2007-Nov/Dec - SSV Medicine

Sierra Sacramento Valley

MEDICINE

November/December 2007

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Gross Knifing at the Medical Society!

24

Student Essay Contest Announcement

Richard Jones, MD

25

CMA’s House of Delegates

7

LETTER TO THE EDITOR How Can Physicians Not Speak Out?

26

BOOK REVIEW Glorious Singing

8

Offshore Hospitals Take on the U.S. Health Care Market

William Peniston, MD

27

SSVMS Officers for 2008

David J. Gibson, MD

28

Annual Meeting Notice

13

Legal Syringe Exchange in Sacramento — at Last!

29

IN MEMORIAM Quentin Bonser, MD

15

A Posit on Global Warming

30

18

Voices of Medicine

IN MEMORIAM George Gross, MD

Del Meyer, MD

31

Board Briefs

20

“Where There is Need, There is Mercy”

33

New Applicants

Sister Katherine Doyle

34

Classifieds

22

Apoptosis of the Species

John Loofbourow, MD

35

A 7.9 Earthquake in Peru

Hernando Garzon, MD

We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below.

Authors will be able to review any edits before publication.

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

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

This is another in a series of covers by ophthalmologist Barbara Arnold, MD, a watercolor painted in October 2003. The setting is the small Spanish town of Carmona, dominated by a 15th century church, the Iglesia de San Pedro. The square is empty in the painting, but it wasn’t when she was sketching it.

“While I sat on a park bench, identical to the one I sketched, many people strolled by — seniors out for morning coffee, kids on bicycles and skate boards — enjoying the freedom of open space. Park benches encircled this central area for a restful stop under a shade tree, and a chance to drop one’s shopping bags and to meet and greet neighbors.”

Volume 58/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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

November/December 2007

Sierra Sacramento Valley

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

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

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

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

Sierra Sacramento Valley Medicine

President’s Message

Gross Knifing at the Medical Society!

By Richard Jones, MD What might grave robbing, dissection, vivisection, venereal disease, and displays of anatomy have to do with our medical society?

Membership recruitment? A new hit medical TV show? Possibly, but that is another story.

In the initiation of our profession, who can forget cleaved specimens, the cadaver-filled stainless steel tanks and the formalin miasma of the anatomy lab? It is our fundamental step in learning about the format and functioning of our calling. We still may appreciate the anatomy that supports a human body, but do we know the functional anatomy of what runs your medical society?

Having just finished reading “The Knife Man,”1 I cogitated about the remarkable life of John Hunter, an 18th century London physician and a pillar in the development of modern medicine. From a humble Scottish farm, he ascended to become the preeminent surgeon in England, physician to King George III and mentor for many American physician pioneers.

With little formal education, he initially distinguished himself by the quality of his meticulous dissections of freshly disinterred corpses.

Since there were few public medical schools, there was an industry in London for private medical education and his labors supported the lyceum his entrepreneurial brother ran. Hunter’s dissections had to be carried out in the winter as the balmy spring and summers led to quick, odiferous putrefaction.

Under cover of the dark morning mists, the carts carried their harvest from the churchyard and gallows to his laboratory. What emerged from a lifetime of the dissected bodies of men, women, and children was a vast collection of

exquisite medically edifying specimens and a greater understanding of anatomy and improved surgical technique.

In his era, physicians were still part of the barber society and adhered to ancient time-worn measures of bleeding, emetics, poultices and poisons. Few physicians had knowledge of the organs, muscles, nerves and systems that made the body tick, so Hunter’s experimental and scientific approach to dissection and investigation heralded a renaissance in the development of modern medicine and theory. He also performed animal vivisections that, despite their PETA nightmare cruelty, led to the progress of physiology and embryology.

His amazing stamina and curiosity led him to author revolutionary treatises on dentistry, military medicine, and comparative anatomy of species partly from his private zoological menagerie in London, (he was the inspiration for the story of Dr. Doolittle of Disney fame). He had penned tomes on geology and nascent theories of evolution predating and perhaps even inspiring Darwin 100 years later.

Since venereal diseases were rampant in promiscuous, though pre-MTV, Georgian England, his clinics were full of aristocratic sufferers. In an experiment to document their effects, he was thought to have inoculated himself with gonorrhea/ syphilis. Fortunately, he didn’t succumb to its tertiary effects or, even worse. its mercury or arsenic treatments.

Despite his position in the upper echelons of aristocracy, Hunter provided free surgical care November/December 2007

in the hospital and his own private clinic. In his waiting rooms he made the rich gentility wait for the working poor, since the former had “nothing but time on their hands.”

Hunter was a leader, too, in his scientific and local medical societies. Ironically, although he was the most accomplished physician in England, he was ostracized by his own hospital board. Their petty jealousies and resentment over his novel and effective systems of surgery and education kept him off the board of governors. He died arguing a point at the board; his fragile chronic anginal vessels thrombosed during one of his passionate arguments about medical education.

Consistent with his roots in anatomical work, his will specified he be subjected to an autopsy and that parts of his body be added to his specimen museum!

So apart from his 4 hours-a-night sleep, hypomanic immense opus of accomplishments, he is still much appreciated for his fine anatomical skills. These I happened to stumble upon at the Royal College of Surgeons when I was looking around that London neighborhood for a bathroom. The Hunterian Collection, besides the fine waterclosets, are a bewildering array of dissections of humans, animals and “monsters of nature” in jars preserved in spirits of alcohol.

Tragically, about 80 percent of the collection was lost in the blitz of WWII, whose blazes the flammable alcohol preservatives stoked. Still, many thousands remain for inspection, his careful ”knife work” revealing structures we only imagined in our own cadavers.

To a vast many of us, SSVMS seems a bit mysterious, unknown and unfathomed in its complexity, like the human body was at the time of John Hunter’s apprenticeship.

Thus I pondered, what if John Hunter was alive to dissect the medial society? What might his observations be to instruct naïve students?

Perhaps it would read as thus:

John Hunter

B

efore us lies the corpus of the species SSVMS of the family CMA. In repose it is a most curious embodiment having no clear

Sierra Sacramento Valley Medicine

definition of its outlines, but one can observe a number of prominent systems.

The nervous system upon dissection reveals signs of tightly woven axonal and grey matter in a manner that greatly suggests this being possessed of a high intelligence and complexity. Its brain is composed of elements of a highly evolved executive function with the upper layers identified as Williamus Sandburgus and Chrisus Stincellius that appear to have multiplexed synaptic adhesions to the 15 member component of the Boardus of Direcotrus.

These structures subsequently divided and appear to interact with all 2,800 cells or organisms of the SSVMS. Cells of the SSVMS appear to differentiate into Boardus Directorus for a period of 2 years before returning to the basement membrane of members. A feedback mechanism appears in place to coordinate the reactions, movement and responses to the corpus of SSVMS. Heart. The heart of SSVMS appears prodigiously large and muscular. In its striations, one can observe the structure known as the SPIRIT Program. It, in turn, is constituted of member physicians who volunteer to provide medical services to the indigent and underserved of the Sacramento community. Over the course of its development, this heart has provided over 2,692,630 million pounds sterling of medical care.2 The heart has other cordea and tendenae that pump beneficial medical nourishment to the community. These are a Pediatric Care Coalition, instrumental in getting children covered with health insurance in the Sacramento Valley, a Community Clinic consortium tasked with care for the Sacramento Valley uninsured, Adopt-A-School, the generous efforts of SSVMS Alliance, and a healthcare scholarship program.

Mouth and Teeth. For such an apparently gentle creature, the SSVMS, subspecies of CMA, have a formidable orifice. This seems to be an adaptation to facilitate communication with members and more importantly to advocate to competing species such as legislators and policymakers. The teeth are concealed beneath a tunicous mucosal membrane, but when retracted reveal lobbyist incisors prepared for active defense or offensive endeavors.

