Programme. Such goodwill is not a sustainable answer to problems of this scale nor does it engender a role for the needy in their own health.

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Instead of waiting for the child to become infected with a disease and then treating his or her symptoms, a physician provides a vaccination to allow the childâ&#x20AC;&#x2122;s own immune system to prevent illness in the first place. Similarly, the world community should provide the tools to take care of its sick children so that any country, regardless of size or wealth, may be able to prevent the unnecessary illness and death of its most vulnerable citizens. If changes are to be permanent, they must take hold from within. The poor are usually more rural yet aid programs in most countries are based in a few major centers. Such centralized setups increase the vulnerability for theft or fraud and decrease the availability of medicine to those who live far away. Bringing services closer to those who need them allows for greater effectiveness and also makes those at the bottom of the chain more invested in their own healthcare. For example, training a member of each town, tribe, or village to be its designated healthcare provider means there is someone responsible for the health of the children in his or her own community who will be able to not only perform vaccinations or distribute certain medications, but also educate the rest of the community on simple ways to promote health. Taking control of their own health situation can empower them and stimulate a greater sense of ownership in their future. Consider what happens in the U.S. when a dozen people get

reason to be hopeful. According to the Global Health Council, only 5 percent of the world’s children were vaccinated 30 years ago compared to 75 percent today. In 2005, UNICEF’s State of the World’s Children reported that the under-5 mortality rate of developing countries experienced a 61 percent reduction between 1960 and 2003. Warren Buffett’s historic $30 billion donation to The Bill and Melinda Gates Foundation has ushered in an exciting time for global health and development and underscored a new vigor in combating disease. When enough of the world focuses its attention on the health of its children, it becomes difficult to look the other way. This is progress in itself and will hopefully encourage even more people to join in helping those least capable of helping themselves. djsalmi@ucdavis.edu

What is it?

This hand-blown glass object has long has been in a display case in the Sierra Sacramento Valley Museum of Medical History — with a big question mark (over one inch high) next to it because its purpose was unknown. The Museum now knows what it is. Do you? The answer is below, printed upside down. It is a breast milk saver shell, used to collect leaking milk during feedings or if feeding sessions have been delayed. It can also relieve engorgement.

food poisoning from a fast-food chain. There are reports on the news and stories in the paper, million dollar lawsuits ensue, and public relations campaigns are launched to restore the customers’ trust in the company’s product. Hopefully, even those in the poorest countries will one day command respect, as well as resources, for their health and well-being. Reviewing the sad tales of many lottery winners is enough to remind us that all the money and resources in the world will just go to waste if people don’t know how to use them wisely. In addition to healthcare workers, management at higher levels needs to be properly trained in order to establish a reliable infrastructure through which changes may be implemented. Ideally, every child would eat a well-balanced diet, receive vaccinations and medications, and have a bottomless jar of vitamins. Unfortunately, malnutrition, micronutrient deficiency, and disease vulnerability are the norm for millions of children. The most efficient way to approach this problem is to promote the use of superfoods. Biotechnology has reached a point where it is feasible and safe to engineer food that is hardy enough to grow in necessary quantities in harsh climates, ample in micronutrients that are otherwise missing in local diets, and endowed with certain medicines. In fact, Sacramento’s own Ventria Bioscience has recently developed strains of rice with the genes for breast milk proteins to be used in the treatment of infant diarrhea. Instead of wealthier countries growing food or manufacturing vaccines and medicine, and then shipping them to poorer countries, perhaps a wiser investment would be made in developing crops tailored to suit their local environment and health issues. Once developed, the seeds can be handed over to needy nations. They would then be able to literally grow the solutions to their problems in their own backyard, giving them control over their health, a sense of empowerment, and a solution that is sustainable. Although there are several hurdles to overcome if we are to alleviate the avoidable suffering of millions of the world’s children, there is also

July/August 2007

Preventing the Cascade How to deal with the collateral consequences of medical board discipline.

By Timothy J. Aspinwall, Esq. The author is an attorney with the firm of Nossaman, Guthner, Knox & Elliott, LLP A physician facing professional discipline is exposed to a number of risks — and one misstep can lead to other consequences, much like a series of falling dominos. This article outlines the major collateral issues that should be taken into account when physicians face discipline by the Medical Board of California. Disciplinary actions can be initiated in a variety of ways. Sometimes the Medical Board files an accusation; sometimes the medical staff at a hospital initiates an investigation; and sometimes discipline is based on a criminal investigation or some other issue. Whatever the allegations and whatever the context, it is imperative to develop a strategy early in the case to limit potential damage. Thirteen potential problem areas should be assessed in any case involving professional discipline. 1. Client’s Mental Health The threat of discipline is extremely stressful and can exacerbate depression or other mental health problems. Also, the behavior at issue in a disciplinary case may be caused by some treatable mental health problem. It is advisable to be very attentive to any indication of mental illness. If the client is not dealing well with the stress, or if it appears a mental health problem may be the underlying cause of unprofessional conduct, the client should be referred to a psychiatrist. It is important that any treating therapist be independent from any forensic psychiatrist

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or psychologist who might be consulted as an expert in the case. There are three benefits to this. First, the client knows the patient-therapist privilege will be maintained. This obviously facilitates more successful treatment. Second, if the client is emotionally stable, he or she is in a much better position to assist legal counsel. Third, if the client’s conduct is related to a treatable mental health problem, any discipline can be mitigated with effective treatment. 2. Foreign States In any disciplinary case, it is important to determine whether the client is licensed in any other states, and, if so, whether the foreign state requires the licensee to provide notice of discipline in other states, and whether the foreign state is likely to impose discipline based upon the current action. Many state licensing boards do not require the licensee give notice of discipline in a foreign state, but do require disclosure on the licensee’s application for renewal. This is the case with the Medical Board of California. The boards in some other states require that a licensee provide notice within 30 days of the imposition of discipline in a foreign state. Most state licensing boards are authorized to impose discipline based upon discipline in another state, without having to prove any of the underlying facts. This means discipline in one state will almost certainly result in discipline in all other states where the client is licensed. With some exceptions, the general tendency is for a medical board in a foreign state to impose a level of discipline similar to the original discipline. One problem, however, is that some licensing boards, including the Medical Board of California, typically toll probation during

