2007-Sep/Oct - SSV Medicine

Sierra Sacramento Valley

MEDICINE

September/October 2007

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Physician Polychronisticism — Does it Compute?

22

Posit: Board Endorsement of Political Candidates

Richard Jones, MD

26

Breaking Language Barriers

7

Will Your Patient Benefit from the HPV Vaccine?

Leonard Fromer, MD

29

Be Still, Oliver

Gordon L. Love, MD

John Loofbourow, MD

9

Physicians as Activists

30

Speechless

Harry Wang, MD

Nathan Hitzeman, MD

11

LETTERS TO THE EDITOR Take Aim at Terrorists, not the U.S. All Governments Need Watching

31

IN MEMORIAM Eleanor B. Rodgerson McKinnon, MD

33

Emergency Memories

12

Physicians Make Lousy Advocates

Eleanor Rodgerson, MD

David J. Gibson, MD

34

Board Briefs

16

Voices of Medicine

35

New Applicants

Del Meyer, MD

36

Classified Ads

18

The Donner Party Survivors

Stephen A. McCurdy, MD, MPH

inside back cover Women Physicians, 1960

21

The SSV Museum’s Iron Lung — a Nurse’s Notes

Anne Rudin

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

Pathologist Gordon Love took this photo of a patient’s vaginal/cervical preparation, showing an “island” of displastic epithelial cells. The perinuclear haloes often signify HPV infection.

Volume 58/Number 5

The specimen has been magnified to 400 times its original size.

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

See page 7 for Dr. Love’s article on HPV infections.

September/October 2007

Official publication of the Sierra Sacramento Valley Medical Society

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

Physician Polychronisticism — Does it Compute?

By Richard Jones, MD My wife may be beginning to wonder if I have adult onset attention deficit disorder — perhaps because I sit in my home office surrounded by three computers, a spinning record turntable, an iPod and a Blackberry.

Despite lots of key pokes and mouse clicks, seemingly little is being accomplished, judging by the pyramid of paperwork and journals tottering on the desk.

To the uninitiated that may seem to be the case, but this reincarnation of channel surfing techniques, perfected during the days of pre Tivo-live TV, is a skill mirroring our multitasking lives. We want to maximize our information input and maximize our output. Cars are turbocharged with DVDs and satellite radio, Starbucks plasma levels are at all time highs nationally and ubiquitous cell phones oscillate with Epocrates, email, images, video and MP3 ring tones. We try to be more productive to meet life’s challenges and stimulate all those apathetic axons and napping neurons. A computer’s quality is classified for its least amount of downtime; can we be judged similarly?

Supporting my rationalization of the merits of a digital and computer-centric lifestyle, a recent article in Archives of Surgery1 indicated some surgeons actually perform better if they have experience in playing video games. My vices were never fully perfected by the physicians’ long apprenticeship of discipline and asceticism, so I am grateful that a certain video game I now play has given me a pretext for foolery and a sympathetic understanding of addictive behavior.

But a dopamine drench from outmaneuvering your computer foe in a video battle is followed by the classic signs of autonomic overstimulation with diuresis, anorexia, and vasoconstriction, and finally a fatigued regret of so much time wasted.

Multitasking is a skill that our profession has perfected. Who of us doesn’t function daily without juggling two telephone calls, maneuvering through a maze of demandingly malafflicted patients, three charts in hand, faxes fluttering with critical lab values, requests from medical assistants for signatures — all the while scurrying to full exam rooms wolfing down a stale bagel from last week’s drug rep droppings?

Thus, the presumed attention deficit disorder at home is just a spillover from work and a manifestation of the multitasking necessary in modern medicine. My new DSM IV classification: Physician Polychronisticism.

So tonight I bask in the glowing aurora borealis aura of three computer terminals on my desk, and try to multitask some more. The projects: September/October 2007

1. Fixing my distressed desktop Windows XP computer, which is invested with critical files and is mysteriously indisposed. It is constipated and not passing any files or my needed PowerPoint lecture.

2. Planning an agenda of an upcoming Physicians Information Technology Computer Help meeting (PITCH).

3. Reading online reports from the CMA on issues with the various proposed state health care strategies.

4. Opening email attachments considering community health care clinic options.

5. On my other, healthy laptop, digitizing my wife’s old vinyl records of Oklahoma! to MP3 so she can play them on her iPod. 6. Trying to think of something edifying to write for my President’s Message worthy of all my distinguished colleagues’ ocular saccades.

Your to-do list is probably longer and likely more important.

Amid the blinking cursors flickering like the lightening bolts of the movie version of Frankenstein’s laboratory, what emerges is a strange amalgam of curiously linked influences.

The diseased desktop bleeps furiously upon the infamous blue background “C :> System resources failure! Insert data file for programming Abort Retry or Fail?”

As I absentmindedly hum the tune of “Surrey with a Fringe on Top,” I ponder if those video declarations pertain to my ailing computer or the state of California’s health system. Similarly, the California health care system is suffering from system resources failure, or soon will be.

“C:> Bad command/ Access Denied.” Gee, this computer seems mysteriously omniscient.

Through lack of leader-

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ship there is a growing class of uninsured whose inability or personal irresponsibility lead to poor access. The delayed care leads to eventual catastrophic care that drives up the cost to all.

“C:>Buffer overflow > Fatal Error.” Once again, I am amazed at the computer’s astute health care analysis. Uncontrolled immigration and growing numbers of un/under insured patients are the buffer overflow overwhelming the central processor unit of hospitals and emergency departments. System resource failure from a dwindling supply of overworked, under compensated and overregulated physicians is heating up and threatens to melt down the core (Fatal error).

We physicians need to be active in inserting the proper data, to do the programming for a better statewide healthcare system. We cannot afford to C:> abort, retry or fail.

I hang my recovery hard drive USB cable into my ailing computer like a digoxin drip, hoping to resuscitate it. The screen fibrillates with: “C:> Resources incipient failure drive insufficient!”

I wearily gaze at a functioning laptop with its email attachments. They deal with Sacramento county indigent health care problems. As the computer predicted, they, too, are threatened with an incipient budget malady coupled with a less than efficient delivery model. Drive insufficient? But, SSVMS is active in leading a community clinic consortium hoping to infuse efficiency and vitality to a better model for the care of our indigent county patients.

“Error code UR: PU Corrupted overflow in excess of hyper floppy GUI merculated port control efflux.”

Uh oh. Didn’t I once get that problem in Mexico? With a pithy statement like that pinging my retinas, I am even more determined that we doctors need a computer users group to do battle with these sometimes evil machines. Physicians Information Technology and Computer Help (PITCH — an SSVMS exclusive) is the inoculum we require to cope with petulant PCs and assaultive Apples. We need an active forum and resource group to help physicians manage and leverage their time more effectively. We are being asked to do more with less, so we had better be able to use all the technological tools at our

disposal to keep ahead. We hoary healers must adapt to newer technological tools or…

Beside me, the LP of Rogers and Hammerstein’s Oklahoma! is the only analog device at my workspace. It spins in a solemn death spiral as the stylus needle caresses the vinyl indentations sending electrical impulses to my third (and working) laptop. There, the analog waveforms are digested, digitized and infused to my iTunes iPod. The LP pirouettes one last revolution, disgorging the final stanza before it is put away, obsolete and destined for the dustbin. Symbolism of non adaptation? The digital version of Oklahoma! will carry on. The analog won’t. Let us as a profession not follow that pattern.

My desktop computer is finally wheezing to life after its electronic enema and some mild verbal and percussive encouragement. It is time for it to really work, so I ask it a final question.

“How will we perform as multitasking physicians of a multi-cultural background and multi-

forum modes of practice and be up to the task of leading a busy life, and the challenges of dealing with health care system on system overload?”

The computer terminal winks, “C :> Resources available!

Multitasker drive is sufficient. Press any key to start.”

Translated into analog-speak, that abbreviates the musical I just recorded: “OK!” rajones@sbcglobal.net 1 “The Impact of Video Games on Training Surgeons in the 21st Century.” Arch Surg. 2007 Feb;142(2):181-6; discussion 186. PMID: 17309970 [PubMed - indexed for MEDLINE]

September/October 2007

Will Your Patient Benefit from the HPV Vaccine?

Expanded HPV testing would help provide the answer.

By Gordon L. Love, MD Dr. Love is a pathologist and a member of the SSVMS Editorial Committee.

Human papilloma virus genotyping is needed, and future HPV vaccines may offer greater flexibility for use in patients with, or without, previous HPV exposure.

Merck’s human papilloma virus (HPV) vaccine, Gardasil™, is recommended for women between the ages of 15 and 26. It is most effective in women without sexual experience. However, women with a history of sexual activity may also benefit if they have not been exposed to the HPV types the vaccine covers — HPV 6 and 11 but particularly HPV 16 and 18, which are the most dangerous. Only HPV typing (genotyping) can determine which HPV types a woman has been exposed to. However, as of this issue’s deadline, no HPV genotyping test to identify specific HPV types has been approved by the FDA for use in the United States.

Most physicians have seen the comprehensive articles on HPV in the May 10, 2007 issue of the New England Journal of Medicine (NEJM).

The extent of HPV infections is staggering (data drawn from Centers for Disease Control MMWR, March 23, 2007).

In women: Cervical HPV newly infects an estimated 6.2 million American women every year. Of these, a small percentage will develop cervical cancer.

More than 80 percent of sexually active women may acquire genital HPV by age 50. All

anogenital warts are caused by HPV. About half of all vulvar cancers are associated with HPV. In both men and women: Approximately 90 percent of all anal squamous cell carcinomas are associated with HPV. Women with high-grade cervical lesions or men who have sex with men are at higher risk for anal cancer.

“Low-risk” HPV 6 and 11 primarily cause respiratory tract warts and papillomas. High-risk HPV 16 has been associated with increasing numbers of oropharyngeal cancers.

No FDA approved HPV Typing Test in the U.S. The NEJM articles described analysis of vaccine and placebo groups in the Gardasil vaccine trials using tests for HPV-16/18 DNA by polymerase chain reaction on vaginal/cervical samples or for serum HPV-16/18 antibodies by immunoassay. As mentioned earlier, these tests are not approved by the FDA. FDA-approved patient HPV testing is limited to the Digene Hybrid Capture/Nucleic Acid Hybridization/Signal Amplification method on cervical Papanicolaou smears (liquid-based) or cervical swabs. This Digene testing produces a “detected” or “non-detected” result for high-risk HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68, but does not indicate the specific high-risk HPV type.

September/October 2007

proteins. This vaccine type would be most effective in patients who have no previous exposure to HPV. Modification of existing infection through inducing antibodies against the E6 or E7 viral oncoproteins to prevent malignant transformation of cervical epithelial cells. This vaccine type could be useful for patients already infected by HPV. Gardasil is a “primaryprevention” vaccine, and at least one other similar vaccine is undergoing FDA review. It is possible that many different vaccines with differing HPV targets ultimately may become A Thin-Prep™ liquid-based cytology of anal canal material showing pleomorphic, dysplastic epithelial cells in a male patient. This lesion is probably HPV-associated (Papanicolaou stain, x1000). Photo by the author. available that would be appropriate for both men Lack of detectable HPV antibodies in and women with, or without, previous HPV some infected people. exposure.

If serology is so helpful in other viral diseases, why isn’t a HPV serology available to physicians Summary in the United States?