Skeletal. SSVMS weight is carried by the underpinnings of over 2,800 structural elements, known as members. These also interdigitate with the nervous system. Some bones are bigger and some are smaller but all are interconnected and seem equally important in supporting the corpus and apparent functioning of SSVMS. Tail. A vestigial appendage is noted that serves no function to the health and vitality of SSVMS. It appears to be constituted of non-member organisms. It may be parasitic in nature and is in close approximation of the cloacal area. Pathogenic organisms, identified as malpractice attornyous terribilus afflict this area causing apparent stress, expense and hardship for the body.

My pardons to Mr. Hunter for so brief and poorly rendered description. His analyses normally ran for hundreds of pages, and a proper description of the SSVMS anatomy, accomplishments, constituents and of its staff and dedicated members would no doubt be of that length. (Editors gasp even at the length of

this piece.) I think Hunter would be proud that SSVMS does embody his concerns of the scientific approach to medicine, indigent care and outspoken leadership in medical policy.

Our society is far from needing a formal autopsy, even by the talents of Mr. Hunter. But it takes a small amount of dedication, cooperation and support from all its members to keep the corpus vital. By each of us mustering just a bit of the energy similar to Hunter’s passion for his profession and dedicating it to CMA and SSVMS, we will keep future ”knife men” from putting us in a specimen jar.

And instead of it being gross anatomy, it would be a fine specimen of growth anatomy. rajones@sbcglobal.net 1 The Knife Man: The Extraordinary Life and Times of John Hunter, Father of Modern Surgery, by Wendy Moore.

2 Or 5.6 million in American dollars.

November/December 2007

Letter to the Editor

Letter to the Editor How can Physicians Not Speak Out?

try that has ever used the atomic bomb, are threatening peoples and countries such as Iran with possible pre-emptive nuclear strikes using warheads many times the size of the Hiroshima bomb. How can physicians not speak out, when the health and humanitarian consequences of such action would be so catastrophic?

— Harry Wang, MD

Re: “Physicians Make Lousy Advocates,” David J. Gibson’s rebuttal to my article “Physicians as Activists” in the September/October issue of SSV Medicine, I stand by my original comments. In a democracy of, by and for the people, there is no justification for anyone — including members of the medical profession — to remain silent when government policies are harming the health and EDITOR’S NOTE: A number of letters were safety of individuals here and abroad. received in support of Dr. Wang. They appear in the Society does grant physicians a level of credonline edition of the magazine. ibility that affords us with the opportunity to make a difference if we act responsibly. We lose this credibility, however, if we remain silent or collaborate with governments when they torture or kill.

A perfect example of action benefiting the public good is the “heavy lifting” by individual members of Physicians for Social Responsibility (PSR) in the early 1960s that galvanized public opinion to oppose atmospheric nuclear testing.

Rejecting government statements about the safety of over 200 nuclear tests that had taken place, PSR physicians throughout the country collected children’s deciduous teeth that were then tested and found to contain radioactive strontium 90, a byproduct of nuclear fission.

This led to passage of the Limited Test Ban Treaty of 1963 and the end of above ground nuclear testing.

Now leaders of our “Henry, did you ask for gender change or a member change government, the only coun-

November/December 2007

operation?”

Offshore Hospitals Take on the U.S. Health Care Market

By David J. Gibson, MD, and Jennifer Shaw Gibson “You’re Going WHERE for Surgery?”

— ad on the PlanetHospital.com website Perhaps the biggest inhibitor to innovation in health care is lack of competition. The predominant business plan for the American health care market has been hegemony. Hospitals seek to become regional monopolies and dictate pricing to insurance companies. Doctor groups seek monopolistic contracts with hospitals for services. Laboratories seek monopolies with doctor groups.

All of this works when the consumer is deliberately excluded as a variable from the market equation.

Actual competition based on price, objectively measured quality and innovation is an alien concept. But winning by forming monopolies is about to change.

Global competition is emerging in health care. A growing number of high-quality health care facilities in developing countries have begun catering to “medical tourists” from the United States and other countries. The Indian government has publicly encouraged medical tourism by offering one-year extendable medical visas, organizing exhibitions to showcase Indian hospitals, and creating a list of recommended hospitals to attract foreign patients.

Most health insurers are aggressively adding low-cost, international facilities to their networks.

This expansion is expected to become commonplace by 2009, just as high deductible consumer directed health plans (CDHPs) become the predominant model for group health markets across the country.

Sierra Sacramento Valley Medicine

State legislators in West Virginia and Colorado have introduced bills offering incentives to state employees to take advantage of the costs savings of overseas medical care. In February 2007, West Virginia Rep. Ray Canterbury (R-Greenbrier), with nine co-sponsors, introduced House Bill 4359 “establishing a system to reduce the cost of medical care paid by the Public Employees Insurance Agency by providing incentives to covered employees to obtain treatment in low cost foreign health care facilities accredited by the Joint Commission International.” 1 In Colorado, Representative Spencer Swalm introduced a similar bill, HB07-1143.

Specifically, the Canterbury bill offers state employees these incentives for medical care abroad: • Waiver of all co-payments and deductible payments; • Payment of round trip air fares for the covered employee and one companion; • Lodging expenses in the foreign country for the companion for the length of the treatment or procedure; • Lodging expenses in the foreign country for the covered employee and the companion for not more than seven days of convalescence after the treatment or procedure; • Payment to the covered employees hiring agency for seven days of paid sick leave, which are not counted against the employee’s accrued sick leave; and • Rebate up to 20 percent of the cost savings directly to the covered employee.

It is unclear whether these bills will become law this year, but we do know that their legislatures are taking it seriously. The WV Legislature

invited PlanetHospital to the Charleston statehouse to present a proposal for administration of such a policy.

The Attraction of Offshore Care Uninsured patients and those with CDHP health plans are becoming more attracted to high-quality health care that is up to 80 percent less expensive than the cost for the same service in the United States. For example, heart surgery can easily cost more than $50,000 in the United States. The same surgery, often with better outcomes data, might only cost $10,000 in India, $12,000 in Thailand or $20,000 in Singapore.

These prices frequently include round trip airfare and four star hotel accommodations for the family.

One conservative estimate in Health Affairs suggests $2 billion in savings if a fraction of Americans went overseas for one of 16 different procedures that the authors believe are easily tradable.2 Table 1 provides an overview of the competitive pricing in the market.

Table 2 lists a few of the hospitals currently competing in the international market. These hospitals have fully computerized and networked hospital information systems, and digital radiology department. They each have 24/7 telemedicine services. Each offers world-class amenities and delivers the highest ratings for customer service and patient satisfaction.

The numbers of travelers and size of the industry are growing every year. Medical tourism grossed an estimated $60 billion worldwide in 2006. A report by McKinsey & Company predicts this will increase to $100 billion by 2012. In 2007, 750,000 Americans are expected to travel abroad for health care. By 2010, this figure is estimated to increase to 6 million.3 Travel agencies that specialize in packaging medical tours for patients and their families are one of the leading growth elements in the travel industry.4,5 The growing online directory

of options and patient travel can be found at: www.medicaltourism.com.

As patients with high deductible health insurance are exposed to the true cost of health care services, we anticipate an explosive growth in foreign competition for high cost goods and services in America’s health care marketplace.

So far, domestic providers have dismissed this trend.

Unable to compete on price, they are becoming progressively exposed to superior outcomes data from foreign competitors.

How quickly will the defined contribution health insurance product, predicated upon the beneficiaries’ financial exposure,

November/December 2007

expand in the group health market? Table 3, taken from a recent Mercer study, demonstrates the likelihood of employers offering CDHPs to their employees in 2007 or 2008.

Large employers who have offered CDHPs to their employees are experiencing significant savings. The accompanying graph demonstrates the average annual cost per employee for the various types of health plans on the market.

CDHPs delivered substantially lower cost per employee than either PPOs or HMOs in 2006. CDHP averaged $5,770 per employee, compared to $6,616 for HMOs and $6,932 for PPOs (but just $6,019 for PPOs with comparable deductibles of $1,000 or more). The average CDHP cost is 5.3 percent higher than last year’s average cost of $5,480. It should be noted that CDHP cost includes the employer account contribution and that many of the new plans added in 2006 were HSAs6, which do not require an employer’s contribution. Cost rose more

10

Sierra Sacramento Valley Medicine

rapidly for both PPOs and HMOs — 7.0 and 6.5 percent, respectively While too early to evaluate the long-term impact of consumer-directed health plans, it appears their cost trend is running about 2.5 percentage points below cost trends in HMOs and PPOs. A consensus is developing among health care economists: CDHPs will likely become the predominant form of group health insurance over the next few years.