any time that the licensee resides outside of the state. This means any licensee living in another state will remain on probation indefinitely, until returning to California to serve probation. To make matters worse, the Medical Board of California now includes in its disciplinary orders a provision calling for cancellation of the license of a physician who lives outside of California for a continuous period of two years during the term of probation. A cancelled license is likely to be the basis for termination of provider status in the Medicare and Medi-Cal programs. (42 U.S.C. § 1320a-7(b)(4)(A)) Moreover, termination from Medicare or Medi-Cal can result in termination from private health care plans. Thus, the California Medical Board effectively forces physicians to choose between leaving their home state to serve probation in California, or stay in their home state and risk losing their provider status with public and private payors. 3. Criminal Prosecution It is always advisable to involve a criminal defense attorney if there is a criminal investigation or the possibility of an investigation into a serious offense. Physicians are required to self-report to the Medical Board within 30 days of being charged with a felony, or of any conviction, including a guilty verdict or plea of guilty or no contest, of any felony or misdemeanor. Failure to report as required is a public offense punishable by a fine of up to $5,000. (Bus. & Prof. Code § 802.1) The most straightforward cases involve a conviction for a misdemeanor such as driving under the influence of alcohol. In a DUI or other substance abuse-related offense, it is important to get the client into an appropriate recovery program as soon as possible. If there appears to be a serious problem, such as two or more DUIs in a relatively short time, the recovery program should be tailored to match the Medical Board’s Diversion Program. The Diversion Program typically includes random chemical testing, individual counseling, and group meetings such as AA. Participation in a recovery program provides mitigating evidence that can be used in settlement or at hearing. An added benefit is that effective

treatment will significantly reduce the chance that inpatient treatment will be required. In cases of drug abuse, physicians should be very cautious about pleading no contest with a deferred entry of judgment. While a deferred entry of judgment may be the best resolution in the criminal case, the no contest plea is a conviction for administrative purposes and exposes the client to discipline by the licensing board and possible exclusion as a Medicare and Medicaid provider. (42 U.S.C. § 1320a-7(a)(4); 42 U.S.C. § 1320a-7(b)(3)) 4. Medicare and Medicaid Exclusions In all discipline cases — and especially in cases involving potential criminal liability, poor quality of care, or loss of licensure — the client is vulnerable to mandatory or permissive exclusion from participation as a provider for federal health care programs. There are five grounds for mandatory exclusion: (a) conviction of program-related crimes; (b) conviction related to patient abuse; (c) felony conviction related to health care fraud; (d) felony conviction related to controlled substance; and (e) failure to enter an agreement to repay a Health Education Assistance Loan. (42 U.S.C. §§ 1320a-7(a), 1395ccc) There are 16 grounds for permissive exclusion from participation as a provider in federal health care programs: (a) conviction related to fraud; (b) conviction relating to obstruction of an investigation; (c) misdemeanor relating to controlled substance; (d) license revocation or suspension; (e) exclusion or suspension under federal or state health care program; (f) claims for excessive charges or unnecessary services; (g) fraud, kickbacks; (h) entities controlled by sanctioned individual; (i) failure to disclose required information; (j) failure to supply requested information on subcontractors and suppliers; (k) failure to supply payment information; failure to grant immediate access; (l) failure to take corrective action; (m) default on health education loan or scholarship obligations; (n) individuals controlling a sanctioned entity; (o) failure to meet statutory obligations of practitioners and providers to provide medically necessary services meeting professionally recognized

July/August 2007

Thus, the California Medical Board effectively forces physicians to choose between leaving their home state to serve probation in California, or stay in their home state and risk losing their provider status with public and private payors.

In investigations or disciplinary actions initiated by a hospital medical staff, the deck often seems stacked against the physician.

standards of health care. (42 U.S.C. §§ 1320a7(b), 1320c-5) 5. Medicare and Medicaid Investigations Most government investigations are initiated because of irregular billing patterns or evidence of poor quality of care. The investigation may be administrative or criminal. All too frequently, criminal investigations come to the provider’s attention with the execution of a search warrant. If possible, it is best to have a criminal defense attorney go to the scene during execution of the warrant. In any event, the client or legal representative should get a copy of the warrant and the supporting affidavit if it is not under seal. Beyond that, the client should be firmly instructed not to talk with investigators. Administrative investigations can be as stressful for the client as criminal investigations. They can lead to a criminal investigation, and administrative sanctions can create financial hardships, including exclusion and civil monetary penalties. 6. DEA Certificate Any physician who prescribes medications to patients must have a certificate from the Drug Enforcement Administration (DEA). The DEA will initiate action to revoke the certificate of any physician convicted of a felony relating to enumerated controlled substances. 7. Private Insurance Private insurers often seek to remove providers from their respective panels because of billing irregularities or allegations of substandard care. These cases are generally initiated because of a criminal conviction or discipline by the Medical Board. Occasionally, though, the insurer initiates its own action. These cases should be taken very seriously because of financial losses that accompany removal from the provider panel, and because insurance companies often share their allegations with the Medical Board and administrators of Medicare and Medi-Cal. There should be an early assessment of whether it will be possible to either explain the issues or put together a corrective action plan that satisfies the insurer. Depending on the insurer’s bylaws, this can

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frequently be done at an informal meeting prior to a formal appeal hearing. 8. Hospital Staff Privileges In investigations or disciplinary actions initiated by a hospital medical staff, the deck often seems stacked against the physician. The medical staff executive committee can initiate an investigation, impose summary suspensions, designate a hearing officer and select physicians to serve on the judicial review committee. The physician does, however, have substantial protections under the Health Care Quality Improvement Act and state peer review statutes. (7 42 U.S.C. §11112; Cal. Bus. & Prof. Code §§809-809.9) If the medical staff or hospital abuses their authority, they can suffer substantial financial liability. (Poliner v. Texas Health Sys, No. 3-00-CV-1007-P, 2006 U.S. Dist. LEXIS 13125 (N.D. Tex. Mar. 27,2006) These cases should be handled by attorneys experienced in this area who can protect the physician’s legal rights and respond to any abuses by the hospital or medical staff. In many of these cases, after careful review of the legal merits and the political situation at the hospital, the physician may be best advised to settle the case without a hearing. This avoids the potential of a highly damaging set of findings. Additionally, the political environment may be so toxic that the physician is at risk of additional legal action if he or she remains on staff. If a formal investigation has not yet been initiated, it should be possible to settle without a report to the National Practitioner Data Bank (NPDB). If an investigation has been initiated or discipline imposed, it will be difficult to avoid a report to the NPDB (42 U.S.C. §11133; Cal. Bus. & Prof. Code §805), though any settlement should include a stipulation regarding the language to be submitted to the NPDB. 9. Specialty Boards The various specialty boards of the American Board of Medical Specialties each have their own standards for membership. Board-certified physicians convicted of a crime or disciplined by the Medical Board may also have certification revoked by their specialty board. The specialty board will often allow a physician to appear