The advent of the HPV vaccine has created Some HPV-infected patients produce no HPV a situation in which HPV vaccine therapeutics antibodies. Immune response may be limited or has trumped available HPV testing. Making deciabsent when a HPV infection is confined within sions for HPV vaccination using the Digene HPV a cutaneous surface. However, papillomavirus test would be similar to deciding whether to L1 capsid proteins assemble into virus-like partivaccinate for hepatitis B using a hypothetical test cles that are good antigens for serologic studies for hepatitis A, B, and C that reports “detected” to detect type-specific HPV antibodies. irrespective of the presence of one or all three Unfortunately, key laboratory reagents have hepatidides. not been standardized, and no reference method At least parts of this testing gap may be or gold standard exists to establish positive or bridged, possibly soon. At least one major labonegative results. A helpful technique in many ratory instrument manufacturer has announced other viral diseases — viral culture — is useless FDA submission of a HPV genotyping test to with HPV, which cannot be propagated in vitro. enable specific detection of any of the 13 highrisk HPV types, although presumably only The Gardasil vaccine is only the first on Papanicolaou smear material. With FDA on the market. approval, this test could be adopted by numerHPV presents two points of attack for vaccious laboratories to become widely available to nation: treating physicians.

Prevention of primary infection through inducing antibodies against L1 or L2 viral capsid gordon@microdiagnosis.com

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Physicians as Activists

By Harry Wang, MD On June 29, Catherine Thomasson, MD, national president of Physicians for Social Responsibility (PSR), was interviewed by Jeffrey Callison on the Capital Public Radio Insight program.1 She was in Sacramento to talk about her recent trip to Iran as part of a peace delegation. During the interview, she stressed using diplomatic (as opposed to military) means to resolve the growing conflict between the United States and Iran.

On July 10, Jeffrey Callison read the following comment from a listener responding to Dr. Thomasson’s interview: “Where is it written that physicians have more expertise than others in political and moral matters? What gives a profession such as physicians a more privileged moral status than, say, plumbers or truck drivers?”2 Should we, as physicians, involve ourselves in social-political issues? Is the public interested in our viewpoints? Do we bring a unique perspective that may be valuable? Do we in fact have a responsibility to be proactive?

Models for Physician Involvement Several models encourage the social and political activism of physicians.3 In the “preventive medicine” model, physicians seek to alter or stop the course of disease and not focus on treatment alone. Achieving or improving health is recognized as more efficient and preferable than treating disease alone. According to this model, supporting laws that ban or limit toxins such as lead and/or mercury in the environment is part of the responsibility of a physician. Trying to prevent war or firearm violence is considered more effective than treating the casualties of war and guns.

The “social medicine” model recognizes the interrelation of health, disease, and social condition. Any improvement in the welfare of society will improve the health of all. In this model,

physicians take an advocacy role to address these factors. For example, economic and social factors need to be addressed to successfully implement an effective worldwide approach to treating HIV illness.

The “activist medicine” model calls for social and political action to reach a desired level of health. This model states that physicians cannot adequately treat illness if there are obstacles to obtaining health.

Following this model, activist physicians advocate for a shift in government priorities from the current funding of the military-industrial-corporate complex ($626 billion requested for FY2008 for the U.S. military and current wars) to addressing more of the health needs of our citizens.

These models provide physicians with a framework and rationale for speaking out on social issues. In some instances, it may even be unethical for physicians to ignore societal conditions that affect health.

Genocide, Torture, Capital Punishment Tragically, there have been instances when physicians have not spoken out and have actually collaborated with governments in killing, torturing, and other unethical actions.

The most horrifying example is the involvement of physicians in Nazi Germany, where almost half of registered physicians were members of the Nazi party. Physicians were involved in developing and implementing radical racist eugenics, medical killings, medical experimentation, and mass genocidal murder.

Following the Nuremberg trials, international laws were created to outlaw torture and genocide. In 1975, the World Medical Association passed the Declaration of Tokyo, which prohibSeptember/October 2007

We do, however, have the same right as any other individual to fight for peace and justice in the world.

We also have the ability — and perhaps

its any physician involvement in torture. In 1999, the American Medical Association stated: “Physicians must oppose and must not participate in torture for any reason.”4 Despite these prohibitions, torture has continued to occur, and physicians have at times been participants. It has now been documented that a number of medical and psychological personnel in Iraq, Afghanistan, and at Guantánamo Bay, Cuba, monitored and devised coercive interrogations, falsified medical and death records, failed to provide basic health care, and failed to report abuse and signs of torture.5 How about physician involvement in assisting with prison executions? Many people accept this as an ethical practice. After all, are they not helping to carry out the “will of the people” and providing a more “humane” death? In the U.S., physicians have helped to design the means of death, evaluate fitness, monitor the execution process, inject the legal substances, and otherwise act as agents of the state. This has occurred even though there is a clear prohibition against physician participation by the American Medical Association, the California Medical Association, and other medical organizations. Despite this, 35 of the 38 capital punishment states explicitly allow physician participation in executions, and in 17 states their involvement is required.6

even the

Physicians and the Nuclear Bomb

moral obli-

Physician involvement in opposing nuclear proliferation is a prime example of addressing a public health issue (the thermonuclear annihilation of the world) through political means. Following the devastation of atomic bombs on Hiroshima and Nagasaki, physicians were quickly overwhelmed by 200,000 civilian deaths. Effective care was impossible given the destruction of medical facilities and the health effects of the nuclear bombs.

In 1952, the U.S. exploded a hydrogen bomb with a yield 1,000 times greater than the Hiroshima bomb. During the 1950s, the AMA was an active participant in governmental civil defense planning for a nuclear attack. This cooperation by physicians began to change in 1962, after PSR physicians published articles in The

gation — to safeguard and enhance the health of humankind…

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New England Journal of Medicine that described the medical consequences of nuclear war in clinical detail. These articles concluded that a medical response to a nuclear attack would be futile and that civil defense efforts provide very little safety.

The authors argued that physicians have a special responsibility to help prevent the use of nuclear weapons because of their expertise regarding the medical effects of nuclear war and their responsibility to protect the health of their patients.7 In 1981, the AMA Board of Trustees passed a groundbreaking resolution that “there is no adequate medical response to a nuclear holocaust” and that the President and the Congress should be informed of the “medical consequences of nuclear war so that policy decisions can be made with adequate factual information.”8 The AMA has subsequently taken a position supporting the elimination of all nuclear weapons and other weapons of mass destruction. In 1985, the International Physicians for the Prevention of Nuclear War, of which PSR is the U.S. affiliate, was awarded the Nobel Peace Price for helping to open arms-control discussions between the U.S. and the Soviet Union and for fostering an international physicians’ anti-nuclear movement.

Why Physicians Need to Act In response to the radio show listener who questioned where physicians gain their credibility to speak out on political and moral matters, we all know physicians do not necessarily have more expertise to speak out nor do they enjoy a more privileged moral status. We do, however, have the same right as any other individual to fight for peace and justice in the world. We also have the ability — and perhaps even the moral obligation — to safeguard and enhance the health of humankind, especially if we raise our voices together through groups like PSR, Physicians for Human Rights, and Doctors Without Borders.

Following the lead of Dr. Catherine Thomasson, we can speak out on social and political conditions that affect the health and safety of our patients, our communities, nations, and the world. We can also strive to create a

Letters to the Editor EDITOR’S NOTE: Draft articles submitted for publication are routinely circulated to the SSVMS Editorial Committee (of which the Society’s president is an ex officio member).

Dr. Wang’s article triggered three immediate responses from Committee members. Two appear on this page and the third is on the following page.

Take Aim at Terrorists, not the U.S. Forests have been felled by publishers declaiming relatively minor and infrequent abuses in the wartime military and CIA while daily hundreds of civilians and our own US troops are subjected to the most heinous of assaults and violations.

Wouldn’t it be more novel and effective to have these well meaning organizations put their efforts and condemnations directed towards Iran, North Korea, Sudan or fundamentalist terrorists that have egregious human rights violations where true and ghastly torture is the norm and are the most likely to precipitate the “nuclear holocaust” so feared?

Where are the articles or protests that condemn systematic torture and atrocities practiced daily in these regimes?

By attacking our own relatively minor infractions these organizations are preaching to the choir. The real fight is against a far more sinister

enemy dedicated to the ruthless destruction of a democratic civilization that gives Western doctors the right to be “activists”! Let them direct their fire and indignation where it is needed most. Our surviving pioneers learned that when you circled the wagons while under attack, you point the guns outward, not inward.

— Richard Jones, MD

All Governments Need Watching I “actively” dissent, with all due respect, from this whitewashing of widespread criminal behavior by the current regime. The problem is not activism, but a lack of enough activism like Dr. Harry Wang’s.

Can one imagine what depths we’d sink to without any active opposition to illegal invasions of other countries, the use of torture, the disappearances into secret prisons, the wiretapping, the lies, the list goes on. No government in the world is trustworthy on its own. They all need the watchful eye of activists to hold them to some moral standard.

What Dr. Jones seems to be saying is we should be like the ugly governments he mentions where “activists” opposing abusive policies are reviled for lack of patriotism.

— John McCarthy, MD

continued from page 10 culture that emphasizes health with a genuine respect for all peoples and lives. harrycwang@comcast.net Harry Wang is president of Physicians for Social Responsibility/Sacramento. The Sacramento PSR website is www.sacpsr.org.

1 www.capradio.org/programs/insight/default.aspx?showid=3402& programid=10 (accessed 8/1/07)

2 www.capradio.org/programs/insight/default.aspx?showid=3456& programid=10 (accessed 8/1/07) 3 Dagi T (1998): Physicians and Obligatory Social Activism. The Journal of Medical Humanities and Bioethics 9(1):50-59.

4 American Medical Association Code of Ethics (1999): Policy E2.067.

5 Miles S (2006): Oath Betrayed. New York, Random House.

6 Gawande A (2006): “When Law and Ethics Collide—Why Physicians Participate in Executions” New England Journal of Medicine 354:1221-1229.

7 Forrow L, Sidel V (1998): “Medicine and Nuclear War.” JAMA 280(5):456-461.

8 American Medical Association (1991): Policies 520.999 and 520.997.

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Physicians Make Lousy Advocates

By David J. Gibson, MD Elsewhere in this issue of SSV Medicine, Dr. Harry Wang, president of Physicians for Social Responsibility in Sacramento, argues physicians should be vocal activists on public policy issues.

My reaction is yes and no — mostly the latter.

Arguing the negative is akin to opposing motherhood and apple pie. For the past decade, the CMA has organized annual “Leadership Academies.” Their purpose is to educate physicians about public policy issues. One goal is to encourage attendees to stand for election to public office. Furthermore, the two most sought after spokespersons by advertising and activist groups are celebrities and physicians.

To clear the table of non-issues, I stipulate that Americans have the freedom to express their opinion on any issue. No matter how tangential, you have the right to express yourself — even if no one cares to listen to your point of view.

What’s more, physician organizations and groups have a vital role to play in expressing expert consensus on issues of the day. Dr. Wang references the AMA Board of Trustees resolution in 1981 that “there is no adequate medical response to a nuclear holocaust.” Few would argue this is not a credible addition to the debate.

My major problem is when individual physicians seek unearned credibility by attaching their academic title to public statements. Mr. Wang does not have the same credibility as Dr. Wang.

In the public square, you defend your position based on reason and facts. To short cut your progress to credibility by flashing the MD degree

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inevitably leads to defeat in the battle of ideas, with loss of credibility for the profession as collateral damage.