If the consumer is exposed to the true cost of goods and services, the monopoly strategy that has predominated for the past half century will no longer work. Instead, American providers will have to compete in the high-end service market that is rapidly developing?

Two variables will require attention. The first is the quality of the service provided. American providers have generally resisted objective measurement and stratification reporting of outcomes data. That must change.

Quality of Service Medical tourism ceased to be a futurist’s fantasy and became a practical reality in 1999, when the Joint Commission on Accreditation of HealthCare Organizations (JCAHO) launched its international branch, Joint Commission International (JCI). Chicago-based JCI has accredited over 100 hospitals in 23 countries.

JCI standards for hospitals include assessing quality of patient care, efficiency and best practices of management, patient safety standards, outcomes data and improvement across key functions. Criteria for JCI accreditation are considered as rigorous as those for US hospitals seeking JCAHO accreditation.

Furthermore, as is demonstrated in Table 4, many of these facilities are affiliating with some of America’s leading academic medical centers for patient care, medical education and research.

The schooling, training and board certification processes for physicians and surgeons at these hospitals are comparable to those in American medical centers. Generally, the surgeons and physicians on staff have trained in the United States or Europe, with many holding licensure within the United States. In 1974, 97 percent

of medical school graduates in both the U.S. and the U.K. were Caucasian. By 2000, this had dropped to 74 percent. Of the 26 percent made up of ethnic minorities, most were Asian. Asian students accounted for 19 percent of new medical students in 2001.

How good is the training and certification of foreign physicians? More than two dozen hospitals in Massachusetts, including Massachusetts General Hospital, now send their CAT, MRI, and ultrasound scans to doctors in Southeast Asia for overnight reading. These radiologists routinely render crucial medical judgments, and are board certified as well as licensed in Massachusetts.

The internationally generated outcomes data are impressive. For example, the Apollo Hospital in Hyderabad India boasts the same surgical success rate as the Cleveland Clinic. Escorts Heart Institute and Research Center in New Delhi and Faridabad, India, performs nearly 15,000 heart operations every year, and the death rate among patients during surgery is only 0.8 percent — less than half that of most major hospitals in the United States.7 The American medical establishment asserts that our system produces the best health care outcomes in the world and therefore our cost structure is justifiable. It is time to prove that assertion or begin to abandon the field.

The U.S. Cost of Care The second issue that must be addressed is the exceptionally high cost per unit of care delivered in the United States. A recent study by the School of Public Health at Johns Hopkins University8 found that the primary cause for America’s disproportionately expensive health care system is the cost of labor. Studies published in May 2004 by the California Workforce Initiative found that labor costs in this state account for almost 70 percent of all health care expenditures.

Health care labor costs key off physician incomes, which are twice as high in the U.S. as in any other industrialized country. Furthermore, the ratio of the average income of U.S. physicians is approximately 5.5 times higher than average employee compensation for the United States as

a whole. By comparison, Germany’s was the next highest, at 3.4; Canada, 3.2; Australia, 2.2; and the United Kingdom, 1.4.

This disparity in income translates through the entire health care industry’s labor cost structure. For example, nurses in the U.S. earn 50 percent more than their counterparts in Canada; similar income disparities are found for physical therapists, occupational therapists, as well as laboratory and X-ray technicians.

The two accompanying graphs demonstrate Organization for Economic Co-operation and Development (OECD) data from 1996, the most recent year for which data from multiple countries is available. These graphs illustrate the magnitude of the problem.

November/December 2007

11

health care system will be unable to compete internationally until labor costs in the industry are restructured.

The axiom that “all health care is local” never applied to complex episodes of care. We have always had centers of excellence in Boston, Houston Cleveland, and Rochester, MN. Patients have long traveled beyond their local market to receive care in these centers.

Now a new competitor has taken the field.

This competitor is not only challenging us based upon outcomes, but also by delivering far lower pricing per unit of service. So far, America’s physicians have not responded to the challenge.

The first graph demonstrates the annual average incomes for physicians among other industrialized countries. The second, and much more important, demonstrates the average physician income compared with other employees. All of health care’s labor cost infrastructure keys off this aberrant physician income. The American

DJGibson@winfirst.com Jennifer Gibson is an economist specializing in evolving health care markets as well as a futures commodity trader specializing in oil and gas. David Gibson is a senior partner and Chief Medical Officer at Illumination Medical, Inc., a health care consulting and medical management company.

1 Bill to amend the Code of West Virginia, designated §5-16-28.

2 Health Affairs, 25, no. 2 (2006): 358-368 doi: 10.1377/hlthaff.25.2.358 3 Source: Devon Herrick (moderator), Milica Bookman and Rudy Rupak, “Global Health Care: Medical Travel and Medical Outsourcing,” National Association for Business Economics, Health Economics Roundtable Teleconference, July 25, 2007.

4 For example, Gorgeous Getaways Pty. Ltd. of Australia arranges cosmetic surgery packages, at www.gorgeousgetaways.com/home.htm 5 http://medicaltourism.com represents a medical professional-based service.

6 A health savings account, or HSA, allows an individual to set aside pre-tax dollars for future medical, retirement, or long-term care expenses.

The individual is allowed to Invest these funds in a broad range of choices, then use them for qualified expenses. The funds roll over from year to year. These investments are transportable as the owner moves through changing employment status.

7 Hutchinson (2005). “Medical Tourism Growing Worldwide.” UDaily, University of Delaware (July 25, 2005).

8 “Health Spending In The United States And The Rest Of The Industrialized World,” Anderson et al.

Health Affairs. 2005; 24: 903-914.

12

Sierra Sacramento Valley Medicine

Legal Syringe Exchange in Sacramento — at Last!

But the exchange program still needs to come up with $85,000 a year to buy needles.

By John McCarthy, MD Eleven years ago, National Public Radio did a special one-hour program on the underground needle exchange program in Sacramento. Noah Adams interviewed a number of local advocates for a public health approach to the problems of infectious diseases related to injection drug use.

They included Dr. Neil Flynn, UC Davis HIV specialist, Rachel Anderson, drug abuse and HIV researcher, myself, and a multi-talented social worker, researcher, drug treatment counselor, and “underground” needle exchange outreach worker named Jim Britton.

The NPR program focused primarily on the actual needle exchange process, following Jim to houses he visited where the syringes were exchanged. This part of the program was intense and more than a little disturbing. Jim risked arrest and personal safety in his very personal mission to help prevent HIV and HCV. He and I also worked as colleagues and friends for the past 12 years at Bi-Valley Medical Clinic. He died in April, 2007.

Ironically, shortly after Jim’s death, I came across the audio cassette of the program that NPR sent me. I was amazed to listen to this program for the first time in 11 years and realize how relevant it remains today. The research on the effectiveness of this kind of public health approach was clear then, as it is now. The willingness of injection drug users (IDU) to change needle sharing behaviors if given accurate information and access to sterile needles was clear then, as now.

The collateral goal of using the exchange as

a source of health information and treatment referrals remains unchanged. The opposition was ideological and fear based, not factual or evidence based; so eventually it began to collapse. The collapse finally occurred at the Sacramento City Council meeting of January 23, 2007.

The case for needle exchange was carried by Councilwoman Sandy Sheedy. Councilman Ray Trethaway led an earlier discussion when pharmacy sales of syringes to addicts (SB 1159) were approved on September 9, 2006.

A number of members of the Medical Society, as well as UCD president and HIV specialist Dr. Claire Pomeroy, addressed the Council in support of syringe exchange as a health measure.

So, 11 years after the evidence was clear from a scientific standpoint, the political process accepted its validity.