before the board to present reasons why revocation is inappropriate. 10. Employment Physician employees are often overwhelmed by the power and financial resources of their employer in an action to either impose discipline or terminate employment. Employees, however, have substantial protections that should be asserted in appropriate cases. In addition to protections against discrimination and retaliation, employment contracts in California and many other states include a covenant of good faith and fair dealing requiring that neither party do anything to injure the right of the other to receive the benefits of the agreement. (Foley v. Interactive Data Corp. (1988) 47 Cal.3d 654, 683) When there is strong evidence of employee misconduct, the best strategy is often to negotiate a departure on the best terms possible. For instance, in cases involving credible allegations of substance abuse, sexual exploitation of patients, or any other unprofessional conduct, it is best to negotiate a confidentiality agreement as part of an exit strategy. A confidentiality agreement will not protect against a lawful subpoena. Moreover, recent legislation makes it impermissible to include in any settlement of a civil dispute a clause that prohibits the adverse party from contacting or cooperating with the Medical Board. (Bus. & Prof. Code § 2220.7) A well-drafted confidentiality agreement will, however, prevent the employer from disclosing restricted information to prospective employers. 11. Immigration Status If a non-citizen is facing possible criminal prosecution or loss of employment, it is imperative to consult with an immigration attorney. The consequences for non-citizens convicted of a crime are simply too severe, and the immigration statutes too complex, for these cases to be handled without an experienced immigration attorney. Similarly, if a non-citizen’s status in the U.S. is based upon employment, it is necessary to consult with an immigration attorney. 12. Tort Liability In any disciplinary case involving allega-

tions of sexual misconduct or substandard care, there is the possibility of a separate civil suit alleging tort liability. The key in these cases is to carefully coordinate the defenses in the separate cases. Very frequently different law firms will handle the various cases, making it imperative attorneys communicate clearly about case strategies. Plaintiff’s counsel is likely to use the administrative proceedings as a source of evidence for a civil case. For this reason, the client should be very cautious about making admissions during an administrative investigation or hearing that may affect an existing or potential lawsuit. In cases involving alcohol or drug abuse, the attorney in the administrative case should seek a protective order to prevent disclosure of any treatment records. The client has a right to privacy regarding any treatment records. Under no circumstances should plaintiff’s counsel be allowed uncontested access to them. 13. Contractual Liability Disciplinary actions can lead to substantial contractual liabilities. For instance, consulting agreements between physicians and medical device manufacturers generally allow the corporation to terminate the agreement in the event of professional discipline. Given the sums involved in consulting agreements, this can be a substantial financial setback. Contractual liabilities can also accrue in recruitment agreements, which typically require that all or a portion of the recruitment bonus be repaid if the relationship is terminated early. For example, hospital physician recruitment agreements almost always require the physician remain on staff for a certain number of years to justify the bonus. If a physician loses his or her license or is terminated from the medical staff, the hospital will seek a full or partial refund. It is imperative to develop a clear strategy early in a case to prevent a career-threatening cascade of events. With careful management of the collateral issues, the consequences of disciplinary actions can be contained, allowing the client to maintain a career in medicine..

When there is strong evidence of employee misconduct, the best strategy is often to negotiate a departure on the best terms possible.

TAspinwall@Nossaman.com

July/August 2007

Demystifying Defibrillators By Kent M. Perryman, PhD This is an abridged version of an article written by the author, a member of the SSVMS Historical Committee, for an exhibit in the Sierra Sacramento Valley Museum of Medical History. Despite enormous medical advances, cardiac arrest still ranks as a leading cause of death in the 21st century. Sudden cardiac death accounts for a quarter of all human deaths. During cardiac arrest, the heart’s rhythmic electrical beat becomes disturbed, resulting in a cessation of blood flow throughout the body and eventual death unless the rhythm is restored within a limited time by electrical shock. Modern compact defibrillators that provide these life saving shocks to the heart can on occasion be witnessed not only in health care facilities but also in some public facilities, commercial airlines and at many businesses for their employees.

Conceptual Development A series of electrical shocks to the chest is necessary for restoring the heart’s normal rhythmic process during ventricular fibrillation. This concept of an electrical shock to the heart to cease its erratic rhythm rests in part on early developments in understanding the electrophysiological basis of fibrillation. In 1775, a Danish physician, Peter Christian Abilgaard, described a series of experiments using chickens whose hearts were stopped by an electric current through their bodies. He noticed the birds could be revived by another series of shocks to their breasts. His were the first recorded accounts of fibrillation and defibrillation. Seventy-five years later, Carl Ludwig, a German physician, physiologist and professor

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at the University of Leipzig, and his student, M. Hoffa, were the first to document the onset of ventricular fibrillation induced by electrical stimulation of a dog’s heart. Hoffa utilized a kymograph for the first time to record arrhythmic wave patterns associated with fibrillation. Later in 1887, John A. Mac William, a British physiologist was able to differentiate between ventricular and atrial fibrillation. He suggested for the first time that ventricular fibrillation might cause sudden death. Mac William also discovered that, unlike ventricular fibrillation, atrial fibrillation could be initiated and arrested with vagus nerve stimulation. Subsequently in 1899, Swiss physiologists J. L. Prevost and F. Batelli reported that while a weak alternating current (AC) or direct current (DC) stimulus can produce fibrillation, a stronger electrical stimulus applied directly to the exposed canine heart could arrest ventricular fibrillation and restore normal sinus rhythm. These findings of cardiac faradizations were replicated in 1940 by Carl J. Wiggers at Case Western Reserve University in Cleveland, Ohio. Wiggers provided the first mechanistic explanation for ventricular fibrillation produced by electrical stimulation. Today these are known as Wiggers stage I, Wiggers stage II, etc. He also further refined the animal model of defibrillation. Claude S. Beck, a thoracic surgeon at the University hospital in Cleveland adjacent to Case Western Reserve was familiar with Carl Wiggers’ work on ventricular fibrillation with dogs. Dr. Beck pioneered cardiac surgery to improve circulation in damaged heart muscles. During open-heart surgery in 1947, the patient, a 14-year-old boy, went into ventricular fibrillation and Dr. Beck first applied heart massage unsuccessfully. An experimental defibrillator