Beyond this central objection to exploiting the degree, physicians have a long and undistinguished history of performing poorly on public policy issues. As Dr. Wang points out, “almost half of registered German physicians were members of the Nazi Party.” The ridiculous racial theories of the Nazis had their roots in an international eugenics movement whose principal supporters included physicians and academics.

In June of this year, Sacramento revisited the sordid past of C. M. Goethe, whose name was attached to a middle school as a result of his philanthropic activities in the 1920s. In addition to his good works, Mr. Goethe was one of America’s leading eugenicists. A recent display in the SSV Museum of Medical History exploring the eugenics movement noted that many physicians in Sacramento and across the state supported Goethe and his preposterous theories.

The idealism of these physicians was unchecked by reality. They helped fuel the worldwide eugenics movement during the first half of the 20th century. English intellectual Herbert Spencer articulated the lofty goal of eugenics by announcing that “all imperfection must disappear.” Margaret Sanger called for forced sterilization, concentration camps, and birth control for the “creation of a new race.”

The ideals of Planned Parenthood’s founder were partially realized through the sterilization of nearly 70,000 people by various state governments, including California. In Germany, these

same ideals — “a new race” — resulted in something far more horrible.

When physicians expand the scope and reach of science in medicine, our accomplishments are unparalleled. When we step outside our area of competence and become activists in the public arena, the results can be tragic. The following admittedly selected list provides but a few infamous examples: Karl Brandt (1904-1948) — Nazi human experimentation.

Radovan Karadžic´ (b. 1945) — ethnic cleansing in Yugoslavia.

François (“Papa Doc”) Duvalier (19071971) — President and later dictator of Haiti.

Josef Mengele (1911-1979) — the “Angel of Death,” Nazi human experimentation.

Jack Kevorkian (1923- ) — convicted of second-degree murder, Michigan, April 13, 1999.

Shiro Ishii — head of Japan’s Unit 731 during World War II, which conducted human experimentation for weapons and medical research.

Khalid Ahmed, Bilal Talal Abdul Samad Abdulla, Muhammad Haneef, Mohammed Jamil Abdelqader Asha — all physicians arrested for involvement in the failed car bombings in Glasgow and London this year.

Physicians who enter politics generally occupy the backbench and remain active in the politics for only a short time. Those who remain occasionally attain prominence but tend to gravitate toward extremes of their political parties.

Tom Coburn, Ron Paul, Jim McDermott and Howard Dean illustrate this observation.

In Team of Rivals, Doris Goodwin discusses Lincoln’s presidency and his cabinet members and political competitors: New York Senator William H. Seward, Ohio Governor Salmon P. Chase, and Missouri’s distinguished elder statesman Edward Bates. Goodwin notes, “All four studied law, became distinguished orators, entered politics, and opposed the spread of slavery.”

Why do physicians have a poor record of accomplishment for political leadership when other professions, particularly the law, spawn leaders in each generation? What is unique

about medicine that generates political extremists in each generation? There are no simple answers. The causality is as varied as are the individuals. However, common threads run through the profession that allow us to speculate.

To begin with, physicians do not represent the norm in any society. We are highly selected for intelligence, work ethic and commitment. We live most of our youth in rigorous and cloistered academic environments and generally enjoy upper middle-income lifestyles. We are highly respected and action-oriented individuals.

All this enhances the physician’s ability to serve society as a trusted healer and confidant.

Unfortunately, none of it translates into moderation in the give and take of the political arena. The following five characteristics detail why physicians should approach involvement in elected political positions or activist roles with caution.

Physicians by Temperament and Training are Absolutists.

Physicians live in a world of absolutes with limited shades of gray. Antibiotics are effective in treating only certain infections. Metabolic syndrome must be addressed at an early stage of the disease. Diabetics should be monitored semi annually with glycosylated hemoglobin (hemoglobin Alc) testing. Most arrhythmias should be aggressively suppressed. All of this works against the give and take of politics with the inevitable compromise required to move forward.

When confronting great social issues, physicians are ill prepared to balance competing and frequently equally correct answers: the value of individual life balanced against a woman’s right to choose; the start of human life versus stem cell research; parental authority and curriculum in the public schools; alternative life styles and family structures. These grey issues require pragmatic fudging of ideals. On these and other controversial issues, physicians tend to seek the “right” answer. Our temperament and training ill prepares us to accommodate the strongly held views of those with whom we disagree (remember the example of Tom Coburn and Howard Dean?). This opens the gravitation to the extreme within single-issue advocacy groups.

September/October 2007

To begin with, physicians do not represent the norm in any society.

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Physicians Lack Political Experience.

Most politicians advance by serving time as elected local officials or as staff members for legislators. Physicians usually bypass this time-ingrade political apprenticeship and enter elected office at the legislative or higher level of public service. As a result, physicians generally lack the comity, relationships and camaraderie other politicians have developed over their years of service — and without which they rarely succeed as effective legislators or political leaders.

We advocate using government’s coercive power to influence fellow citizens to make choices they would make themselves — if only they had our strength of will and sharpness of mind.

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Physicians Generally Fail to Grasp Unintended Outcomes in Public Policy.

Physicians’ personal experience with debilitating and fatal illnesses clouds their ability to grasp nuances of public policy. Thus, we tend to embrace ideologies that promise to save the world but invariably fail. Instead, these ideologies breed fanaticism, justify dishonesty, and cloud reality. They keep adherents transfixed on the unreachable goal of human perfectibility.

Crimes, lies, and even murders committed on the ideology’s behalf are ignored, excused, and denied. Aristotle, in his Lyceum lectures on Nicomachean Ethics, observed that most evil is committed in the name of the good.1 This physician tendency to obeisant support for Nicomachean Ethics appears in the creeping dominance of “nanny medicine” — the coercive use of tax policy to curb sinful behavior. Taxing “bad” but legal products and activities — such as foods that are high in sodium or fats (a Twinkie tax may be on the horizon) or taxing alcohol all lead to the same public policy conundrum — illustrates government’s progressive dependence on regressive sales and excise taxes. Low-income households in California now pay a greater share of sales and excise taxes than the wealthy.

Additional nanny taxes will only exacerbate this problem.

The cigarette tax is a classic example of unintended tax policy outcomes. Cigarettes are the world’s most heavily taxed consumer product (state taxes range from 5 cents to $2.46 per pack; the federal tax is 39 cents). Smokers are about as popular in this country as terrorists and

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telemarketers; so there are few easier targets for legislators’ voracious hunger for new tax revenues (cigarette taxes, by the way, are rarely used to treat resulting disease in that it is not in the states’ interest to to reduce the use of the sinful taxed product). In 2004, the states took in $12.3 billion in cigarette taxes.

Should tobacco taxes plummet because smokers stop using tobacco or, more likely, the product’s distribution go underground,2 the evolving black market created by tobacco taxes will make the Sopranos look like choirboys.

California would stand to lose $2.3 billion annually, New York $2.1 billion, Texas $1.7 billion and Michigan more than $1 billion.

All of the above is bad for medicine. We are collectively viewed as paternalistic prudes and scolds. We advocate using government’s coercive power to influence fellow citizens to make choices they would make themselves — if only they had our strength of will and sharpness of mind. In the past, this behavior was indigenous to “church ladies” and led to derision. We risk for the same fate. Medicine’s patron saint will soon be Carrie Nation.

Physician Politicians Frequently Favor Their Own Pecuniary Interests.

Physician political groups frequently use the political process to advance their own pecuniary interests but inevitably, as Nicomacheans, posture that they are protecting the patient’s interest. This cynicism inevitably lowers the public’s respect for the profession. For example, the annual mosh pit process of lobbying and political campaign contributions in exchange for protecting scope of practice franchises sickens the public.

Another current example: state medical societies in Illinois and Massachusetts are pushing for new regulations to impede the growth of nurse practitioner-staffed convenient care clinics in retail settings. They are using expensive permit requirements, and prohibitions against advertising that compares fees of convenient care clinics with those of physician offices. These efforts that drive up the cost of primary care at the public’s expense have not gone unnoticed.

Activism Diverts Limited Resources.

The primary reason for discouraging physician engagement in the public square relates to the waste of our most critical resource.

Expounding on subjects about which we have little knowledge detracts from our contribution to solving looming problems about which we know a great deal. The cost of health care in this country is destroying our economy. This problem cannot be successfully addressed without engaging motivated and articulate physicians.

I support Dr. Harry Wang’s contention that physicians, as individuals, should be active in the public debate. Despite the dangers of physicians participating as activists and partisans in the political process, as an American I support engagement as individual citizens.

As an individual, you have the right to become a condescending, self-righteous prude if you wish. You can talk at length about things you know little about. Of course, no one is

obligated to listen to you.

However, do not use your respected MD degree to short cut your way to credibility — it will not work. Furthermore, do not presume to speak for me — you do not. If you want to represent the profession, do it the hard way. Engage in organized medicine. Become a leader on your medical staff. Write articles for peer reviewed specialty journals. In short, do the heavy lifting of consensus building.

Otherwise, as an individual, feel free to bore everyone to death with your points of view on social responsibility and world peace.

DJGibson@winfirst.com 1 Source: Daniel J. Flynn is the author of Intellectual Morons: How Ideology Makes Smart People Fall for Stupid Ideas (Crown Forum, 2004), and editor of www.flynnfiles.com.

2 It is estimated that more than $1-billion in cigarette tax money is lost nationwide each year to crime, with a quarter of that amount in California.

This year Sacramento County Supervisors, at the request of the County Sheriff, rejected allowing sale of up to 10 sterile needles and syringes without prescription. Yolo County and the City of Sacramento permit these sales.

Cartoonist Gary Williams works with the Whatcom County Washington Health Department.

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Voices of Medicine A “medical” marijuana problem, ER’s growing caseload, on the sidelines of a Great Game.

By Del Meyer, MD

My Neighbors the Potheads Emily Dalton, MD, writes on “Medical Marijuana” in The Bulletin of the Humboldt-Del Norte Country Medical Society, July 2007.

“My neighborhood is going to pot. Literally.

There is a house on our block that has little or no traffic. The window shades remain down all the time. No one comes, no one goes, nor is anyone ever seen tending to the yard.

Music never emanates from the home, but a funny aroma does — fragrant, aromatic and pungent. Back when the home went up for sale I hoped a young family would move in. The neighborhood is perfect for children: a dead end cul-de-sac with scattered basketball hoops and nice lawns. Unfortunately, young families can no longer afford the nicer homes. Someone bought it and decided to make it a rental. Renting to a grower generally allows the owner to charge double or even triple the usual amount.

“According to an officer in the Sheriff’s department, an indoor grower can produce tremendous amounts of marijuana in the space of an average living room. These indoor marijuana outfits are quite common in Humboldt County. If a complaint is received, the approach taken by the drug enforcement unit is to pay a visit and ask what is going on and why the place smells like pot. If the grower has a 215 card, things stop there. If the grower cannot produce the card, then a search warrant can be issued and arrests made.

“Think about it — the fate of these dope growers depends on a physician’s authorization. How did this problem ever get thrown in our laps? Unfortunately, there is no shortage of

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unscrupulous doctors to dole out the 215 cards, and they undoubtedly earn more than most of the rest of us who work legitimately…”

The entire article, including references, is at www.humboldt1.com/~medsoc/images/bulletins/ JULY%202007%20BULLETIN_for%20web.pdf

Non-Emergency Emergencies Dr. Joshua Weil, chief of Emergency Medicine at Kaiser Santa Rosa, writes on “Another Straw on the Camel’s Back” in Sonoma Medicine, the magazine of the Sonoma County Medical Association.