It reminds me of the German physician Virchow’s famous dictum (he fought to convince 19th century Berlin of the health hazards of raw sewage): ”medicine is politics.” Eventually, like Berlin, Sacramento got it right: the City Council approved a legal needle exchange in Sacramento City by a vote of 7–2. But, it provided no money for the program.

The next victory came when the California Office of AIDS awarded grants to two community-based outreach programs, Harm Reduction Services (HRS) and Safer Alternatives through Networking and Education (SANE), for infra-

November/December 2007

13

structure development and staff support of Sacramento’s authorized exchange program.

HRS is a local outreach agency bringing healthcare education, HIV and HCV testing, and treatment linkages to out of treatment drug users.

SANE, through its syringe exchange program and research experiences, developed the model of using IDU social networks to develop satellite exchanges.

But there is one more step in this unduly prolonged process: the state grant specifically excluded money for purchase of needles. The buck was passed (or not passed) to the community to manage. This is where we are right now!

What’s the local evidence for effectiveness of ”harm reduction” policies like needle exchange and outreach education?

Dr. Flynn tells me that the prevalence of HIV now among out-of-treatment IDU is about 1 percent. In 1992 it was 11 percent among methamphetamine users and 4 percent among heroin injectors1.

We were all fearful of the kind of epidemic that hit East coast drug users, where the prevalence of HIV reached 40–50 percent. Four programs were put in place locally back in the early 1990s to control the viral epidemics among IDU. First was the underground exchange which came from grassroots activists, usually linked

to researchers gleaning information from their work.

The other three prevention programs were supported by federal grants promoting HIV counseling and testing among IDU, sponsoring a cable channel TV program called ”User Friendly TV” (former Mayor Anne Rudin, a visionary, courageously appeared on this program), and a HIV prevention poster campaign that targeted business or clinics frequented by drug users.

All these interventions are part of the success of our local HIV prevention efforts, but without the sterile needles these other important efforts may have been wasted.

As readers can imagine, raising money for syringes for drug users is not one of the universally accepted fundraising targets.

“You want to give needles to addicts so they can inject illegal drugs?”

Well, yes, but understanding the logic of this kind of intervention requires compassion, an openness to research evidence, and an awareness that needle possession laws have failed to control injection drug use and have, instead, become a significant cause of the infectious diseases endemic among IDU. This is a tall order.

It is estimated, based on numbers of needles distributed in Sacramento during the years of underground operation, that 850,000 needles will be needed per year. Needles cost about 10 cents each.

This means raising $85,000 a year for the next three years to operate the two programs.

For those very special people who wish to support this important public health effort, all tax-deductible donations for the purchase of syringes should be made to Harm Reduction Services2 or SANE3.

And in memory of Jim Britton, I promise we will carry on his work. jmccarthy@bivalley.com 1 Zeldis JB, Jain S, Kuramoto K, Richards, C, Sazama K, Samuels S, Holland P, Flynn NM. “Seroepidemiology of Viral Infections Among Intravenous Drug Users in Northern California.” Western Journal of Medicine 1992;156:30-5.

2 Harm Reduction Services, 3647 40th St., Sacramento, CA 95817 or hrsdir@pacbell.net 3 SANE, 8015 Freeport Blvd, Sacramento, Ca 95832 or rjvanderson@ucdavis.edu

14

Sierra Sacramento Valley Medicine

A Posit on Global Warming “Whether humanity contributes significantly to global warming is a matter of no significance to health or to the practice of medicine at this time.”

The current e-posit was prefaced by this assertion: “The world will never significantly reduce or control production of greenhouse gasses voluntarily.”

Posits do not necessarily reflect the views of SSV Medicine, the Medical Society, or its Board of Directors. Among 102 responses, 78 disagreed, while 22 agreed with the posit. Edited commentary from 27 people appears below. Unedited commentary is viewable online.

“Any factor that affects health care is a matter of significance to the practice of medicine. The true human contribution to climatic change has not been determined. It is unknown if human contribution is significant. It is politically correct to join the bandwagon of ’global warming.’ I seem to recall that Greenland was, in fact, green some long time ago. The question is what can reasonably be done about it.” — Lee Snook, MD “Clearly, it MATTERS if human activity contributes to global warming. The debate (not clearly delineated in the mainstream media) is whether global warming even exists (vs. being a ’normal’ cyclical change in climate) and if human activity does contribute significantly to it...there IS valid scientific debate on that topic.”

— James Sehr, MD “Adverse climate changes will affect human health. Therefore, as citizens of the world, whether we are part of the medical profession or not, we should participate, as best as we are able, to prevent adverse climate changes caused by man.” — Bryant Sheehy, MD “Regarding greenhouse gases, water vapor is by far the most significant, with carbon dioxide relatively insignificant. Of the latter, a tiny fraction may be attributed to human activity.… [In the past] the consequences of higher

global temperatures were apparently beneficial to humans. The wild imagination of fear mongers (some with a lust for power) has brought us some dramatic fictional scenarios of global warming consequences.… [Their hope] is to achieve more centralized control of power and resources — ostensibly to save us from warmer temperatures. This would be at the expense of individual liberty and of activities for which people might choose to spend their resources, such as medical care. This…represents the triumph of political propaganda and indoctrination over true education, science, and open debate. Responsible, intelligent citizens must educate themselves and act accordingly.” —Lee Welter, MD “Unfortunately the federal government is so divided between the left who favor regulation and litigation to solve the problem and those on the right who consider it of no consequence to the environment that no measurable standards for developing a healthy environment will be realized in our lifetime.” — William Johnson, MD “That is one of the most abominable statements I’ve heard regarding the crisis of global warming. As health care providers we should be leaders, being examples for the rest of the industries, showing everyone that taking care of the earth is all of our responsibility. As people get sick from problems associated with global warming (everything from mental health to respiratory problems), we, in our over-stretched systems, will feel the ramifications first.” — Tracy Burns, MSI “This is a confusing posit, and hard to know exactly what I am agreeing or disagreeing with.

I disagree with the Posit, but agree strongly with the Assertion. Global warming will never volun-

November/December 2007

“Unfortunately the federal government is so divided… that no measurable standards for developing a healthy environment will be realized in our lifetime.”

15

“Genuine science is exposing the theory of manmade global warming as a fallacy and political fraud.”

16

tarily be stopped or slowed significantly. Greed and fear will ALWAYS trump good sense. A large enough percentage of the earth’s population will continue to produce significant quantities of greenhouse gases despite all attempts to curb them. Global warming will dramatically affect health, the practice of medicine, and almost every aspect of life in the next 100 years and beyond.” — Ivan Schwab, MD “The monetary loss will be too high to be acceptable to the lobby unless something catastrophic occurs — and, as usual, always too late then.” — Kenneth Corbin, MD “Many other concerns that affect the health and well-being of people in this world and medicine should be at the forefront of those issues. The importance of preventative medicine and public health will contribute significantly to sustaining culture and surviving this world’s climatic changes.” — Forrest Junod, MD “You MUST be kidding!” — Nancy Gilbert, MD “Whatever man does to negatively impact his health is an issue for the delivery of health care…global warming...this weekend is not as high on the list as drunken driving, wars, famine, etc...there is a difference between global warming as it is portrayed in the current political media and cyclical weather patterns...both affect health as they affect people. This is not a 30 sec sound bite problem.” — Walter Malhoski, MD “The two questions are independent and should be posed separately.” — Thomas Blumenfeld, MD “Genuine science is exposing the theory of man-made global warming as a fallacy and political fraud. I strongly believe that we should discard prejudicial political correctness-driven research (aka junk science) and put our efforts towards meaningful discovery. Only through honest science can we expand our knowledge, improve the human condition and fulfill our obligation as a responsible custodian of our planet.” — Don Hause, MD “We have a responsibility, especially those of us in the occupational environmental field, to endorse preventive actions.” — Janet Abshire, MD

Sierra Sacramento Valley Medicine

“To consider any environmental alteration of no consequence to human health science is absurd. In basic physiology, responding to changes in one’s surroundings brings about physical responses, not the least of which is stress.” — Jose Ma C. Leuterio, MD “We’d better get working at a fix — we are already pretty late thanks to the current Administration of non-believers in science.”