was brought into the operating room from Dr. Beck’s research laboratory and 1500 volts were applied to the boy’s exposed heart, restoring the normal cardiac rhythm. This defibrillator was a large monstrosity operated from conventional AC wall sockets using a bulky step-up transformer. Two metal paddles had to be positioned on either side of the heart and voltage applied for ¼ to ½ second. Not a lot was known at that time about the amount of voltage necessary to restore a normal sinus rhythm. This was the first documented and published success of a human patient resuscitated during ventricular fibrillation. Beck’s success encouraged the medical community to adopt defibrillation for cardiac resuscitation. Then, in 1956, Paul M. Zoll, a cardiologist at Harvard Medical School, demonstrated the lifesaving benefits of employing defibrillation on a closed chest. He applied 15-ampere AC currents that produced 710 volts across the chest for 150 milliseconds. Zoll went on later in the 1950s to develop an external pacemaker for closed chest. Coinciding with these experimental and clinical trials were attempts by the medical and engineering communities to develop a satisfactory defibrillator. In the first half of the 20th century, many linemen were electrocuted during the power companies’ electrification of America. Inspired by these grim statistics and some research funding from Consolidated Edison of New York, William B. Kouwenhoven, an electrical engineer and William Henry Howell, a physician at Johns Hopkins University, began to study the ravages of electric shock. In 1933 Kouwenhoven and Hopkins neurologist Orthello Langworthy demonstrated that an internally applied alternating current could be used to produce a counter shock that reversed ventricular fibrillation in dogs. Eventually, Kouwenhoven and Langworthy revolutionized cardiovascular resuscitation. Together with cardiovascular physiologist William Milnor, Kouwenhoven began evaluating various electrical parameters in the 1950s that would restore a normal sinus rhythm during closed chest shocks to dogs. Kouwenhoven and

Milnor soon discovered that electrical stimulation was more effective and required less voltage if current flow followed a vertical rather than a horizontal path through the heart. Eventually, after repeated testing on dogs, Kouwenhoven assembled a 200-pound machine on wheels that delivered AC shocks from two electrodes, one positioned over the suprasternal notch and the other over the apex of the heart. In addition to the Hopkins AC Defibrillator, Kouwenhoven went on to later develop and refine the Mine Safety Portable.

Other Efforts There were early attempts by other individuals to develop electrical apparatus for cardiac resuscitation. During the 1930s, Albert S. Hyman devised a machine to produce an electric shock to the heart by a needle inserted into the patient’s chest wall. This device turned out to be more of a primitive pacemaker than a defibrillator. The electricity was produced by a hand-operated magneto (DC generator). The device was never approved by the medical community. Then in 1949, electrical engineer John A. Hoops designed and built a vacuum tube cardiac

July/August 2007

This is a defibrillator model of about 1970.

This is a modern defibrillator.

stimulator for doctors Wilfred Bigelow and John C. Callaghan that utilized a catheter electrode. The stimulating electrode was to be introduced to the heart via the right external jugular vein. This device was never employed for medical service with a human patient. During the 1960s, Bernard Lown of Harvard School of Public Health and K. William Edmark of the University of Washington demonstrated that direct current could be employed for ventricular defibrillation. These DC defibrillators were safer and portable permitting their use outside of hospitals. The portability issue becomes a primary concern in reaching out to patients during ventricular defibrillation. The normal sinus rhythm has to be restored within minutes if the patient is to survive. Two cardiologists in Northern Ireland realized the potential life-saving benefit of bringing a portable defibrillator to the patient. Doctors J. Frank Pantridge and John S. Geddes equipped an old ambulance with a portable defibrillator and thus established the first mobile intensive care unit in 1966. Two 12-volt car batteries powered the defibrillator, which was operated

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by a physician and a nurse. Subsequently, paramedic teams have come to occupy and operate the emergency medical equipment in these mobile units. Defibrillation by emergency medical technicians (EMTs) without the presence of physicians was first employed at Portland, Oregon in 1969. The personnel in these units are in communication with a hospital’s intensive care unit, receiving transmitted EKG recordings from the patient en route and receiving emergency medical advice as needed. In the latter part of the 20th century, intelligent computer chip circuitry has on some occasions partially obviated the need for medical advice when a health specialist is inaccessible. During the 1980s, the computer industry incorporated electronic circuits into defibrillators along with computer algorithms that recognized ventricular fibrillation. These “smart” defibrillators, also known as automatic external defibrillators (AED), interpret the patient’s rhythm from the EKG signal — recorded off the same stimulating electrodes that can deliver a series of shocks to restore normal cardiac rhythm. The EKG signal is analyzed with a combination of signal parameters including rate and amplitude criteria. In addition, the QRS (electrocardiographic) waveform is also analyzed as to its slope, morphology, power spectrum density, and time away from the isoelectric baseline for preset levels defined as abnormal. Samples of the EKG are taken at 2–4 second intervals. If any abnormal complexes are detected for more than double the frequency of any other QRS for three consecutive checks, the AED will be ready to deliver a shock. Voice-chip technology is also incorporated into these devices to prompt the operator by verbally coaching procedures. The operator must stand clear during the shock phase and administered cardio-pulmonary resuscitation (CPR) to the patient during periods of EKG analysis. The AEDs have a reported sensitivity of 76–96 percent in reliably detecting ventricular fibrillation and specificity (correctly identifying non-ventricular rhythms) of close to 100 percent.

Implantable Defibrillators Implantable defibrillators were also developed in the 1980s. Rushing a portable defibrillator to an individual in ventricular distress is usually too late. Michael Mirowski and Morton M. Mower at Johns Hopkins Hospital developed a miniaturized defibrillator for implantation. This first generation of implantable defibrillators was the size of a portable compact disc player and used electrodes directly contacting the heart. Implantation was performed only as a last resort for open-heart surgery. With time, implantable defibrillators were reduced in size by developing computer chip technology. The latest implantable defibrillators are small enough to be placed under the skin over the chest. Their circuitry is housed in a titanium chassis that also serves as a return current pathway for a fine wire electrode threaded through a vein to the heart. Consequently, open-heart surgery is longer required. Battery life on these devices is in excess of eight years following the adoption of utiliz-

ing biphasic stimulation pulses. This industry standard has also been adopted for AEDs. The biphasic pulse is more physiologically effective, as well as resulting in longer battery life and a substantially reduced recycle time to build up successive charges. In addition, EKG information is recorded, stored on the chip and downloaded later to a computer for diagnostic analysis and troubleshooting. However, only a small fraction of patients with potential heart disease come to the attention of a cardiologist before their first attack. Twenty percent of ventricular fibrillation cases occur in individuals with no previous diagnoses of heart disease. Ventricular fibrillation is still the leading cause of death in adults. Defibrillators will be needed until medical science better understands ventricular fibrillation and can prevent it. In the meantime, defibrillators are not quite ready to be relegated to a museum. kperryman@aol.com