“It’s a typical Saturday night in the Kaiser Santa Rosa emergency department. More than 30 patients crowd our 17-bed ED. Every bed is full, including the six hallway beds, and about a dozen patients are still waiting to be roomed.

I pick the ‘next to be seen’ chart out of the rack and scan over the triage paperwork: 26-year-old female with pelvic pain and normal vital signs.

I look more closely for better detail: ‘Pain for six months.’ I do a double take. ‘Pain for six months?’ I ask myself. ‘When did this become an ”emergency”?’

“It’s a rhetorical question in a frustrated moment. But it’s one I also ask of our patients (in a less frustrated tone), to try to get a feel for what has changed when they present to the ED with chronic problems. In this case, nothing much has changed; but the patient’s mother has grown tired of listening to her complain of the pain, and tonight seemed like a good time to see a doctor. With no insurance and no doctor, they headed to our ED for answers...

“Over the past few years, we have experienced a steady climb of non-Kaiser members presenting to our ED, most of them uninsured

or underinsured. From the 7-8% of four or five years ago, the number of nonmembers has grown to 12-13% of the 30,000+ patients that we see each year…

“The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that any person presenting to an ED receive a medical screening exam to ensure that no life- or limbthreatening emergency exists. What constitutes a medical screening exam is open to some interpretation; but as the Department of Health Services has both the final say and the ability to levy large fines, the vast majority of patients will be seen and evaluated in the ED… “What is clear is that the standard of care in the ED is different than in the office. While the office-based physician focuses on what is most likely to be the problem, my job is to exclude what is most likely to be the lethal diagnosis. ’Heartburn’ can be readily addressed as GERD in the clinic, whereas I am obliged to perform more rigorous evaluations to exclude coronary ischemia in that same patient. These procedural differences are even more pronounced for patients with little or no history in our system and with whom we are not familiar — especially if timely follow-up cannot be assured. In some cases, this lack of knowledge may even necessitate hospital admission, which is surely more costly…

“What may be less obvious are the hidden costs of meeting regulatory and compliance requirements, such as nurse staffing ratios and timelines for cardiac, stroke, and pneumonia patients. EDs must staff to meet these demands — and staff isn’t free. Meanwhile, hospitals and EDs across California are closing even as populations are growing …”

To read the entire article, go to www.scma. org/magazine/scp/sm07/weil.html.

Capturing the Medical Superstructure “The Great Game” is the topic of Dr. Jason Campagna in the Bulletin of the California Society of Anesthesiologists, Summer, 2007.

“It was called ’The Great Game,’ and it referred to the epic imperial struggle for supremacy in 19th century central Asia. For well over

100 years, The Great Game occupied the minds of the best men in the most powerful governments on the planet. Today, another Great Game is afoot — and it refers to who will control the vast resources and wealth associated with the entire medical superstructure.

“Like the Great Game of the 19th Century, there are concrete and tangible rewards to be had by playing — and winning — today’s version of The Game. Then, the rewards were oil, natural gas, and other precious resources, along with the money that derived from their control. Today, the prize is the medical superstructure in its entirety. Such control allows one to lay claim to one of the most benevolent offerings one human can provide another — medical care.

With this claim comes great power: power over people, and, more important, power over vast sums of money.… Like any game, some potential players remain on the sideline. Some do so for strategic reasons, while others do so out of fear. During this time, the active players make mistakes, joust with one another and withdraw.

Most important, however, they learn — learn better how to play the game, how to attack their opponents with force and brutal efficiency, and how to lie low and wait when in danger. In short, these players are getting quite good at the game, while those on the sidelines are not. This does not bode well for those observers.

“For physicians, these details of the Great Game, and understanding the players and the observers, are vitally important. The key issues, unfortunately, are that physicians do not like this game, they are not very good at playing it, and, sadly, they are one of the most conspicuous of those groups now on the sidelines…. If indeed we would like to become players in this game, there are some things we must just simply acknowledge and then move on. Chief among these is that there is nothing inherent in the concept or title of ’physician’ that grants us any cultural authority, economic power, or political influence…”

To read about those factors, go to www. csahq.org/pdf/bulletin/issue_17/campagna072.pdf.

The key issues, unfortunately, are that physicians do not like this game, they are not very good at playing it, and, sadly, they are one of the most conspicuous of those groups now on the sidelines….

DelMeyer@MedicalTuesday.net

September/October 2007

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The Donner Party Survivors

By Stephen A. McCurdy, MD, MPH This article is adapted from McCurdy, S.A., Epidemiology of Disaster: The Donner Party 184647. Western Journal of Medicine 1994; 160:338342 “Well, Ma, if you never see me again, do the best you can.”

— 8-Year-old Martha (Patty) Reed. taking leave of her mother and rescuers to return to the cabin at Donner Lake to care for her 3-year-old brother.

Starvation is an enduring aspect of the human condition and reduces the capacity to withstand environmental stresses, including cold. In the history of the American west. the experience of the Donner Party, a group of emigrants trapped with inadequate food stores in the Sierra Nevada mountains in the winter of 1846-1847, has fascinated generations with its tales of privation, cannibalism, and heroism.

Despite the high level of interest in the Donner Party, little attention has been paid to epidemiologic aspects of the disaster and how factors such as age, sex, and social support affected survival. Although these events occurred over a century and a half ago, they hold contemporary relevance as political and natural upheavals cause starvation and forced migration in present-day populations.

In the United States of the mid-1840s, population growth and economic instability led many to conclude that their futures lay farther west, in Oregon and California. Contributing to this was the view that it was the “manifest destiny” of the United States to encompass the rest of the North American continent west of the Mississippi River.

California was of particular interest because of its fertile lands and the likelihood that it would

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soon pass from Mexican possession. Thousands packed up their belongings in prairie wagons and gathered in Independence, Missouri, to embark on the Emigrant Road.

Travelers risking their lives and fortune to travel west had a relatively narrow window of time. They would have to leave in the spring and traverse the Great Plains to cross the Rockies and the Sierra Nevada before the winter snows. They were encouraged by expansionist politicians, newspaper editors, and pamphleteers. One of these was Lansford W. Hastings, whose book, The Emigrants’ Guide to Oregon and California, proved fatally influential for the Donner Party.

California-bound emigrants usually traveled northward into present-day Idaho before turning south and west to California. Hastings championed a new route — the Hastings Cutoff — that appeared to shave 350 to 400 miles from the journey. He proposed leaving the main Emigrant Road at Little Sandy Creek in presentday Wyoming, proceeding to Fort Bridger, traveling south of the Great Salt Lake and through the Salt Desert, and rejoining the main California Trail in Nevada.

The Donner Party At Little Sandy Creek, a group of emigrants coalesced and decided to follow the Hastings Cutoff. The company elected as their leader a prosperous farmer from Springfield, Illinois, Captain George Donner.

At Fort Bridger, the emigrants stopped to rest in late July 1846. From there a connecting trail was their last chance to turn north and rejoin the main Emigrant Road. But many in the group had read Hastings’s pamphlet describing the shortcut and, eager to push on, ignored warnings to rejoin the main trail. On July 31, 1846, the Donner Party headed west on the Hastings Cutoff.

Almost immediately, the group experienced unanticipated hardships. They had to hack a road through the Wasatch Mountains, which took them about three weeks. Crossing the Great Salt Desert, which Hastings had described as a two-day journey of 40 miles, was in reality an 80-mile journey requiring five days. Finally they meandered through the Ruby Mountains of eastern Nevada before rejoining the California Trail. The “shortcut” took nearly two months of precious time and was actually 125 miles longer than the original Emigrant Road.

From the time the Donner Party chose the Hastings Cutoff, social cohesiveness unraveled as difficulties multiplied. One person was simply left behind to die when he became unable to walk; members were unwilling to carry him in a wagon. Arguments erupted. James Reed killed a man during an altercation. Initially threatened with hanging, he was banished from the party.

He and a companion crossed the Sierra Nevada ahead of the company and before the winter snows. Ironically, his expulsion contributed to the party’s salvation because he organized relief efforts that later brought in survivors.

A Disastrous Snowstorm Aware of their peril should they fail to cross the Sierra Nevada Mountains before the winter snows, the remaining emigrants pushed on with increasing desperation. They had been weakened by the delay and had lost numerous oxen and wagons. Struggling through early snows, the party reached the crest of the Sierra near Truckee Lake (now Donner Lake) on November 3, 1846.

Exhausted from their ordeal, they halted, intending to make the final crossing, now within sight, in the morning. These plans were dashed by a heavy snowstorm the night of November 3.

When the emigrants looked around them the following morning, they were surrounded by 3-meter high drifts of new snow. Defeated, they turned back to Donner Lake to establish camp.

The party now consisted of 81 persons huddled in makeshift shelters near the lake.

Of 88 persons who left Independence in the spring, 6 had died (3 of trauma, 2 of “consumption,” and 1 abandoned in the wilderness), 3

had crossed the mountains in advance of the party, and the party had been joined by 2 Native American guides sent by Capt. John Sutter.

The Forlorn Hope As their situation grew increasingly desperate, 15 members — 10 men and 5 women — attempted to hike over the pass on snowshoes and on to Sutter’s Fort in Sacramento. Calling themselves the “Forlorn Hope,” the group left in mid-December, taking six days’ rations. Beset by snowstorms, they lost their way and wandered for 33 days before coming to a small settlement.

Eight men and none of the women perished.

Those who survived resorted to cannibalism and were able to kill game en route. In addition, they were helped by members of a Native American village. Ironically, the two Native American guides from Fort Sutter were consumed after probably being murdered by a member of the group.

With the arrival of these survivors, efforts for rescue attained new urgency. On February 18, 1847, the first relief party reached the lake. The rescuers surveyed a scene of misery and destruction. Corpses lay piled in the snow, and the survivors were gaunt skeletons, barely subsisting on boiled animal hides. Over the next two months, several relief parties journeyed to the camp. Because of the difficulty in reaching the lake, they were unable to bring in large stores of food and brought out only small groups of the strongest survivors. Paradoxically, the situation for those remaining grew more desperate, and the group resorted to cannibalism. On April 21, Lewis Keseberg, the last remaining member of the party, left Donner Lake.

The Donner Party experience provides an opportunity to examine the effects of simple demographic characteristics — sex, age, whether traveling alone or with family — on the likelihood of survival under severe conditions. Based

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The Hastings Cutoff and present-day Highway 40.

But not shown is the Great Salt Lake, which was there then and now. The Hastings Cutoff went south of the Lake.

Source: www. route40.net/history/ hastings.shtml

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Two risk factors for mortality observed in this study — age and male sex — cannot be altered or mitigated, but they could identify high-risk groups in starvationaffected populations.

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on contemporary accounts, 42 of 90 persons died — nearly 50 percent.

The high mortality was not evenly distributed among the members, however. There is a clear age effect, with highest mortality among the very young and persons older than 35 years. Men were at double the risk of mortality compared to women, and persons traveling alone were at double the risk of those traveling with family.

The immediate cause of death cannot be ascertained for most individuals. Although several deaths were related to trauma, most were due to complications of starvation and hypothermia or other rigors.

Why the increased death rates among the very young, the old, men, and those traveling alone? I believe the answers are based in both biologic and social factors. Biologically, the extremes of age are associated with less stamina and vigor. In cold environments with insufficient food, men have greater caloric needs and less body fat for insulation and energy than do women. Loners may have been less fit biologically — explaining their loner status — and thus less hardy than persons traveling as families.