— Mary Cunningham, MD “Increased incidence of allergic rhinitis due to the increased presence of ragweed pollen is just one simple example. If a few retired US generals can create a report outlining suggested war games (to include a new theater of operations in an ice-free Arctic Ocean and to include the war for drinking water instead of the war for oil), then why can’t we physicians prepare for the strong likelihood that our patients will have multiple co-morbidities and complications related to global warming? Whether or not it will happen is less a debate now, but even if one still believes that global warming is not a reality, why not help prepare for such a contingency — for the sake of our patients’ well-being — or would we prefer to stay within ’party lines’ as we see more cases of heat related diseases?” — Syed Ameen Khasimuddin, MD “I agree [but the posit is] poorly worded.”

— Kent Hart, MD “Whether humanity contributes significantly to global warming is a matter of conjecture at this time.” — Richard Gray, Jr., MD “When global warming causes the oceans to rise such that places like Bangladesh flood, I would think drowning or being in an environment with tons of bacterial and vermin infestation would have impact on human health.”

— Erica Li, MSI “According to the WHO, an estimated 150,000 people died from the effects of climate change in 2000. That is not an insignificant impact on humanity’s health and survival!”

— Stephanie Voyles, MSIII “Hope I read the question appropriately.

Global warming bad. Too many people on the planet. Population control/reduction is the real key.” — Stephen Ferronato, MD

“The thing that makes us fairly unique as human beings is our ability to control our behavior, and to understand its consequences.

What could be more pertinent to health than maintaining the habitability of our planet?”

— Francisco Prieto, MD “Rediculous [sic] statement.” — Anthony Russell, MD “It is already a fact that many informed and thinking Americans and most civilized governments are actively and seriously working to reduce the causes of climate change. The leaders of a few large polluting nations (including the current internationally isolated Bush administration), for reasons related to the politics of shortterm profit, ignorance and lack of vision, have either cynically denied the facts or attempted to delay their accountability. This will change when their disastrous turn at governing is over. If those who practice medicine are first human beings and citizens of (before any country) the human race, then the consequences of climate change

must be of significance to them.” — Daniel Egerter, MD “There are probably multiple causes for global warming to include increased solar radiation to natural and man-made greenhouse gasses.

Some of the factors are beyond human control.

Nevertheless, smart and efficient use of energy is crucial to world health, stability, and security.

Current US production of ethanol is not smart or efficient. At best, it takes as much energy to produce as it generates while more greenhouse gasses are generated in the production and burning of ethanol than gasoline. We have been lucky to weather the 200% price increase in oil over the past few years without severe economic impact. Even if more oil reserves are found, worldwide demand is climbing and supply lines will remain constrained. If we do not become more efficient with our energy generation and consumption, our economy and the money required to deliver quality healthcare will be severely impacted.” —Craighton Chin, MD

November/December 2007

“What could be more pertinent to health than maintaining the habitability of our planet?”

17

Voices of Medicine Huge profits = no health care, a merged Vital Signs, a wrong direction for prescriptions.

By Del Meyer, MD

Losing Out at the Casinos Stephen Kamelgarn, MD, argues that “It’s Time for Casinos to Contribute,” in Editor’s Thoughts of The Bulletin of the Humboldt-Del Norte County Medical Society, August 2007.

“It is increasingly expensive to provide health benefits for one’s employees, and in today’s business climate of decreasing profit margins this can be the difference between making it and bankruptcy.

“However, there are businesses that do earn a significant amount of profit, and it is important for them to pick up their fair share of the load. WalMart has been rightfully blasted in the national press for not providing benefits for their employees. This is a world-wide corporation that earns billions of dollars in profits every year.

Yet, somehow, they can’t seem to get it together to provide benefits for employees who, in many cases, are earning just enough money to keep them for qualifying for Medicaid (Medi-Cal, here in California). Because of the national outcry Wal-Mart has begun to provide benefits for its employees.

“Locally, we’re seeing a similar situation with some local businesses. These are concerns that earn tremendous amounts of money, yet don’t provide for their employees. I am referring to the 3 local casinos (four, if you count the one in Klamath). In 2005, the Bear River Casino in Loleta grossed over $100 million, yet they provided no health insurance for many of their employees. If we assume that the other two casinos are doing as well as Bear River, then $300 million is going into their coffers.

“This is more than two thousand dollars

18

Sierra Sacramento Valley Medicine

per year for every man, woman and child in Humboldt County! It is not my point here to get into either the economics or morality of tribal gaming. But it is important to see that these casinos are tremendous cash generators, and a significant source of employment in the community, both for tribal members and nontribal community members. Despite the fact that California State policy is that, in businesses of more than 50 employees, employers must provide insurance for anybody working more than halftime, the local casinos, being sovereign nations and therefore exempt from the rules, don’t provide for many of the employees who work much more than 20 hours per week. This is true, not only of Bear River, but also Cher-ae Heights, and Blue Lake casinos.

“I find this reprehensible. The fact that businesses can earn a quarter of a billion dollars in gross income, and not provide benefits for all of their employees bespeaks a level of callousness and greed that I find incomprehensible…”

The entire article can be read at www. humboldt1.com/~medsoc/images/bulletins/ AUGUST%202007%BULLETIN_for%20web.pdf

A New Vital Signs Sandi Palumbo, the Executive Director for two medical societies, has announced a merger of their membership publications.

“With this month’s issue of Vital Signs, the Fresno-Madera Medical Society (FMMS) and the Kern County Medical Society (KCMS) are pleased to announce the merging of their respective membership publications, FMMS Vital Signs and KCMS Bulletin, into one combined enhanced monthly publication.

“This combined publication is yet another

cooperative effort on the part of FMMS & KCMS designed to meet the needs of both organizations while decreasing the individual financial burden of such activity for both organizations.

(Effective with my employment as FresnoMadera Medical Society’s Executive Director early last year, through mutual agreement I also continued employment as Executive Director for Kern County Medical Society.)”

Incentivizing Prescriptions David Aizuss, MD, warns “Beware These Prescribing Minefields” in the October issue of Southern California Physician, the publication of the Los Angeles County Medical Association.

“Health plans are now incentivizing their patients to convince their doctors to change medications.

“Physicians are under constant pressure to alter their prescribing habits — and new developments are adding to the force.

“In the past few years, there has been tremendous negative publicity about pharmaceutical manufacturers’ efforts to influence physician prescribing via ‘drug reps,’ or pharmaceutical detail salespeople. As a result, the Pharmaceutical Research and Manufacturers of America promulgated regulations that constrain what drug reps may do when they visit physicians’ offices.

For example, the representatives must combine education with an offer of dinner or lunch.

Further, the medical profession continues to debate the ethics surrounding pharmaceutical ‘freebies.’ I consider this a tempest in a teapot.

What ethical physician would alter his prescribing practices based on pens and sticky notes?

“More recently, insurance companies are entering the game to alter physician prescribing habits. For example, earlier this year, as a patient, I received a letter from my insurance company suggesting that I ask my doctor to prescribe double the dose of my medication, so I could save money by cutting those pills in half with a pill cutter at home.

“I was incredulous — such a policy is clearly not in the patient’s best interest, but in the insurer’s best interest. It might reduce the copay for the patient, but it definitely reduces

administrative overhead and processing costs for the insurer. Worse, the practice may even hurt patients. Among the obvious dangers are that patients cannot necessarily cut pills exactly in half, the distribution of medication and binder is unknown, the effect of gastric absorption cannot be quantified, and patients may become confused and cut the wrong pills.

“Another even less ethical practice was just brought to my attention. Some health plans are now offering physicians financial incentives to switch their patients from higher-cost to lowercost drugs. One plan paid physicians to switch patients from Lipitor to a generic version of its competitor, Zocor. The physicians were paid $100 for each patient switched between Jan. 1 and March 31, 2007. Incentivizing physicians to switch a patient’s medication distorts the doctor-patient relationship and should not be permitted. The only consideration should be prescribing the best medication for the patient’s condition.