Wilke Fleury ad p/u May/June 07

July/August 2007

2007 Ship Doc 2: Inside Passage to Alaska By John Loofbourow, MD In the previous issue, the author described a trip as ship’s doctor on an icebreaker in the Antarctic. This time he heads north, on a much plushier cruise liner. I usually prefer to travel with some sort of connection to people and place; something that makes me, for a time, a participant. And I had never been to Alaska. So, after surviving the application process required by a large Alaska cruise ship line, I agreed to serve as ship physician to about 1,300 passengers on a two week round trip from Vancouver, British Columbia to Seward. A full-time Filipino physician would care for 650 crew members. We would be assisted, (or directed!), by two experienced full time nurses. Vancouver is a collage of water, mountain, industry, and ordered British style residential areas. It’s like a Seattle or Portland on the metric system, and with many more mosques. Arriving there the night before, at 6:30 the next morning I was picked up at my airport hotel and transported to the cruise ship passenger terminal at Granville Square, where big cruise ships tie up surrounded on three sides by Money: modern multistoried business, financial, and commercial buildings lining manicured central city streets. As in the Vancouver airport, luggage carts in the huge ship passenger terminal are free. Hundreds of debarking passengers filed by in the opposite direction, but only crew on my side of the operation, so I gratefully passed with a few other crew members through the security

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screening, emigration and immigration barriers, up the gangway, and checked in with the ship’s security officer. After reviewing my tired documents for the third time that morning, he gave me a pass key, and I found my way to my 6th deck cabin. Leaving my gear there, I asked my way to the 2nd deck infirmary. The ship interior was such a maze that I was lost much of the time, unsure which was port or starboard, forward or aft. But at last I found the infirmary, and met the outgoing physician, the nurses, and the crew doctor. The clinic was surprisingly spacious, consisting of four private patient rooms, a one-bed intensive care unit, XRay, a lab, substantial pharmacy medical supplies, associated offices, storage, bathrooms, a kitchen, and three cabins for full time medical staff. Most of the on-board automated lab testing — cardiac enzymes, tox screens, chemistries, ETOH measurement, etc. — would be illegal in the U.S. because of oversight regulations or legislation. We tend to ban the good in favor of the perfect, greatly increasing the cost of medical care. On the other hand, a ship captain, and indirectly the medical staff, is free to exercise common sense and reason. My office had a small medical library, a computer with online access for browsing and email, printer, and an electronic desktop covered with a daunting array of memos and procedural documents. There was online access to E.pocrates, and several other medical electronic resources not familiar to me. The debarking physician led me on a tour of the ship, and iterated the dress requirements: dark blue blazer and pants with white shirt and

tie; a lab coat could be used in the clinic, a tuxedo or dark blue suit and tie for formal dinners. The ship physician is provided a voucher to buy drinks for passengers, and is requested, but not required, to socialize. Gambling and socializing in cabins is verboten. The crew’s weekly fire and lifeboat drill followed, and I completed several hours of environmental and emergency training programs required of crew, and returned to the infirmary to review emergency medical procedures with them.

The Crew The entry level crew consists largely of young men and women from Indonesia and the Filipinas. They work very hard, especially in Vancouver and Seward, because the cruise begins and ends there. They must disembark 1,300 passengers, and take on a like number the same day. That implies at least 5,200 pieces of luggage on eight decks, to be taken to and from the dock. They must clean and make up all the cabins, offload huge quantities of waste, and bring aboard even larger amounts of new supplies. At the same time, new passengers unfamiliar with the ship and its routines require patient responses to about 100,000 questions. These youngsters were the life of the cruise. They were always animated, polite, and attentive. They put on nightly shows at dinner, with elaborate costumed ethnic dances, and shows in the ship theater. I naively assumed them to be people lost between two worlds, having left remote rustic villages, now forever changed by exposure to the wider world, so that they were essentially noble but homeless cruise ship migrants. I was wrong. The average steward has studied English and tourism for several years in a non-village like Jakarta; has survived a competitive employment screening, and had 6-month training with the cruise line before starting a one year contract. Most return home to find other work in the tourist trade. Some become long time employees or rated maritime officers: Not the average unskilled migrant worker.

As the last passenger boards, we leave Vancouver in the late summer light for a night at sea, to awake in Ketchikan. On the second evening, again at sea, the officers, including the physician, are introduced to the new passengers officially, and the first formal dinner takes place. Each night there are two dinner seatings, and several show productions. An impressive array of optional activities is offered throughout the day and evening. There are two pools, a gymnasium, fitness classes, art classes, art auctions, a spa with amenities, a casino, shops, restaurants, bars, dance venues — so many things to do that I can’t remember them all.

Physician duties include: • Carrying a beeper for 24/7 on call. An exception is that while in port half the medical staff can be ashore by turns. • Attending office (clinic) twice daily at 8–9 a.m. and 5–6 p.m. • Completing the considerable paperwork required. Passenger makeup was roughly 30 percent families with children; 45 percent couples of various age, often healthy retireds; 10 percent singles of all ages; and15 percent people in delicate states of health, usually elderly. Of most concern to the physician are people with serious or complex illness who hope to make a

July/August 2007

last voyage on an elegant cruise ship before they leave this life. This is not an exaggeration. The physician I replaced attended one death. The nurse who came aboard left a Hawaiian Islands cruise ship where three people died. I was fortunate, though I preventively debarked anyone who gave off a whiff of sudden death, or was likely to have an event beyond our capabilities — like the suspect deep vein thrombosis who, once ashore, was MRI-morphed into an embarrassingly minor ruptured baker's cyst. I was only called out at night twice in 14 days, for people with chest pain; and even then, was back asleep in a few hours while the full time staff ran the unit. By current U.S. standards, most typical myocardial infarcts would receive on board clot dissolution therapy, because timely transfer to an appropriate facility is not possible. Exceptions include cases where the event occurred in port or in certain further evolved infarcts. I often made cabin phone calls or visits to check on ongoing problems like a nasty brown recluse spider bite of the foot and an infected leg laceration. There was no norovirus epidemic though I obediently quarantined a couple of suspects, according to protocol, knowing that had it been the real thing it wouldn’t have mattered because the virus is so highly infectious. Neither was there a respiratory infection run. The ship was rife with hand sterilizing gel. Perhaps it was effective.