Sociologically, women probably benefited from a division of labor that left the most demanding work to men as well as from a culture of protection. My personal view is that women were also shrewder. The council that decided to take the Hastings Cutoff was entirely male. I cannot imagine a mother looking at her brood and all her possessions in a wagon and agreeing to go on a risky and untried trail to save a week of travel time. Those traveling with family also appear to have benefited from the care and protection given family members, leaving loners without a support network.

Cannibalism is one of the best-known aspects of the disaster, but its effect on survival is difficult to ascertain based on these data.

Because of the strong social stigma attached to it, information may not be reliable.

Although the Donner Party disaster occurred long ago, it retains relevance because the factors associated with increased mortality likely have a biologic basis or are due to enduring behav-

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ioral characteristics. Two risk factors for mortality observed in this study — age and male sex — cannot be altered or mitigated, but they could identify high-risk groups in starvation-affected populations. Family structure was an important independent determinant of mortality, which suggests intervention strategies for similar disasters. Specifically, measures to keep family groups intact so they may draw on their internal support network may improve survival.

Epilogue Over a century and a half have elapsed since the Donner Party disaster, yet the story possesses an enduring power and immediacy. The last members of the original party survived into the 1930s, well within the scope of living memory.

These events left many visible threads in the fabric of the West. Truckee Lake was renamed Donner Lake. A museum and memorial statue showing the depth of the snow (6.7 meters) in that winter of 1846-1847 have been established near the encampment.

Several members of the party went on to become prominent figures in California. Patrick Breen kept a diary that provides an invaluable firsthand account of the disaster; this document is kept at the Bancroft Library at the University of California, Berkeley. James Reed became a leading citizen in San Jose. His daughter, Martha (Patty), had weakened during an initial rescue attempt and had to return to Donner Lake, subsequently to be rescued by her father.

Throughout her journey she carried a doll, now on display at Sutter’s Fort in Sacramento.

An interesting historical footnote is that the last person to be rescued from the site, Lewis Keseberg, was vilified by a public deeply offended, in part, by his uninhibited and lurid descriptions of his cannibalism during the ordeal. He settled in Sacramento and opened a restaurant — an ironic career choice, considering the basis for his notoriety. He died in 1895, at the age of 81, at the Sacramento County Hospital, which later became the University of California, Davis, Medical Center. samccurdy@ucdavis.edu

The SSV Museum’s Iron Lung — a Nurse’s Notes

By Anne Rudin Anne Rudin wrote this article for the iron lung exhibit at the Sacramento Sierra Sacramento Valley Museum of Medical History. Her late husband, Dr. Ed Rudin, was editor of SSV Medicine.

As a student nurse at Temple University Hospital, I had an affiliation in communicable diseases at Philadelphia Municipal Hospital.

That was where individuals with the usual childhood diseases were quarantined. We knew that they would get well and one day go home.

But this was an extraordinary opportunity to learn more about the dreaded disease known as infantile paralysis and how it affected people, whose prognosis was a mystery. My training predated the discoveries made by the doctors Sabin and Salk, and poliomyelitis was endemic, soon becoming epidemic and greatly feared.

The etiology was still speculative, the means of transmission uncertain, and, accordingly, there was no known prevention or cure.

The polio wards were filled with children and young adults with varying degrees of severity of the disease. Those whose arms and legs were affected were treated with “Kenny packs”1 several times a day — application of squares of woolen blanket material dipped in steaming hot water, along with “re-education” of the muscles through passive exercise.

Those whose intercostal muscles were paralyzed were placed in respirators — giant metal capsules powered by electricity that created a negative pressure in the chamber, pumping rhythmically with huge gasps, day and night.

Only the heads of patients were exposed, A small

mirror mounted above them enabled them to see what was going on around them. On the side of the machine were portholes for the caregivers to reach in to provide essential nursing care such as bed baths, medication and massages.

At each respirator there was a nurse in constant attendance for each of three shifts, 24 hours a day. One never left the patient’s side for one moment without a relief nurse. Our chief responsibility was to keep our patients as comfortable as possible and be alert to any emergency that might arise. If the patient was unable to swallow, tube feeding and aspiration of secretions was necessary. Occasionally we would move the patient’s limbs to prevent decubitus ulcers or muscle cramps. And, of course, we did our best to keep up our patients’ spirits, writing letters to family members for them, chatting about the news of the day, and even reading to them.

In the event of a power outage, caused by an occasional summer thunder and lightening storm, all nurses and other attendants sprang into action, taking over the pumping function manually until power was restored. Thanks to the development of polio vaccines by Dr. Albert Sabin and Dr. Jonas Salk, the iron lung can be seen today only in museums such as this. annerudin@gmail.com 1 Named after Sister Elizabeth Kenny; the “sister” was an Australian Army Nurse Corps title.

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Posit: Board Endorsement of Political Candidates “It is important for a representative body like the SSVMS Board of Directors to exercise its authority to endorse the candidate for political office who most clearly reflects the views of the majority of our members.”

“All too often, however, our organization takes positions based not on overwhelming opinion of the membership but rather on the opinions of a majority of those in leadership positions.”

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Posit Background: 1) SSVMS has interviewed all candidates for the10th Assembly District election in 2008. The Society has always interviewed statewide candidates and made recommendations to the CMA’s political action committee, CALPAC. 2) All candidates appeared to be knowledgeable and capable in assessing concerns of our profession.

3) SSVMS has never endorsed a candidate for public office. In 2005, this policy was revised to allow the Board to make such endorsements.

4) The board has been considering whether to endorse the candidate who is most well known to us (see Board Briefs page 34). Some felt our professional organization should remain above election politics, in order to speak with authority about issues affecting medicine and health. They suggest political activity and endorsements are individual choices but not proper for SSVMS. Others felt that if the Society fails to participate in the election process we lose political relevance; no one fears a toothless dog. They suggest it is the Board’s responsibility to lead, to risk, and to represent the views of the majority of members. Some felt that while it is good to have the option to endorse, it should be exercised very cautiously. In this instance they suggest endorsement is not prudent.

Results: 54 members agreed with the posit, while 54 disagreed and 5 expressed no opinion. There were 29 comments from those who disagreed and 9 from those in agreement.

Edited commentary follows, while complete

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commentary is viewable in SSV Medicine online at SSVMS.org.

“This is an extremely important issue. There is no question that assisting legislators in their election can at times improve an organization’s ability to gain that legislator’s ear when issues arise. There is a larger issue, however, that troubles me greatly. Specifically, the CMA takes stands on many issues that are rather contentious. I agree that our organization should represent our interests when there is agreement, or at least a great deal of agreement, among the membership. All too often, however, our organization takes positions based not on overwhelming opinion of the membership but rather on the opinions of a majority of those in leadership positions. I for one think that such activity is unfortunate and should stop. There are few things more frustrating than to hear that my organization is lobbying for legislation that I and many other CMA members do not support.

The choice of who to vote for is an extremely personal choice. If a candidate publicly opposed the CMA on multiple issues of great importance to our organization, then I would support opposition to such a candidate. In a field of many candidates with myriad pros and cons each, I think it unwise for the leadership of our organization to pick a candidate for official endorsement.” — Alexander Kon, MD “Even though I often disagree [with the board] this the fairest way to voice our opinions. However, sometimes you make some BIG mistakes, like supporting the Medical Care

Foundation. — Allan Galbreath, MD “Endorsement of some candidates can be offensive to some members, which can cause serious divisions in the Society’s membership.

It would be better for the Board to notify the membership when there is a candidate who claims to strongly support the principals & political endeavors of the Society & CMA, as well as those candidates, who do not. In this way, the Board is representing all members of the Society rather than just some, whether a majority or not.” — Bryant Sheehy, MD “You do not need to tell me for whom to vote. But it would be helpful after a knowledgeable exchange with candidates to tell the membership those things which are relevant to medicine from your interviews. You would not then be saying that the medical society endorses, but rather this is what you learned, [saying] ‘make up your own minds.’” — David Ruderman, MD “I agree that the society should make recommendations and share reasons to help educate our members and give them more to think about. The political process is here to stay, and we must use it as much as possible to help our patients and protect our interests. Our opponents do it.“ — John Osborn, MD “Since SSVMS members hold a wide range of views, from socialist to libertarian, I do not think that SSVMS endorsement is essential. The result of the interviews should be made available to members. However, if an endorsement is made, it must be for a candidate who supports the majority views of SSVMS, and a follow-up evaluation “report card” would be useful. In the past, a published article revealed that those candidates who received the most AMA support were least likely to support the AMA’s positions on legislation. I think that those unhelpful politicians in California included Stark and Waxman.” — L. Welter, MD “I don’t think we should be publicly in politics. I want to serve Democrats, Republicans, Muslims, Vietnamese: all who come to my office for help. This is my calling. It doesn’t matter how they vote; politics are not part of doctoring. I don’t think we should endorse any candidates. It

is fine to do interviews and provide information for voters on candidates’ positions to help voters make up their own minds. But we should remain neutral and advocate only for patients. I think that divergent opinions simply reflect different opinions on how to accomplish the same goals anyway. No on politics because we are gentlemen!” — William G. Cushard, Jr., MD “Although ideally the medical society should remain ‘above election politics,’ undoubtedly other organizations are using the political system to their advantage. Unfortunately, sometimes you must ‘play within the rules of the game’ so as to better serve the medical society’s agenda and thus serve the medical community as well.

Therefore, we need to do what we can to endorse politicians who share in the vision of the medical society.” — Robert Madrigal, MD “We are a professional society and not a labor union. As the issue of Universal Medical Care matures and likely comes to fruition in the next few years, we do NOT want to position ourselves on one-side-or-the-other (or, with onecandidate-or-the-other). We want to offer our best advice for the population we serve within whatever system is adopted. Let’s focus on issues rather than candidates.” — Donald Lyman, MD “Given the limited choices, I must ‘Disagree,’ but I would not prohibit SSVMS from endorsements, [and] would argue that they should be done only rarely, and then very carefully. 1. Don’t get involved unless the campaign is centered about a hot issue affecting medicine that most of us, and the candidate, support. 2. Don’t back a loser against a probable winner just because the loser is ‘doc-friendly.’ You will only make the winner more ‘doc-angry.’” — Jim Rybka, MD “I don’t think that it is appropriate to endorse a specific candidate. However, I think that it is appropriate for the board to provide information about candidates with regards to how they stand on issues that might affect our profession directly and let us individually decide whether a particular position on a subject would be enough to affect our choice. I’m sure most of us base our support of a candidate on many issues and not just the issue of medicine.” — Maynard Johnston, MD

September/October 2007

“The political process is here to stay, and we must use it as much as possible to help our patients and protect our interests.

Our opponents do it.“

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“I would like to think that there could still be some organizations that can float high above partisanship, in reality as well as in appearance.”

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“I don’t see how an endorsement by the SSVMS Board of Directors can ‘most clearly reflect the views of the majority of our members.’

All such an endorsement can reflect is the views of the majority of the members of the Board of Directors.” — Bill Peniston, MD “Perhaps we should just go ahead and declare ourselves a union and an extension of the Democratic Party. That is the course that our nursing colleagues have chosen to pursue.

Personally, I believe that medicine is an asset that is bipartisan.” — David Gibson, MD “Too often the board doesn’t necessarily reflect the opinion of the general membership.”