“If two medications have an equivalent effect on the patient, then it is reasonable to factor cost into the prescribing decision. However, in the example above, the patient was not a consideration. Cost alone was the deciding factor, and the incentive failed to consider patient needs.

“Finally, a colleague on the Los Angeles County Medical Association board recently showed me a letter that a health plan in California sent to its patients. It offered patients a free month of simvastatin if they convinced their physicians to switch them from Lipitor.

Consequently, health plans are now incentivizing their patients to convince their doctors to change medications. This strikes me as wrong. It clearly undermines the doctor-patient relationship. We prescribe medications we think are best for patients, only to see them back in the office waving a coupon for a free month of medicine if we switch their prescriptions…”

The entire article can be found at www.socalphys.com/article/articles/581/1/Presidents-Letter--Beware-These-Prescribing-Minefields/Page1.html

Consequently, health plans are now incentivizing their patients to convince their doctors to change medications. This strikes me as wrong.

DelMeyer@HealthCareCom.net

November/December 2007

19

“Where There is Need, There is Mercy”

By Sister Katherine Doyle, RSM The author is an archivist and historian for the Sisters of Mercy. This paper stems from her talk at the Sierra Sacramento Valley Museum of Medical History about the 150th anniversary of the Sisters’ arrival in Sacramento.

Building a legacy of healthcare in the city of Sacramento was not part of the plan for the five Sisters of Mercy arriving in Sacramento at dawn on October 2, 1857. They came to teach and to care for the city’s orphans. The same plan brought them to San Francisco only three years earlier. Circumstances wrote a different history.

“Catherine McAuley, founder of the Sisters of Mercy, had special concern for the sick. In her own lifetime she attended the sickbeds of dying family members, young consumptive members of her community, and cholera victims in Dublin.

Her sisters did no less. They moved out into the homes of the sick and dying. They answered the call in 1854 to become nurses in the army hospitals of Crimea. They went where they were needed regardless of the risk to their own health and safety. It was this legacy of care and compassion that the first California Sisters of Mercy brought to San Francisco and Sacramento.

When the Sisters arrived in San Francisco, the city had no health regulations to confine disease. Within days of their arrival, cholera came and later small pox. Using skills learned from experience, the Sisters offered their services.

They were granted administration of the county hospital, thereby gaining the respect of friend and foe alike. They lived the instructions of

20

Sierra Sacramento Valley Medicine

Catherine McAuley: “great tenderness must be employed and when death is not immediately expected it will be well to relieve the distress first and to endeavor by every practicable means to promote the cleanliness, ease and comfort of the patient…”

While the Sacramento Sisters engaged primarily in education, each day after school they would walk to the homes of the sick, becoming Sacramento’s first visiting nurses. In early Sacramento, there was the Railroad Hospital and the County Hospital, but neither served what would be termed “private pay” patients.

Sacramentans had to journey to San Francisco for major surgeries.

By the 1890s the situation was serious.

The doctors of the city, knowing the level of excellence provided by the Sisters at St. Mary’s Hospital in San Francisco, repeatedly asked the Sisters to open a similar facility in Sacramento.

Due to lack of personnel and money, the Sisters had to decline their request.

Recognizing the serious gap in available healthcare in Sacramento, Dr. Thomas Huntington, chief surgeon of the Southern Pacific Railroad Hospital, approached the Sisters once more and, this time, succeeding in securing a “Yes.” Dr. Simmons, owner of a small sanitarium called Ridge Home, sold it to the Sisters, who took possession on August 1, 1895. At the time it had two patients.

The Sisters quickly recognized that the facility was inadequate and began plans to build a new hospital on the property. The new hospital, Mater Misericordiae, celebrated its groundbreaking on November 26, 1896 and open for business on May 9, 1897.

Starting with a capacity of 30 beds, the hospital soon doubled in size to accommodate Sacramento’s growing population. A surgical suite was added and the Sisters sponsored a thriving nursing school. Even though Mater Misericordiae expanded once more, bringing its capacity to 90 beds, it was evident by 1912 that it was too small and that the wood frame building was too vulnerable to fire.

As early as 1914, the Sisters began to look for a new location. The site owned by the Inderkum family was selected even though it was swampy at the outset. Benefactors and medical community alike began planning for the new hospital, but plans were put on hold by the outbreak of World War I. The limits of available space challenged the Sisters during the flu epidemic of 1918. There simply was not enough space for the sick. The Sisters transferred all the infants to their orphanage at Stanford Home to make room for more patients.

It was not until 1925 that a new Mater Misericordiae would open at 40th and J Streets.

Mother Mary Carmel McNaughten oversaw the move from 23rd and R Streets to the new building. Everyone helped, including boys from Christian Brothers who lent their muscle to carry beds and equipment out of the old building into their new home.

Since 1925 Mercy Hospital has been the heart of Mercy healing in the city of Sacramento.

From there the Sisters reached out to other communities in need of healthcare: Redding in the 1940s; the northern suburbs through Mercy San Juan in the late 1960s; and Folsom in the early 1980s. Prior to Medicare and Medi-Cal programs, Mercy offered a free clinic for children and opened a Children’s Hospital. Mercy trained nurse cadets for service during World War II, provided long term care for patients unable to stay in their homes, established a nationally honored cardiac program and reached out to the economically poor through clinics and community service.

Such a tradition never comes from one source, yet it has been shaped by the vision of Catherine McAuley. That vision has been kept alive by many, such as Sister Mary Peter Carew,

Sister Mary Kevin Redmond, Sister Mary Ligouri Madden.

It has been shared by dozens of dedicated physicians, healthcare workers, student nurses trained by the sisters, and by all who have worked to ensure that Sacramento sick have a medical facility in which they experience not only healing of the body but solace of the heart and spirit. mkdoyle@mercysisters.org

Mater Misericordiae Hospital in 1909

November/December 2007

21

Apoptosis of the Species

By John Loofbourow, MD A Child walked the beach near Gualala on a clear moonless summer night. The sea breeze had let up and she gazed at the rising darkness, disordered by an occasional satellite mirroring the sun below the horizon. A strange figure approached her, a diminutive man costumed in a mail coat and carrying a plumed steel helmet under one arm. He could not be ignored as they were completely alone.

“Who are you, anyway?”

“My Welch name is Gwalchemei, but the Brits call me Sir Gawain, and the Cthix call me… something you’d find unpronounceable. I have a message for Merlin. Could you please direct me to him?”

“I doubt it. Merlin lived hundreds of years ago on the other side of the world.”

“I detest the autocratic, bureaucratic, incompetence of the CPGW. You’d think they could pay more attention to simple details. I had hoped to alert your world earlier. I suppose I shall have to make do with you, with here, with now.” He looked into his helmet while rotating it slightly. “I see; this is 2007 your time, in America, right? “ “Very good. Pacific Standard Time.”

“I’m only allowed one contact. No touching.”

“Not to worry. What’s the CPG…what you said?”

“The Commission to Promote Galactic Warming.”

“Wow! Where are you from?” asked the Child.

“I am from Infinity, Time.

“Time! There is really only one time. Now.” “Ah, no. There is time, and there is Time.

22

Sierra Sacramento Valley Medicine

Augustine said, there is knowledge, and there is Knowledge. They are different.

“You are as weird as you look. Short and confused.”

“Knights were all short by your standards.

I think my representation is very good indeed.

By a knight’s standards Americans are blubbery giants. But enough pleasantries. What are you doing here alone at night?”

“I’m looking at the stars. In West Sacramento, there are only a few.”

“Stars? What do you know about them?”

“They are just stars. More here than at home.”

“We are all made of stars; but what are they, really?”

“OK, I’ll bite. What are all those stars?” said the Child. “ “Well” said Gwalchemei hesitantly, it’s a long story. They are created by the apoptosis of species; of worlds. “ “ A pop-what?” “ I’m not sure you are old enough to understand. I shouldn’t have mentioned it.”.

“I’m fifteen! My teacher said stars are Suns.”

“Gods help me! A huge teenager! Well, yes; they are stars; why are you out here looking at them?”

“Well, I guess… I wonder…” the Child hesitated. “How did they get there? Who made them?”

“People something like you made them.”