The Paperwork Medical records were hand written, extent and overall detail at the discretion of the physician. The cruise company provides $1 million malpractice insurance; even though that seems marginal, maritime law is a different tort environment than that in the U. S. So is the billing procedure. The cruise company itself charges for all medical care, excepting injury sustained aboard, which is free of cost. A passenger’s credit card is billed, and a detailed receipt is provided on the spot so passengers can later collect from their own insurance, or trip insurance. It seemed to me that charges for office visits, medications, and treatment for minor illness or injury were reasonable compared to California, while charges for intensive or step-down type care were comparably miniscule. Physician pay is nominal, but a spouse and or child in the same cabin are without cost, except for optional extras like body repair in the spa, shopping, side trips, etc. I would not hesitate to recommend that experienced emergency department colleagues try working the Inland Passage cruise to Alaska. It is stunningly beautiful, particularly in the spring, when the mountains are still dressed for winter. The springtime sea is quickening with life, and is usually well-behaved, sheltered by the off shore islands. Cruise ships often dock directly along the main streets of picturesque Alaskan towns like the capital, Juneau. While side trips are many and varied, I met an elderly European expatriate from Vancouver who does a tour about three times yearly just because he likes the cruise life. He doesn’t go ashore at all. The industry — that is certainly what it is! — has been very successful in part because of our continent’s north coast physical features, but also because the large ship trips are relatively reasonable It costs from $100 to $200 per day to be pampered and paraded in luxury among scenery that otherwise would extract a considerable physical and economic toll on the traveler. In my advancing old age, I might go as a passenger, free to lose sleep at the poker table instead of the infirmary. john@loofbourow.com

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In Memoriam

Glenn Emmett Millar, Sr., MD 1908 – 2007

Dr. Glenn Millar, Sr., was a dedicated physician in Sacramento and Amador counties for 57 years. He lived in Sacramento’s Curtis Park and South Land Park, in Pollock Pines and, recently, in Rancho Murieta. Glenn was born in Medford, Oregon, to George Millar and his wife, Anna Roden. An only child, he moved with his parents to Reno, Nevada, in 1910, growing up there and attending the University of Nevada. He transferred to Stanford University where he received his undergraduate degree in 1931. He attended Northwestern University Medical School and received his MD degree in 1935. While attending medical school he met Helen Scott and they were married in 1934. They moved to Sacramento in 1935 and had two children. Glenn interned and completed a surgical residency at the Sacramento County Hospital. In 1937, he entered private practice as a general practitioner. He volunteered for military service in the Navy in 1943, and served as a medical officer on the USS Shasta in the South Pacific, completing his service in 1945. After his military duty, he resumed his general practice. He married a second time in 1954 to Beverlee Neal; they had three children. He continued his private general practice until 1977. In 1978, he became medical director of the Plymouth and Pioneer Medical Clinics in Amador County, serving there until retiring in 1994. Glenn was an avid fisherman in the Sierra Nevada and Southern Oregon areas. He also

enjoyed trips to Death Valley and to Bodie, Nevada, and other ghost towns. He was a member of the Sierra Sacramento Valley Medical Society since1935, and until last year he served on the Historical and Scholarship & Awards Committees. He was a member of the California Medical Association and received an award for 50 years of dedication and commitment to the American Academy of Family Physicians. He was a life member of the Veterans of Foreign Wars Post 1267. He was a member of AMVETS, Ben Ali Shriners, California State Grange Exchange Club of Sacramento and SIRS, a Master Mason for 76 years, and a member of the Sacramento Scottish Rite Free Masonry Glenn Emmett Millar, Sr., MD since 1939. He is survived by his oldest son, Glenn Millar, Jr., MD, who cares for medically indigent adults in Placer County; daughters Sue Millar and Lisa Cozzens; and son David Millar. He is also survived by 10 grandchildren and 2 great grandchildren. After a memorial service on March 20, he was buried on March 23 with full military honors at the new Sacramento Valley VA National Cemetery in Dixon. Glenn cared for generations of Sacramentans and delivered thousands of babies during his 40 years in general practice. Those who knew him were friends of a great gentleman and a fine doctor. — Frank J. Boutin, Sr., MD

July/August 2007

Book Review

The Coronary Care Scandal at Redding Medical Center It took a priest’s request for a second opinion to trigger an investigation.

By George Meyer, MD CORONARY: A True Story Of Medicine Gone Awry, Stephen Klaidman, Scribner, New York, 2007, ISBN: 0-7432-6754-0, $25 After reading this book about the cardiology scandal at Redding Medical Center, I came away with two questions. Why can’t medicine police its own, and why is there a place for for-profit medical facilities in the United States? In the early 1990s, National Medical Enterprises, a for-profit medical company, had removed itself from management of most of its general hospitals and was focusing on psychiatric hospitals where there was less oversight. Administrators were rewarded for exceeding their target hospital incomes with bonuses of up to 50 percent of their base pay. They were hiring bounty hunters to identify potential insured patients to admit; they were maximizing hospitalizations until insurance had been used up; and they were caught after kidnapping a child in Texas and taking him to one of their inpatient psychiatric facilities. As a prior commander of a military hospital on the East Coast, I had been receiving similar complaints as early as 1989 about the abuse of children in psychiatric care, especially those eligible for CHAMPUS care. NME eventually paid more than $600 million in penalties. After several of the leaders left the group, it was renamed Tenet in the early 1990s.

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In 1978, NME recruited a Korean-born cardiologist from his fellowship at the Cleveland Clinic to develop a cardiology program at the Redding Medical Center. In 1987, he recruited a cardiovascular surgeon part-time and, by 1989, fulltime. By 1999, the coronary bypass rate was double that in Sacramento hospitals. It wasn’t until a Catholic priest sought a second opinion following an episode of chest pain and was told he had a coronary lesion (spontaneously dissecting artery — a very rare finding, but often “found” at RMC) that the investigation of the practices at RMC took off. Several health care professionals had had suspicions, had talked to administrators of RMC, and had been ignored. Eventually the FBI raided the hospital to acquire data to close the program and take the licenses of the participating physicians. Some of the physicians had tried to get the program reviewed but administrators, seeing the increased bottom line, did not want to gore their cash cow (were they continuing to get tremendous bonuses?). The Medical Board of California refused to take up oversight of the program when it had been reported to them. Many concerned physicians in Redding were afraid to be too aggressive, because they might lose referrals from those supporting the cardiology programs at RMC. So, many unnecessary procedures (caths and CABGs) were performed unnecessarily with many deaths and severe complications in operated patients. There was no quality control or

oversight of these programs, an issue that led other HMOs to leave Redding. After the smoke cleared, in August 2003 Tenet paid a $54 million fine but eventually paid more than $900 million to the government. There was no criminal prosecution (read the book to understand why), but both the cardiologist and surgeon were fined $1.4 million. I do have a couple of observations about the author’s lack of understanding of medical issues. “Although he was not board certified in cardiology, he soon began doing interventional procedures such as angiograms and angioplasty at RMC.” (page 32) We all know that board certification is not a prerequisite for skills. Plus many non-native speakers are unable to finish a timed board examination because they often have to translate the exam into their native language and back to English.