— Peter Carruth, MD “I disagree. We have CalPac at the STATE level.” — Kuldip Sandhu, MD “I agree with reservations.” — Harvey Wolkov, MD “I would like to think that there could still be some organizations that can float high above partisanship, in reality as well as in appearance.

Endorsements of the type suggested could lead down the path toward accusations of placing partisanship over altruism and scientism.”

— Alfredo Czerwinski, MD “This is a professional organization. The CMA expresses its political positions through CALPAC. We can invent a similar vehicle if desired. The California Nurses Association (CNA) has lost all credibility as a professional organization by becoming essentially a political union.” — James Affleck, MD “[It is] OK for board to poll its members and communicate the result to SSVMS members.

Not OK for board to form an opinion and then announce it as the position of SSVMS.” — J. Robert Griffin, MD “As long as ‘All candidates appeared to be knowledgeable and capable in assessing concerns of our profession,’ I do not think we should endorse any one candidate. If there is an individual who would hurt our profession, then I think we should speak up.” — Caroline Peck, MD “I feel the Medical Society should interview candidates to learn their positions on the medical, public health, and social issues which are important to our members. Candidates’ strengths

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and weaknesses should be made known to members. However, the Medical Society should not presume to tell members which candidates they should support. We don’t all agree on the way government should address medical issues such as medical insurance reform, licensing of non-physician providers, decriminalization of drug dependency, increasing regulation of air and water pollution, etc. Even if we did agree, there may be other non-medical issues at stake in an election that take precedence in members’ decisions of which candidate to support.” — Robert Meagher, MD “I believe that the SSVMS Board of Directors should have the authority ‘to endorse the candidate for political office who most clearly reflects the views of the majority of our members.’

My concern is that the Board may be unable to determine the views of its members and in taking a political action could disenfranchise Medical Society members who may disagree with the action taken by the Board. Without assurance that the board will accurately represent the membership, I cannot support the proposal.” — Scotte Doggett, MD “I question if the board can truly speak for the majority of the members without an election.” — Gilbert Mandell, MD “My personal endorsement may not agree with the endorsement of SSVMS Board of Directors so I would not want my name attached to such an endorsement.” — Sandra Lai, MD “I would not favor the Board of Directors choosing/endorsing a candidate on their own.

I would favor them proposing endorsements to the members based on the issues and the result of their explorations. I think they could do the Society and/or its members a service by sharing what they have learned about the candidates and the issues. Individual members, unfortunately, may not have had the time and opportunity to explore the candidates and issues. If the membership then backs an endorsement, that could possibly increase the organizations political ‘relevance’. But even without the endorsement, by informing the membership of the issues at hand and how the candidates weigh in on those, the Society would be providing a very

relevant service to the membership. I certainly would welcome that.” — Nancy Gilbert, MD “I think CMA should be taking a position on issues that deal with the medical profession. If we allow each Medical Society [to] have a different position, we will look fractured and ineffective.” — John Tucker, MD “We have a responsibility to promote our political agenda when there are issues that are directly related to health such as smoking in public places, use of seat belts, etc.

However, supporting one political candidate is a different matter. I doubt there will ever be one candidate that the majority of our membership would comfortably back. While [candidates] may support our healthcare agenda, they may be supporting causes liberal or conservative that many find unacceptable. Let’s keep our politics to the issues, not the candidate.” —J. Rabinovitz, MD “I think it is more important to endorse policies and views that contribute to our mission and vision of improving the care [and the] professionalism of the care in the community. It is not the views of the members that should determine our support but the ability to advance our cause as a medical society.” — Thom Atkins, MD “In trying to do this, SSVMS is losing sight of its primary purpose.

The reputation of the political arena at present is far from noble. Let those who strongly feel one way or another express their views through PACs and other organizations whose primary purpose is politics. The disclaimer at the end of this mailing is particularly interesting in its cautious phrasing and tone. That is how it should stay.”

— Jose Ma C. Leuterio, MD “Physicians have a great deal of influence and should use it carefully to advance public health and physician well being. If the chiropractors and other providers are endorsing candidates, I don’t see any reason why we should not do the same.”

— Joanne Berkowitz, MD “While I think that we should have an opinion, we should voice that opinion through CalPac. It would be much more effective that way and preserves our image of being non-partisan.” — Sidney Scudder, MD “I agree that the board should be able to make an endorsement, but should do so with caution. If no one is outstanding, there is no need to take a stand.” — Richard Gray, Jr., MD “Endorsements of candidates for political office are appropriate, but only when one candidate is clearly superior, based on the consistency between his or her positions and those of the Soc [only] one political party. The Society should also back up its endorsements with a clear statement of why one candidate was found to be preferable to the other(s).” — Patrick Romano, MD

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Breaking Language Barriers

By Leonard Fromer, MD Dr. Fromer is a past president of the California Academy of Family Physicians and co-convener of the Medical Leadership Council on Cultural Proficiency.

He practiced family medicine at the Prairie Medical Group in Santa Monica for 21 years before becoming a private consultant in 2004.

This article is reprinted from the May issue of Southern California Physician

Delivering high-quality healthcare in 2007 requires that physicians provide care in the languages patients best understand.

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Addressing language access issues and boosting cultural proficiency are critical parts of delivering high-quality medical care. Yet those challenges can seem especially daunting in Southern California. Read on for practical tools and useful resources to bridge communications gaps between doctors and patients.

Delivering high-quality healthcare in 2007 requires that physicians provide care in the languages patients best understand. This can be a real challenge in California, where 12.4 million people speak a language other than English at home and 6.2 million people cannot understand or speak English well enough to communicate adequately in a healthcare setting.

Physicians must meet this challenge, though, because the cost of failing to do so is too high.

Most practicing physicians are personally familiar with cases in which the lack of interpreter services adversely affected patient care.

Consider the case of a pregnant, Spanishspeaking woman seen in an emergency room for preterm bleeding. Another patient was used to interpret; the pregnant woman left the ER believing everything was fine. Two months later, wondering why her baby had not grown, she again sought care. Upon reviewing her medical records, it was discovered the woman had in fact lost her baby that night in the ER.

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Finding Language Access and Cultural Proficiency Resources for Your Practice Ensuring language access and cultural proficiency are critical parts of delivering high-quality care. Yet those challenges can seem especially daunting in Southern California. In Los Angeles County alone, there are significant communities of people speaking Spanish, Chinese, Tagalog, Korean, Armenian, Vietnamese, Farsi, Japanese, Russian, French, Arabic, Cambodian, German, languages of the Pacific Islands, Italian and Hebrew.

Thankfully, none of us is alone in this effort these days, as resources are increasingly available.

The California Academy of Family Physicians, for example, has been a leader in helping physicians better serve limited English proficient (LEP) patients. We coordinated the development of the popular continuing medical education course, “Addressing Language Access Issues in Your Practice,� now available online. Offering a toolkit, expert speakers and Web resources, the program helps physicians in California become comfortable and proficient in providing quality care to LEP patients.

Other resources include publications from The California Endowment, a foundation supporting healthcare improvements. On its Web site, the endowment provides a wealth of information about boosting language access, working with interpreters and developing cultural proficiency.

The Medical Leadership Council on Cultural Proficiency, a group of physician, healthcare and advocacy leaders convened by CAFP and supported by The California Endowment, provides on its Web site meeting summaries outlining federal and state mandates, policy developments, funding ideas and technical

solutions for providing language access. On that same Web site, a new searchable database provides interpreter contact information, downloadable health education materials in numerous languages, and local resources for patient and family support in each county in California.

“Clearly understanding what a patient is saying is the cornerstone of gathering an adequate history and practicing good medicine,” says Mark Dressner, MD, MEd, a Long Beach Memorial Medical Center Family Medicine Residency Program faculty member, a Los Angeles County Medical Association member and an “Addressing Language Access” faculty member. “Although this can be a challenge in the presence of so many different languages, there are ways we can organize a medical office efficiently and in a fiscally sound manner in order to provide LEP patients the same quality of care as patients who speak proficient English.”

Making sure patients and physicians clearly understand each other can improve not only the actual medical care delivered, but bolster patient satisfaction and compliance. “The patient advocate in our health system finds that many complaints from patients with limited English proficiency are resolved when she reviews the chart and simply explains to patients why their care was delivered as it was,” says Asma Jafri, MD, chair of family medicine at the Riverside County Regional Medical Center, director of the

Family Medicine Residency Program, a Riverside County Medical Association member and an “Addressing Language Access” faculty member.

Communicating More Effectively With LEP Patients There is a process to effective communication. “The first step is painfully obvious, but usually not done,” Dr. Dressner says. “The practice has to identify the preferred language of all LEP patients. This should be accomplished during initial contact with a patient.” The information can be recorded on paper or in the computer, but it must be easily retrievable and available early enough to arrange interpreter services. “There must be some kind of flagging system so that the preferred language is not discovered right at the time of the visit or even after the visit has started,” he says.

The next step — providing interpreter services--is the most complicated, Dr. Dressner says. One should never use family members, except in an emergency, because confidentiality cannot be guaranteed and dealing with sensitive material is difficult. Children should never be used as interpreters — their understanding of complex medical issues is limited at best and addressing a parent’s illness or health conditions can be stressful or even damaging.

Physicians can hire office personnel who speak the most prominent languages in their practices, but most staff members will require

• • • • • •

Ask patients about their language preference.

Color-code each patient’s chart.

Add special field for patient language in your electronic record system.

Order “I Speak” cards.

Assess your language skills and comfort level.

Provide training for bilingual staff interpreters.

Arrange easy access to telephonic interpreters.

advocate in our health system finds that many complaints from patients with limited English proficiency are resolved when she reviews the chart and simply explains

Checklist for Language Access •

“The patient

to patients •

Purchase and install high-quality speakerphones.

• Negotiate a group contract with a telephonic interpreting agency.

• Gather information on interpreter services provided by your health plans.

• Order patient education materials.

• Track interpreter use.

Source: “Addressing Language Access Issues in Your Practice--A Toolkit for Physicians and Their Staff Members,” www.familydocs.org/ practice-resources/cultural-proficiency.php

September/October 2007

why their care was delivered as it was.”

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additional training in medical terminology and appropriate interpreting practices. Everyone doing interpretation — physicians and others — should be tested to determine the actual level of language fluency.

Office staff cannot cover every language possibility, Dr. Dressner notes, so at times an outside interpreter will be needed. Most charge for their services, but payment for services is provided by some health plans. “Having a staff member research how to obtain interpreters for each health plan for which one is a provider may take some time initially, but may pay off in the end with free [to the provider] interpreter services and ultimately a high standard of care for LEP patients,” he says.

When staff or health-plan-provided interpreters are not an option, a physician must provide an interpreter by other means. “For quick interviews, telephonic interpretation is ideal,” Dr. Dressner says. “Your medical office must have at least one phone set up in such a way that

confidential interpretation for the patient can take place. This can include a speakerphone in at least one exam room or perhaps the use of a cell phone with extra attachments. You might also join together with other providers to contract services more economically.” Increasingly, video interpretation and other technological innovations are also available.

In-person professional interpretation is another option, Dr. Dressner says. It can be costly, but may be necessary for prolonged patient encounters. “Here, too, a group of providers may be able to contract for services at a reduced price, and some cost-effective interpreter services may be available through a local hospital.”