“No way!.”

“They didn’t plan to make them. It just turned out that way.”

“That’s dumb.”

The Knight sighed deeply, shivered, and sank to his knees. “Do you mind if I lie back here on the sand? It’s still warm from the day and my mail is cold in the sea air. I’ll tell you about Sun,

your closest star, and you will know about all the rest.” He threw a heavy faded woolen garment over himself, rested the nape of his neck on his palms, looked fixedly at the starred darkness, and continued without shifting his gaze.

“Once Sun was a planet. Not an ordinary planet. Life developed there. Beings appeared, but of a different shape and size than yours. They evolved. The most aggressive and lethal flourished. They became Creators of Tools, Language, Gods, and Writing, much like humans. They seized Dominion of their planet and all life there. They learned the secrets of Things. They gathered and accumulated Knowledge without the capability to understand it.”

“But God created everything, knows everything, loves everything.”

“Oh yes indeed. But the beings who lived on that long ago planet created God; many Gods.

Some Gods feared one another.”

“Which Creator was First?”

“There was no First. First implies that Time has meaning. That is why this story is so hard to tell. It has to do with Infinity.”

“Why, I know what that is!” said the Child eagerly. It’s when you divide a number by zero.

It’s when something has no end and no beginning like numbers or fractions; like i.”

“You do know, don’t you! You are a good student. But I doubt you really understand infinity. One thing is to know; another very different order of things is to understand. People know the concept of infinity; not what that implies.

You talk of life eternal, or infinity squared, and ‘orders of infinity’ as if you understood. You know some things that big numbers can do. As when a baby takes its first breath, it breathes in so many molecules of gas that in its whole life it will never breathe them all out of its own lungs.

So you know that. But not the implications of Infinity or Time. Both are beyond the ignorance of reason.”

“You say there’s no First? Do you mean like the Chicken and the Egg?” “I do mean something like that. Because the question has no meaning. The question about the ultimate or beginning or ending has no meaning.”

“Well, laughed the child. “You lost me.”

“Of course. We are all lost in Time and Infinity.”

“OK OK OK!” said the Child, with an impatient look. “Get back to the stars.” “ OK OK OK!” replied Gawain with a shudder. “The Stars. Sun was once merely a planet, but Life lived there, and evolved into Beings, who gained more and more knowledge of Things, of the Universe, of Universals. And one day one of these intelligent clueless creatures discovered how to unlock the power of dark matter; and, inevitably, did it. All that energy that was trapped in the Stuff of this galactic region was unleashed and self-destructed, like what you call a Super Nova. Every one of the stars you see overhead began that same way. Can you imagine all those intelligent beings, worlds, brilliant discoveries, achievements, insights, atrocities, vanities? No one can. It is in the nature of Life that this happens: all life forms are born and develop. One species succeeds beyond reason, and ultimately self-destructs. Round and round in infinity, where all time is One Time and all places One Place. Apoptosis on a grand scale; sorry; google it.

“On Earth that process started with religion, proceeded to magic, alchemy and onward. I had hoped to convince Merlin to slow down the process of apoptosis for humanity. Now thanks to the bunglers at CPGW, I must rely on you, although it’s very late, and I must leave. It’s up to you.”

“Go on!” cried the child, turning away.

“It’s Gawain, not Gowon.” Said the Knight with a sad smile.

“Whatever.” said the child. “I too have to go on. Good night, good Knight, you crazy dwarf.”

“You must go on; that is truer than you suspect. Please think seriously about what I’ve said. Adios.”

“Ah! Dios! “, said the Child, smiling archly.

They walked away in opposite directions, occasionally looking back to see if the other were real, while the distance between them kept its pace with infinity. john@loofbourow.com

November/December 2007

23

24

Sierra Sacramento Valley Medicine

CMA’S House of Delegates Thirty-four SSVMS Delegates and Alternate Delegates attended the California Medical Association House of Delegates annual meeting on October 27–29 in Anaheim.

The House of Delegates establishes the policies that govern the Association and elects CMA’s president. The House convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues.

Each item of business is assigned to “reference committees” of six members of the House, which hear testimony for or against it from other CMA members and delegates.

The committees then formulate recommendations for action by the full House.

Adopted policies are implemented by the 3 Board of Trustees, which also deals with many interim policy issues arising between annual sessions.

The House of Delegates has more than 400 delegates in all, elected by members of component medical societies, specialty societies, CMA sections (Organized Medical Staff Section, Young Physicians Section, Ethnic Medical Organization Section, Medical Student Section), the Resident and Fellows Section and CMA mode of practice forums.

5

2

4

6

1

1) Our CMA Trustees, Drs. Joanne Berkowitz (Sierra Sacramento) and Dean Hadley (Butte-Glenn). 2) L-R Delegation Members Drs. Margaret Parsons, Marcia Gollober, Janet O’Brien listen to testimony before the CMA House of Delegates. 3) SSVMS President-Elect

and CMA Delegate Dr. Margaret Parsons providing testimony before the CMA House of Delegates. 4) SSVMS Past President and CMA Delegate Dr. Jon Finkler giving testimony before CMA Reference Committee C, Membership, Finance & Governance. 5) SSVMS President Dr. Richard Jones before the CMA House of Delegates, as Chair of CMA Reference Committee A, Medical Practice Issues. 6) Dr. Barbara Arnold, Chair of CMA Reference Committee F, Health Professions & Facilities, addressing the CMA House of Delegates.

November/December 2007

25

Book Review

Glorious Singing

By William Peniston, MD THE STRANGEST SONG: One Father’s Quest to Help His Daughter Find Her Voice,

by Teri Sforza with Howard and Silvia Lenhoff.

Prometheus Books, 2006, 296 pp.; ISBN: I found this to be one of the more intriguing books that I have read during the last couple of years. It is about three separate but related subjects: Gloria Lenhoff, a woman with an IQ of 55 who can sing opera in 25 different languages; Williams syndrome, which afflicts Gloria; and Gloria’s father, Howard Lenhoff, and what he has done to promote the nationwide recognition, understanding, and wellbeing of people with Williams syndrome.

Gloria gets lost easily, and can’t do basic arithmetic, tell left from right, or read music,* but she is a classically trained lyric soprano with a repertoire of thousands of songs.

She was born in 1955 and her infancy and childhood were filled with developmental and behavioral problems. She was small in size, had “terrible” colic, a slight heart murmur, and was “cranky beyond imagining.”

But very early in childhood her intense interest in music became so strikingly apparent that her mother, Sylvia, began to take steps to assure her talent was developed. By the time she was 32, she had received extensive musical training and was singing in foreign languages. She also was singing with a band of what were, at one time, labeled with the dreadful name of Idiot Savants, which later resulted in the production of a public television program titled “Gloria.”

This led to the Lenhoffs becoming aware that she had Williams syndrome.

The physical characteristics of Williams syndrome were first described by cardiologist J.

26

Sierra Sacramento Valley Medicine

C. P. Williams in 1961 and a year later by cardiologist Alois J. Beuren.

The psychological characteristics were described in 1964, at which time the children’s “friendly and loquacious” personalities and “unusual command of language,” as well as their enjoyment of music were noted.

Some of the fundamental research on Williams syndrome began in the mid-1980s

by Ursula Bellugi of the Salk Institute in San Diego. Although Bellugi felt her area of expertise didn’t include the inquiry of music, she and her coworkers found an asymmetry in the left and right planum temporale of Williams syndrome people similar to that seen in professional musicians.

In 1993 Colleen Morris of the University of Nevada reported that one of two elastin genes on chromosome 7 is missing and a length of DNA on either side of it also is missing. The absence of the elastin gene is considered significant for the physical characteristics and abnormalities of Williams syndrome.

Additional research findings by Bellugi and her group on higher order thinking skills, spatial skills, and “theory of the mind” are also well documented in the book. Williams syndrome is considered a scientific mystery that offers a window into the mechanics of the human mind and Bellugi considers it one of the most interesting things she has ever come across.