Another author error: His doctor “told Frank that if he liked he could have one of his interns do a treadmill test.” (page 179). Internal medicine continues to have difficulty getting the public to understand the difference between an intern (we rarely use the term any more for an R-1) and an internist (specialist in internal medicine). This is a very readable book. There are several lessons to be learned from its story. One is that we should be very suspicious about forprofit medical groups; their loyalty is to their stockholders, not necessarily to their patients. Another is that we must police ourselves. We need to do regular evaluations to ensure that our practitioners are meeting standards. We all have a responsibility to make certain our colleagues are practicing up-to-date medicine. I highly recommend the book. geowmeyer1@earthlink.net

July/August 2007

Board Briefs May 14, 2007 Serving as the Administrative Board to BloodSource, the Board: Approved the BloodSource Executive Committee’s recommendation to begin the process of changing the organization’s name from Sacramento Medical Foundation dba BloodSource to, simply, BloodSource. The change should reduce confusion among patients and others over the organization’s name. Approved these appointments to the BloodSource Executive Committee and Board of Trustees: Michael Ueltzen, CPA, Memberat-Large, George Chiu, MD, Vice President and Chris Ann Bachtel, Member, Board of Trustees. Serving as the SSVMS Board of Directors, the Board: Approved the nomination of the following physician-members to CMA Councils or Committees for 2007-2008: Barbara Arnold, MD, Committee on Medical Services; Richard Gray, MD, Council on Ethical Affairs; Gordon Love, MD, Committee on Quality Care; Richard Pan, MD, Council on Legislation; Lee Snook, MD, Consultant to the Committee on Quality Care. The CMA Board of Trustees serves as the Nominating Committee to the House of Delegates for appointments to CMA Councils and Commissions. The nominating process requires the component medical society to nominate their members who are interested in serving on CMA Councils and Committees. Approved development of a membership certificate program to provide SSVMS members with a certificate attesting to the physician’s membership in the Medical Society and CMA. The certificates will be a daily, tangible reminder to patients and the physician of the principles the physician supports by being a member.

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Approved the Membership Report: For Active Membership — Sharmila P. Amolik, MD; Rose E. Arellanes, MD; Jeffrey J. Casper, MD; Emily Y. Chan, MD; Sufen Chiu, MD; Vahid Feiz, MD; Bianca C. Fernandez Y. Garcia, MD; Audrey Y. Fu, MD; Kathy G. Gaspar, MD; Lynne A. Hackert, MD; Sarah J-K Heringer, DO; Russell F. Jacoby, MD; Rakhshi Khan, MD; Rakhi Khatri, MD; Esther S-Y. Kim, MD; Rodger D. Kobes, MD; Michele C. Lim, MD; Anna Mirzoyan, MD; Joseph E. Morales, MD; Soni Hageswaran, MD; Mary A. O’Hara, MD; Susanna S-C Park, MD; Michelle P. Rhodes, MD; Ernesto S. Rivera, MD; Leah L. Roxas, MD; Sasha L. Szytel, MD. For Government Membership — Olivia C. Kasirye, MD For Reinstatement to Active Membership — Richard P. Clark, MD; David L. Estep, MD; Breanna M. Ruthrauff, MD; Steven J. Schorer, MD. For Retired Membership — Timothy Baker, MD; Gary W. McLaughlin, MD; Wayne C. Matthews, MD. For Resignation — Michael D. Arca, MD (Transferred to Placer-Nevada); Lynette Francis, MD (Transferred to Alameda-Contra Costa); Harold J. Wadley, MD. Approved terminating membership of the following physicians for nonpayment of 2007 dues: Amr Al-Hariri, MD; Robert Allen, MD; Najam A. Awan, MD; Ranjit S. Bajwa, MD; Cesar A. Banda, MD; Vincent Caggiano, MD; Henry Chang, MD; Rizwana S. Chaudhry, MD; Benjamin R. Craycraft, MD; Donald Daniel, MD; Theresa A. DeMarco, MD; Gregory J. Dixon, MD; Evelyn G. Fainsztein, MD; Erina N. Foster, MD; Anne M. French, MD; Ostashe N. Godlen, MD; Laura A. Halliday, MD; Jay A. Hendrickson, MD; William Hicks, MD; Robert M. Jarka, MD; Michael S. Jedrzynski, MD; Richard L.S.

Jennelle, MD; Kheeraj Kamra, MD; Stephen A. Kannwischer, MD; Irina Korman, MD; Joan Z. Kutschbach, MD; Carolyn C. LoBue, MD; Shahriar Mabourakh, MD; Akshay J. Manek, MD; Michelle Mattison-Kelly, MD; Pasquale X. Montesano, MD; Ira J. Nabi, MD; Sean Nealon, MD; Patricia Ostrander, MD; Ravi J. Patel, MD; Timothy Phelan, MD; Mark Ratley, MD; David T. Rideout, MD; Beth S. Rogers, MD; Paul Rosenberg, MD; Jan M. Rosnow, MD; Steven L. Schule, MD; Alan Shatzel, Jr., MD; Alan Silverman, MD; Carlos G. Solis, MD; Lisa Swensson, MD; Kenneth M. Toft, MD; Loan T. Tran, MD; David Z. Tzeng, MD; Michael C. Ullery, MD; Kristen M. Vandewalker, MD; Jill Walsh, MD; Robert C. Ward, MD. Since the Board did not meet in April, the Board: Approved the April Membership Report: For Active Membership — Michael Ali, MD; Charles F. Carpenter, MD; Anton Chen, MD; Brett D. Christiansen, MD; Troy S. Dickson, MD; Yoav Hahn, MD; Asraa L. Namiq, MD; Hasina Nasir, MD; Irene S. O’Farrell, MD; Neena M. Reddy, MD; W. Taylor Vance, MD. For A Change in Membership Status from Resident to Active — Eric H. Schwartz, MD. For Postgraduate Leave of Absence — John T. Cornelius, MD For Retired Membership — Dennis L. Fung, MD; Robert W. Meagher, MD; Raymond E. Porter, MD; Lynn Taylor, MD.

Arvind K. Bhasin, MD. Approved a $500 contribution to the Loaves and Fishes 25th Anniversary Fund and, if requested, will provide the Medical Society’s mailing list for use in their fund raising campaign. Approved a recommendation from the Emergency Care Committee requesting SSVMS to send a letter to the Sacramento County Board of Supervisors requesting implementation of SB 1773 (by former Senator Ken Maddy). Other counties throughout California are implementing this legislation; it allows $2 of every $10 in fines, penalties and forfeitures collected for criminal offenses to be deposited into the Maddy Emergency Medical Services Fund. Approved terminating the Medical Society’s pension plan administration with Benetech, Inc. and changing to Polycomp Administrative Services, Inc. Approved the nomination of Ruth Haskins, MD, to the CMA Council on Legislation for 2007–2008.

Though lying on his deathbed, Alexander Pope was assured by his doctor one day that his breathing was improving and his pulse steadying, among other encouraging signs. “Here am I,” he remarked to a friend, “dying of a hundred good symptoms.”