“I’m bilingual in Spanish and English, and bicultural,” explains Michael Rodriguez, MD, MPH, an associate professor at UCLA’s Department of Family Medicine, a LACMA member and an “Addressing Language Access” faculty member. “I also have patients who speak Mandarin, Korean, Russian and other languages, and it takes advance planning to be sure an interpreter is available, espeValuable Language Resources for Practicing Physicians cially when serious health conditions must be addressed. We’ve all been in the situation where a family member California Academy of Family Physicians or friend is interpreting, talking with A toolkit and CME course, “Addressing Language Access Issues in Your the patient for several minutes and Practice-A Toolkit for Physicians and Their Staff Members” then gives the physician a simple www.familydocs.org/practice-resources/cultural-proficiency.php yes or no answer. I worry during Kaiser Permanente those encounters that valuable mediA tool to help in providing culturally competent care cal information is lost.” www.familydocs.org/assets/Multicultural_Health/CulturalComp_Card.doc For more information on assessMedical Leadership Council on Cultural Proficiency ments and training for bilingual A database, searchable by county, of language access services; continustaff, ways to find and work with ing education resources; and meeting summaries and reports on language both paid and volunteer interpreters, access policy and practices ways to determine which language www.medicalleadership.org assistance options are best for the The California Endowment practice,when to use face-to-face vs.

More than 30 downloadable resources and publications on language telephonic interpretation and much access and cultural competence more, download the free publication www.calendow.org/reference/publications/cultural_competence.stm “Addressing Language Access Issues in U.S. Census Bureau Your Practice-A Toolkit for Physicians “I Speak” cards with the message “Mark this box if you read or speak and Their Staff Members” at www. (language),” in 38 languages, to help identify a patient’s preferred familydocs.org/practice-resources/ language cultural-proficiency.php or call CAFP www.usdoj.gov/crt/cor/Pubs/ISpeakCards.pdf at 415/345-8667 to order.

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Be Still, Oliver

By John Loofbourow, MD Oliver Twist is a found dog, an orphan of the universe, like all living souls. Someone rescued him on the freeway as a pup and left him at the pet store. Seeing him there 15 years ago, we could neither forget nor refuse the appeal in his shining golden eyes, and we brought him home.

He became the best behaved, most predictable, and most affectionate member of the family. Now, with the children grown into young adults, he has become a child again who still retains his mongrel health, ChesapeakeShepard-whatever formation, and thick dogscented, rust gold coat. His only known illness was an exuberant hematuria following a delicious snack of rat poison.

Though we live on a wooded creek, we have never given him heart worm prevention, and his blood tests have always been clean. He keeps his teeth sound and polished by chewing on pine cones, and by not eating table food. Except for a three-week outing when he followed an exquisitely compelling scent to its timeless source, he has lived in our one dog family in post-operative celibacy.

Oliver has always been a timorous soul. He is deferent to strange dogs. When a puppy, he leapt into the pool and almost drowned because he couldn’t find the step to get out. Since then, the closest he gets to deep water is to delicately squat at the shallow end in three digit heat.

He was always frightened by noise, but now the 4th of July explosions or the occasional thunderstorms have no terror for him because he is deafer than the average oak log. He probably sees well, yet his expressive yellow eyes are slightly milky; he guards the house from his bed by the sliding glass door, and his deep bark sounds only when sight arouses it.

He has visible arthritic swelling of the wrists

and ankles. A few years ago, he started to yelp occasionally while sprinting after a ball, and has gradually stopped fetching, even though it was once his chief remaining physical joy. He seems a bit confused at times, and has begun to scratch at his bed or the kitchen floor, as if to dig a hip hole.

In early summer this year, Oliver took to his bed and refused to eat.

When I lifted him to his feet, he peered at me accusingly and walked reluctantly, unsteadily, his hind legs splaying and slipping on the smooth floor.

The vet came, examined, tested, and opined: He is old. He has degenerative arthritis. It hurts. His heart, lungs, blood, and chemistries are fine. An ”NSAID” may help, and if that doesn’t, try some prednisone. He gave a shot of cortisone. An antibiotic “just in case”. Indeed, after regular doses of Carprofen, Oliver improved physically.

But not animically. These days he has a need to never be alone. He often paces about anxiously, restlessly searching for…what?

I wondered. Has he been around people too long,, exposed to human concerns too heavily? Has Oliver accreted from all these books and all this talk an inner existential burden, an undoglike need for answers to the unanswerable? A vague and oppressive awareness of age and decay and the unknown? An ineluctable doubt about doG, the immortal, the omnipotent creator bitch? Perhaps he needs to believe that there is some marking of his passage, his territory in this limitless illusory plane of time.

Last night he wandered through the house complaining plaintively until I got up to speak with him. He was troubled without knowing

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Speechless

By Nathan Hitzeman, MD Yesterday, I talked to my heart’s content.

With friends shopping, My grandson getting married soon.

How I bragged about my spring roses!

And then the words stopped.

Like a lightbulb at its end, A part of my brain went black.

They tell me my Broca’s broken.

I find myself in this cold room, In a bed for sick people.

I have always been well.

And am still well.

Except that my thoughts can no longer connect With my tongue and mouth.

If only I could have lost one of those pesky organs — A gallbladder, an appendix, a uterus.

Or even a limb — I have plenty of those!

But we are only given one voice.

I have become an alien on my own planet.

My ocean of words, once clear and deep, Has all but evaporated.

The river of ideas, once flowing, Now locked in a glacial crawl.

So slow to come, no one can bear to wait.

They finish my sentences for me.

Squeeze my hand.

Shower me with platitudes and sympathy.

How long can I stay like this?

The words like steam welling within me, Nowhere to release.

They could drill into my skull for all I cared, But that the words would come.

I am so tired of listening to my thoughts.

So I will just repeat one of the few phrases My mouth still seems to speak.

“I-I-I don’t know.

“I don’t know. I-I don’t know.”

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why. After a while, we went outside and mutually confessed uncertain truths and lies in the summertime predawn air.

I sang him some snatches of the song Peggy Lee did so well. “If that’s all there is my friend, let’s keep on dancing.” He told me what dogs dream of when they thrash and run while asleep.

“Good night Oliver; be still,” I said. “We are what we are, and this is our home, at least for now.”

We returned to our beds, and slept quietly, soundly, while the heedless earth raced purposefully round the sun turning to a new day. john@loofbourow.com

Call for Awards Nominations Nominations are being sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting in January 2008. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy.

The nominee must be in practice for at least 15 years, and may be active, retired or hold an administrative position The Medical Honor Award, is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado-Sacramento-Yolo region.

The candidate must be member for at least 5 years.

The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El DoradoSacramento-Yolo region who has made a significant contribution to a medical or public health problem.

Please send nominations to the Scholarship & Awards Com­mittee, SSVMS, 5380 Elvas Ave. #100, Sacramento, CA 95819. Deadline: November 1, 2007.

In Memoriam

Eleanor B. Rodgerson McKinnon, MD 1908–2007

Most of us knew Eleanor late in her life, when the physicians with whom she had worked were gone.

Yet she leaves behind much that speaks of her century on earth.

Perhaps she herself would claim her remarkable family as her major achievement. For 10 years she left a busy OB practice to be with them. The beautifully written article in the Bee after her death was written by her son, and we include it in the online version of SSV Medicine, with an article from Stanford, where she was an undergraduate.

We offer here, in memory of Eleanor, a collage of photographs, and personal anecdotal sketches by those of us who wish to remember her in a way she would appreciate: in prose.

— John Loofbourow, MD Dr. Eleanor Rodgerson and her mother shopped at my father’s meat market where I helped after school and on weekends. A friendship began then and spanned over 60 years.

During World War II, customers were grumpy from the rationing of foods and commodities and the delay in service. Whenever Dr. Rodgerson came into the store, she was like a breath of fresh air. She was patient, cheerful, and thoughtful; it was a pleasure serving her. Her graciousness in accepting inconveniences and changes reflected a characteristic evident throughout her life.

In Dr. Rodgerson’s kindness and concern for those in need, she volunteered obstetrical and gynecological services to unwed mothers at Fairhaven Home. She also accommodated a large segment of Chinese women in Sacramento who wanted to give birth at home attended by a woman physician. Despite a demanding

schedule, Dr. Rodgerson took time, too, to give insight and answer questions from my sister and me about a career in medicine. My sister also became a physician. Dr. Rodgerson continued to be a mentor to many, including my family and me.

Remembered always will be Dr. Rodgerson’s inspiration and encouragement to improve the quality of life of others. Remembered always will be her teaching and her leading through example. My family and I shall miss her greatly.

— Frank Chinn, MD Eleanor was the third OBG doc in Sacramento, and the first woman. On her arrival, one of her colleagues was Eleanor B. Rodgerson very discouraging, stating she would never survive, as he had been practicing for three years and barely made ends meet. The other, however, welcomed and encouraged her, ceding half his caseload to her, including the Fairhaven Hospital for unwed mothers. Moreover, the large and influential Chinese community preferred a woman physician who would agree to attend deliveries at home. Her practice prospered.

Dad (Donald McKinnon, MD) was battalion surgeon at Iwo Jima and on surviving the war, he was shocked to find that Eleanor had bought a beautiful home on 38th Street, one he was sure they could never pay for. He consoled himself by stocking the new refrigerator with a six-pack of beer. But Eleanor claimed that her refrigerator was not for beer!

During a very severe case of postpartum

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and stories that illustrated just how special she was. Imagine her in medical school at Stanford, hoping to become an OB/GYN, and being told that she could not attend a seminar of birth control with the male students.

— William A. Sandberg

hemorrhage at Mercy Hospital, the head nurse left to fetch a priest, apparently feeling the soul was in danger. Although the patient survived, Eleanor soundly lectured the nurse, telling her to never leave in the midst of a medical emergency. The following day, it was Dr. Rodgerson who was asked by the administration to resign.

Only by apologizing, was she able to continue on the staff.

— Jane McKinnon Dr. Rodgerson was a very quiet, polite and unassuming person.

She seemed to enjoy listening more than talking, something we could all do better.

She certainly enjoyed writing and regularly attending our Editorial Committee meetings.

Her book, Adobe Bricks and Steel, published by the Medical Society, is a fascinating look at the early history of our local hospitals and homes for the sick.

Those who spoke at her memorial service enlightened the audience with fascinating facts

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The UC Davis library holds a five-foot shelf of Eleanor Rodgerson manuscripts, including priceless letters she wrote to her family, about her OBG residency in the Chicago Women’s Center. She tells of 1938 Chicago, dating, courting, and inter and intra-hospital politics. Of home deliveries that seem incredible today, attended by interns and supervised by residents: posteriors, twins, forceps extractions, breeches, versions, retained placentas and management of the various bleeds, in-home transfusions, difficult episiotomy repairs under marginal conditions.

She describes the social and physical world where these took place, including a mother who insisted on side positioned labor followed by an uneventful, on the floor, knee chest delivery.

Eleanor was always a writer, and consequently, a reader, eager to find a worthwhile new or old book. As a member of the Editorial Committee her later work was reflective, pensive, personal, and brief, in contrast to those of us who can’t easily hold our tongue, or keyboard in check.

Though she was wife, mother, writer, and the first woman OBG physician in Sacramento, she was much more. Eleanor Rodgerson was the living example of what is possible if one has lived long, fully, wisely, and well. In her 10th decade, her carriage was erect and elegant, as was her demeanor, appearance, and comportment.

She radiated quiet strength, and dignity.

She felt it was a sign of respect for self and for others to look and be her best. She was unafraid to act decisively based on her own conclusions.