June 11, 2007 The Board: Approved the First Quarter 2007 Financial Statements and Investment Performance Report and Recommendations. Approved the Membership Report: For Active Membership — Janet B. Abshire, MD; Neema M. Aghamohammadi, DO; Rita G. Azzam Caso, DO; Suketu M. Khandhar, MD; Boaz Ovadia, MD; Dawei (David) Zheng, MD. For Reinstatement to Active Membership — Richard D. Grutzmacher, MD; Richard A. Lewis, MD; Lawrence S. Morse, MD. For Resignation — Douglas H. Beernink, MD;

July/August 2007

UC Davis Medical Students Run Five Inner-City Clinics There’s always a need for physician volunteers to lend a hand.

By Charles Casey, UC Davis Health System, Office of Public Affairs

Dr. Ronald Jan at the Paul Hom clinic with students.

By the courtyard of a downtown Sacramento mosque, where children are laughing and playing on an early Sunday morning, patients trickle into the small waiting room of a converted apartment building. It’s the start of typical weekend day for UC Davis’ Shifa Clinic, established in 1994 as a way to provide health care for the Muslim community and others facing language and related cultural barriers to needed medical services. The clinic is able to provide Urdu, Arabic, Farsi and Punjabi interpreters, and its volunteers are dedicated to meeting not only patient needs, but also religious and cultural preferences.

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It is just one of five community clinics sponsored by UC Davis School of Medicine and run entirely by its medical students and undergraduates…with help, of course, from physician volunteers.

Patient Care, Physician Training For more than 30 years, UC Davis has been operating clinics like Shifa in the inner city neighborhoods of Sacramento, providing free care to uninsured and low-income patients. Students and physicians like Sacramento vascular surgeon Dr. Ronald Jan volunteer their time to help those who don’t have access to regular medical care. During the past decade for example, Dr. Jan has spent his Saturdays helping “serve the underserved” as he calls it, while also playing a key role in helping train students who are on their way to becoming practicing physicians. “It’s a wonderful atmosphere for patients, medical students and doctors alike,” says Dr. Jan. “These clinics embody all the reasons for which we go into medicine.” The clinics annually offer thousands of people with what is often their only access to health care. The program gives medical students and undergraduates hands-on experience and allows them to take part in the challenges and rewards of patient care and community medicine. As an integral part of their first two years of medical school, many students say it is this unique opportunity to work directly with

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 ABSHIRE, Janet B., General/Preventive Medicine, UC Davis 1992, 2701 J St, Sacramento 95816 (916) 208-2522

CALLAHAN, Debra L., Pathology/Blood Banking Transfusion Med, Ohio State Univ 1996, BloodSource, 1625 Stockton Blvd., Sacramento 95816 (916) 456-1500

KHAN, Radia W., Internal Medicine, Rawalpindi Med Col, Pakistan 1995, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

AGHAMOHAMMADI, Neema, DO, Pulmonary/ Critical Care, Western Univ Health Sciences 2000, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040

DOBBIE, Allison M., Otolaryngology, Wayne State Univ 2007, UCDMC, 2521 Stockton Blvd., #7200, Sacramento 95817 (Resident)

LEE, Timothy D., Radiology/Interventional Radiology, Univ Texas, Galveston 1996, Sacramento Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

BISHOP, Gerald F., Internal Med/Endocrinology, Oregon Health Sciences 1973, Aetna, 1215 K St 16th Floor-1647, Sacramento 95814 (916) 503-1341

ESTEP, David L., Anesthesiology, UC San Diego 1980, C.A.S.E. Medical Group, 3315 Watt Ave, Sacramento 95821 (916) 481-2525

MAAGDENBURG, Tanya, OB-GYN, St. Petersburg Pavlov Univ, Russia 1997, Capital OB-GYN, 77 Cadillac Dr #230, Sacramento 95825 (916) 920-2082 MORRIS, Joseph G., Emergency Medicine, Albert Einstein 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

patients that attracted them to UC Davis in the first place. Undergraduates also volunteer in the clinic program and can gain invaluable skills. Those with plans for careers in health care often volunteer by serving as interpreters, patient advocates, receptionists and lab workers. Volunteer licensed physicians like Dr. Jan supervise the students and assist with patient care at each clinic.

Four Other Clinics In addition to the Shifa Clinic, there are four other clinics run by UC Davis students. Each offers a unique contribution to the health of Sacramento residents. For the Asian-Pacific Islander community, the Paul Hom Asian Clinic provides primary and acute care services to elderly Asians and recent immigrants. Founded in 1972, it is the oldest Asian health clinic in the United States. More than 50 medical and undergraduate students and more than 40 physicians, led by Dr. Ron Jan, volunteer on an annual basis. Clinica Tepati got its start in 1974, with a focus on serving downtown Sacramento’s Hispanic population. Its Spanish translation services allow volunteers to communicate effectively and help care for more than a thousand

uninsured patients of all ages each year. Working with some of the community’s most troubled residents, the Joan Viteri Memorial Clinic delivers care, health information and compassion to a patient population composed mainly of drug users and prostitutes. The Imani Clinic was established in Sacramento’s Oak Park neighborhood in 1994 to help address the persistent morbidity and mortality rates from hypertension, heart disease, cancer and inadequate prenatal care among African Americans. Volunteers emphasize health education and awareness with each patient, and the clinic operates as a ‘weekend extension’ of the Sacramento County primary care facility in the neighborhood. These unique clinics are always in need of more physicians to help precept medical students. If you would like to volunteer, please contact Amy Jouan at (916) 734-4106 or amy.jouan@ucdmc. ucdavis.edu. You can also find out more about each clinic by visiting http://www.ucdmc.ucdavis. edu/medschool/clinics/ For more information about being a physician volunteer in one of the UC Davis clinics, feel free to contact Dr. Ron Jan at ronjanfacs@yahoo.com or by phone at (916) 207-6898. charles.casey@ucdmc.ucdavis.edu

July/August 2007

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Membership Has Its Benefits!

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BUSY PRIMARY CARE CLINIC in Midtown area seeks PT and FT MDs. Multi-lingual staff. Competitive Compensation. Please call (916) 275-3747 or fax resume to (916) 760-0837.

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Medical Buildings-Mercy San Juan Hospital. South Sacramento locations also available (916) 224-9100.

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West Sacramento Medical Office Space to Rent. Conveniently located. 1-4 exam rooms, 600-1000 sf. Full services available. Contact Liz: (916) 275-3747.

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Amanda Bouillé, a graphic designer and the daughter of retired orthopedic surgeon Gilbert “Gib” Wright, has painted a number of street scenes. This is one of them, called “Sheppard Concrete.”

This painting, “Hans and Domonique,” is by Terri Sacré, an administrative analyst at Mercy San Juan Hospital.