When she started her practice here, her lab coats were tailored, with inside pockets to keep the stethoscope from flopping out grotesquely. She designed her first office, including the front entrance, layout, even furniture and exam tables.

While husband Don was in Iwo Jima, unaware, she bought their first home on 38th Street,

Emergency Memories

By Eleanor Rodgerson, MD This is the final article submitted to SSV Medicine by Dr. Rodgerson, who served on the Editorial Committee for many years. This piece is about half the length of her typical contribution.

Like most of her articles, it stems from a personal experience.

There is one memory that stayed. In time it would have important consequences. It requires thought. For sure.

What is it?

It is not 16 hours of waiting in Emergency, droopy, short of breath, shivery, only the floor to lie on, close by a child in a tantrum, parents ignoring.

It is not a search for an embolus, chest x-ray, leg ultrasound, CAT scan, blood tests.

It is not a line inserted at an elbow that leaks and makes another line necessary for an antibiotic in the small hours of the morning.

It is not a dozen incidents in the Emergency that helps it save lives. It is none of those.

It is the wheelchair! It is made extra broad.

Why? To fit the populace.

Forget the diet programs, suggestions that living habits be changed, that medium wheelchairs fit. As the populace grows bigger, so does its accommodations.

There must be a philosophy here somewhere.

continued from page 32 which would be their last home as well.

She was not reticent to voice her personal opinion, and occasionally did so with some intensity. Yet she was reticent to speak of herself; one had to pull her tongue for her to do. Eleanor was a living lesson in life, and in its constant companion, death. We can do no better than to try to honor her example.

— John Loofbourow, MD During the last five years or so, I probably attended about 50 meetings of the Editorial Committee with Eleanor, commonly sitting next to or across from her. I learned that she had graduated from the same medical school as I, and that she had practiced Ob-Gyn in Sacramento, but little else about her career.

She introduced me to The Number One Ladies Detective Agency by Alexander McCall Smith, and we discussed that and several other books written by that author. She obviously admired good writing and I know of no one who didn’t

consider hers some of the best.

There were other subjects that we discussed but I can’t recall anything monumental. My remembrance is of a very pleasant, modest, and unassuming lady, always a lady in every sense of the word, a woman of strong and steadfast character with many important accomplishments. But she was a lady of the present, someone living for the daily pleasure of what she was doing now, with little thought of past achievements. She made me feel good about being ordinary.

— Bill Peniston, MD

September/October 2007

33

Board Briefs July 9, 2007 The Board discussed formally endorsing candidates in the 2008 election. It was voted to table discussion of this issue for a time indefinite and requested the Executive Committee to review the possibility of a Posit on this issue.

The Board approved the following: Authorized individual members of the Board and staff who choose to support Mr. David Sander, a candidate for the 10th Assembly District, be permitted to use their SSVMS affiliated title in the Sander campaign material if requested; Authorized the use of SSVMS facilities for a fund raiser(s) for David Sander and that the Society’s full name and address may be used in the invitation for the fund raiser in the SSVMS building; Authorized SSVMS staff to assist in the planning of any political fundraisers that may be held at the Society office; Authorized staff under existing policy to lend the SSVMS mailing list to any candidate support committee who wishes to support David Sander or who desire a mailing list for a fundraiser.

The Board approved the Membership Report: For Active Membership — Debra L. Callahan, MD; Robert A. Equi, MD; Radia W. Khan, MD; Timothy D. Lee, MD; Tanya Maagdenburg, MD; Catherine E. Moizeau, MD; Joseph G. Morris, MD; Elam A. L. Trias, MD. For Resident Membership — Allison M. Dobbie, MD For Reinstatement to Active Membership — Gerald F. Bishop, MD; Diamond Kassam, MD; Arun C. Patel, MD For a Change in Membership Status from Postgraduate Leave to Active Membership — Connie Mitchell, MD For a Change in Membership Status from Multiple to Active Membership — Dennis A. Chu, MD For Resignation — J. Antonio G. Lopez, MD (moved to Idaho); Michelle G. Puzdrakiewica, MD (left area).

The Board approved the following members to serve as Alternate-Delegates to the California Medical Association House of Delegates: Richard Gray, MD; Robert Madrigal, MD; Connie Mitchell, MD.

…with apologies to Benjamin Franklin…

A penny saved is a government oversight.

The older you get, the tougher it is to lose weight, because by then your body and your fat have gotten to be really good friends.

Did you ever notice that the Roman numerals for 40 are “XL”?

If you think there is good in everybody, you haven’t met everybody.

34

Sierra Sacramento Valley Medicine

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 APPLEMAN, Duva J., Ophthalmology, Univ Wisconsin 1990, Mather VA, NCHCS-Eye Clinic, 10535 Hospital Wy #112, Mather 95655/UCDMC, 4860 Y St #2400, Sacramento 95817 BURKE, Kelly E., Family Medicine, Philadelphia Col of Osteopathic 2004, Sutter Medical Group, 2210 Del Paso Rd #A, Sacramento 95834 (916) 285-8100 CHEN, Steven L-W., General Surgery/Surgical Oncology, Univ Michigan 1998, UCDMC, 4501 X St #3010, Sacramento 95817 (916) 734-8296 DIETRICH, Peter S., Family Medicine, UC Davis 1986, Sac Sheriff’s Correctional Health Services, 9616 Micron Ave #850A, Sacramento 95827 (916) 875-9844 DOBARIA, Prakashchandra V., Internal Medicine, M.P. Shah Med Col, India 1994, Marshall Primary Care Med Assoc, 1100 Marshall Wy, Placerville 95667 (530) 626-2920 EQUI, Robert A., Ophthalmology, UC San Francisco 1998, Retinal Consultants Med Grp, 3939 J St #106, Sacramento 95819 (916) 454-4861

FISHER, Todd M., Internal Medicine, Hahnemann Univ 1995, Sutter Medical Group, 8170 Laguna Blvd., #220, Elk Grove 95758 (916) 478-6565

MORIN, Tammy L., Family Medicine, Univ Texas, Houston 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 6886612

GIORGI, Louis J., Urology, St. Louis Univ 1996, Sutter Medical Group, 2801 K St #205, Sacramento 95816 (916) 733-5005

PEARLMAN, Joel A., Ophthalmology, Baylor College 1995, Retinal Consultants Med Grp, 3939 J St #106, Sacramento 95819 (916) 454-4861

GLATTER, Kathryn A., Cardiology/ Electrophysiology, Harvard 1993, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 668-2666

TELANDER, David G., Ophthalmology, Univ Minnesota 1999, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6074

HARABOR, Bianca, Internal Medicine, Carol Davila Univ, Romania 2001, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

VANDENBERG, Bryon F., Cardiology, Georgetown Univ 1980, No. Calif Cardiology Associates, 1004 Fowler Wy #4, Placerville 95667 (530) 626-9488

ISAKARI, Marcia T., Family/Occupational Medicine, Pontificia Univ, Brazil 1993, Woodland Clinic Medical Group/Occupational Health Services, 2330 West Covell Blvd., Davis 95616 (530) 756-2364

ZHOU, Jennifer Z., Internal Medicine, Shanghai Med Univ, China 1983, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2323

MENDIS, Roger E., Gastroenterology, Tufts Univ 1984, Sutter Medical Group, 2801 K St #502, Sacramento 95816 (916) 733-8730

September/October 2007

35

Classified Advertising

Positions Available PART-TIME PHYSICIANS for urgent care center. Hours flexible. BC/BE in FP, IM, EM preferred. Competitive compensation and malpractice paid. Kim Marta, MD. The Doctors Center, 4948 San Juan Ave., Fair Oaks, CA 95628. (916) 966-6287.

Membership Has Its Benefits!

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

Mercury Insurance Group 1-888-637-2431 www.mercuryinsurance.com

Billing & Collections

Athenahealth 1-888-401-5911

Car Rental

Avis: 1-800-331-1212 (ID#A895200) Hertz: 1-800-654-2200 (ID#16618)

Clinical Reference Guides-PDA

EPocrates 1-800-230-2150 / www.epocrates.com

Collection Services

I.C.System 1-800-279-6620 / www.icsystem.com

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

MBNA 1-866-438-6262 / Priority Code: MPF2

Office Supplies

Corporate Express /Brandon Kavrell (916) 419-7813 / brandon.kavrell@cexp.com

Practice Management Supplies

Histacount 1-888-987-9338 Member Code:11831 www.histacount.com

Electronic Claims

Infinedi – Electronic Clearinghouse 1-800-688-8087 / www.infinedi.net

Healthcare Information Technology Products

KLAS / HIT Consumer Satisfaction Reports 1-800-401-5911

Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...

Marsh Affinity Group Services 1-800-842-3761 CMACounty.Insurance@marsh.com

HIPAA Compliance Toolkit

PrivaPlan 1-877-218-7707 / www.privaplan.com

Investment Services

Mercer Global Advisors 1-800-898-4642 / www.mgadvisors.com

Office Space

Magazine Subscriptions

Carmichael American River Medical Plaza Suites from 600 sf to 2100 sf. Low Rent. Call Owner at (916) 489-7724.

Subscription Services, Inc. 1-800-289-6247 / www.buymags.com/cma

Notary Service/Free to Members

Medical Society (916) 452-2671

Security Prescription Pads

Medical Buildings-Mercy San Juan Hospital.

South Sacramento locations also available (916) 224-9100.

Rx Security 1-800-667-9723 http://www.rxsecurity.com/cma.php

Professional Publications

UCG Decision Health 1-877-602-3835 / www.decisionhealth.com

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

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.

WOODLAND HEALTHCARE, a 100+ provider multi-specialty group, and community affiliate of Catholic Healthcare West, is seeking BE/BC physicians in Family Practice*, Internal Medicine*, Hospitalist, Endocrinology, Orthopedic Surgery, Pediatrics*, and Radiology. *Spanish fluency is preferred!

We offer a very competitive salary and benefits package including medical, dental and vision insurance, malpractice coverage, relocation assistance, retirement plan, shareholder status after 2 years, and life insurance. Just minutes from Sacramento and close to San Francisco, Napa and picturesque Lake Tahoe, Woodland is the perfect place to call home! You’ll have access to affordable real estate, family-friendly neighborhoods and countless outdoor and cultural activities and events. For more information, please contact Megan Landgraf, Physician Recruiter: P: (530) 669-5443; F: (530) 668-9833; Megan.Landgraf@chw.edu

West Sacramento Medical Office Space to Rent. Conveniently located. 1–4 exam rooms, 600-1000 sf. Full services available.

Contact Liz: (916) 275-3747.

Doctor’s Placement Agency All medical personnel (916) 457-4014

36

1-800-901-5830 • 31 years of medical experience • 1,600 Northern California physicians • 45 well-trained & professional operators • State of the art computer technology • Discounted rates for new SSVMS accounts • Spanish speaking operators during most shifts

Sierra Sacramento Valley Medicine

• • • • • • •

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

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

Women Physicians -- 1960. When this photo was taken, women made up 5 percent of Medical Society members; by June of this year, they made up over 24 percent. Pictured are, front row from left, Drs. Eleanor Rodgerson, Nadine Janushkowsky, Delores Hardre, Helen Rotous, Libby Marks, Shirley Gunn, Kathleen Mannion, and Sigrid Lenert. In the back row, from the left, are Drs. Marion Kirkpatrick, Margaret Masters, Maude Tillotson, Marie Babich, June Wright, Betty Soo, Suzanne Snively, Julia Fong, Edna Mae Fong, and Kit Huang. Six other women physicians do not appear in the photo.