Howard Lenhoff is a biochemist, now retired, who is described as the sort of person who could work himself into fits of passion over biochemistry and its infinite possibilities. His field of research was freshwater hydra, which he strongly hoped would someday help us understand normal and abnormal embryonic development.

When he learned that Gloria had Williams

syndrome and that many people with the syndrome had unusual musical talents similar to Gloria’s, he became interested in promoting greater recognition of those talents. He soon was devoting all of his great energy and abilities to publicizing the unusual musical gifts so many of these people have to offer.

By this time two separate organizations had been formed: the Williams Syndrome Association, primarily a support service for parents; and the Williams Syndrome Foundation, involved in funding scientific research and long-term planning.

Howard soon became president of the foundation’s board of directors and enabled the funding of research into the musical abilities of Williams syndrome people. Such research was considered threatening to the association’s support of parents who felt their children had no special talent for music. The resultant infighting is a fascinating story in itself.

The author presents these three subjects clearly and understandably without oversimplification, and masterfully segues from one to the other. peniston@mcn.org * For details about physical abnormalities that may be associated with Williams syndrome see http://children.webmd.com/ Williams-Syndrome-11011, or http://www.Williams-Syndrome. org

Simplified HIV Test Consent AB 682 allows physicians to test for HIV without a separate written consent beginning January 1, 2008. There is still a requirement for verbal counseling, letting patients know that they may decline testing, and documenting this in their charts.

But this is one more step in making HIV testing like any other test done in a doctor’s office. CMA worked closely on this bill.

SSVMS Election Results 2008 Board of Directors President: Margaret E. Parsons, MD President-Elect: Charles H. McDonnell, III, MD Immediate Past President: Richard Jones, MD District 1, North: Alicia Abels, MD District 2, Central: Michael Lucien, MD; Phillip Raimondi, Jr., MD; Glennah Trochet, MD District 3, South: Katherine Gillogley, MD District 4, El Dorado: Ulrich Hacker, MD District 5, Permanente: David Herbert, MD; Robert Madrigal, MD, Elisabeth Mathew, MD, Stephen Melcher, MD, Anthony Russell, MD District 6, Yolo: Marcia Gollober, MD 2008 CMA Delegates and Alternates District 1, North: Jon Finkler, MD, Delegate; Robert Kahle, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Samuel Ciricillo, MD, Alternate District 3, South: Barbara Arnold, MD, Delegate; Kenneth Ozawa, MD, Alternate District 4, El Dorado: Ronald Foltz, MD, Delegate; Demetrios Simopoulos, MD, Alternate District 5, Permanente: Elisabeth Mathew, MD, Delegate; Boone Seto, MD, Alternate District 6, Yolo: Craighton Chin, MD, Delegate; Marcia Gollober, MD, Alternate At-Large, Office #7: Charles McDonnell, MD, Delegate; Kuldip Sandhu, MD, Alternate At-Large, Office #8: Margaret Parsons, MD, Delegate; Gerald Upcraft, MD, Alternate At-Large, Office #9: Norman Label, MD, Delegate; Vacant, Alternate At-Large, Office #10: Satya Chatterjee, MD, Delegate; Robert Jacoby, MD, Alternate At-Large, Office #11: John Ostrich, MD, Delegate; Alicia Abels, MD, Alternate At-Large, Office #12: Robert Midgley, MD, Delegate; Jeff Suplica, MD, Alternate At-Large, Office #13: Earl Washburn, MD, Delegate; Richard Gray, MD, Alternate At-Large, Office #14: Richard Pan, MD, Delegate; Robert Madrigal, MD, Alternate At-Large, Office #15: Richard Jones, MD, Delegate; Connie Mitchell, MD, Alternate At-Large, Office #16: Michael Burman, MD, Delegate; Anthony Russell, MD, Alternate At-Large, Office #17: Janet O’Brien, MD, Delegate; Sanjay Jhawar, MD, Alternate

November/December 2007

27

28

Sierra Sacramento Valley Medicine

In Memoriam

Quentin Bonser, MD 1920–2007

Quentin Bonser, MD, an icon of the El Dorado County medical community, died at home with his family just short of his 87th birthday.

Known to his friends on the Marshall Hospital medical staff as “Quint” or “QB,” Dr. Bonser had a profound influence on medicine in El Dorado County during his career here from 1961 to 1989. Even after his retirement, Quint chaired Marshall’s morbidity and mortality meetings for another decade.

Quint was born in Washington State and spent his teen years in Whittier, California.

His high school basketball team won the state championship in 1938. He eventually attended UCLA, where he also played basketball “before that Wooden fellow came around,” as he told me once (with a twinkle in his eye).

He earned his MD from UCSF in 1945 and was chief of surgery at Travis Air Force Base in 1951–52. After practicing for five years in Visalia, Dr. Bonser moved his family to Placerville in 1961 — just two years after Marshall Hospital opened its doors. He was the first board-certified physician in Placerville. He was chief of staff at Marshall twice and influenced nearly everything that went on at the hospital.

In 1971–73, Quint volunteered for three tours of duty of two months each in Viet Nam. There he treated civilians and military alike. He once said to me, “I was in the military for World War II and the Korean War, and I went over for Viet Nam. They are going to have to do the next war without me.”

Quint was a doctor’s doctor. His consultations were always a model of thoroughness and yet they were also succinct and clear. Nothing important was left out and nothing unnecessary was included. How I wish that today’s computer generated consultations could come close to

duplicating Quint’s H&Ps! Quint’s dedication to his patients was legendary. His nightly rounds always included double-checking the addition of each patient’s I & O charts. He often found errors and once said to me, “They know I’m going to add these columns up every night.

Wouldn’t you think they would at least double-check the totals on my patients before I get here?”

Quint was one of a group of crusty Marshall Hospital medical staff oldtimers when I started practice in 1976.

I learned a lot from those guys. He and Howard Bliss, MD, used to laughingly refer to themselves as “Statler and Waldorf” (the two old curmudgeons who occupied the box seat and heck- Quentin Bonser, MD led the performances in The Muppet Show). The analogy was apt.

Quint was also very close to John Mathewson, MD. These two doctors found inspiration from their daughters, who became nurses.

They founded a Mathewson-Bonser Nursing Scholarship for Marshall Hospital nurses. The Scholarship is funded by an annual Oktoberfest event.

No review of Quint’s life would be complete without mentioning his family. He and his wife, Loie, were married for 62 years. They have four children, 12 grandchildren and six great-grandchildren. All of them were dear to Quint. When I saw him with his family I saw a very different man, one who seemed infinitely patient and amused with whatever his grandchildren could cook up.

The Bonsers have a family cabin at Echo Lake. For years Quint would invite the Marshall Medical Staff By-laws Committee up to Echo Lake to review the the By-laws. These were the continued on page 30 November/December 2007

29

In Memoriam

George Gross, MD 1923–2007

George Gross, MD

When I first came to Sacramento in 1971 and joined the medical community, George Gross, MD, was one of the younger of the pioneering psychiatrists. He first joined the medical staff of Sutter Memorial in 1955 and was chief of the psychiatric department 1972–72.

He was a key member of the Sutter Community Health Center. He had both clinical and administrative duties and was always willing to take on new challenges including adolescent psychiatry, electroconvulsive therapy, and partial hospitalization, and was very knowledgeable about new psychiatric medications.

He served as a mentor to me and several other psychiatrists who soon followed. He was well respected and liked by his colleagues, both psychiatric and non-psychiatric physicians, staff, patients and their families. He was always willing to take on difficult problems and handled them skillfully.

His interest in organized psychiatry included the Central California Psychiatric Society, a district branch of the American Psychiatric Association. He was the first president of this

organization and designed its logo. The APA recognized all these contributions by awarding him the prestigious title of Distinguished Life Fellow.

He had special interests in medical ethics and was responsible for updating ethical standards in the APA. He also was a pioneer in psychiatric peer review and his work locally set up guidelines that were established nationally.

Many of his patients were impaired physicians and this was another area of his leadership and innovation.

His mentoring with me resulted in my becoming a president of the CCPS and to make medical and psychiatric peer review a significant part of my clinical practice.

George and Vivian “retired” to Florida several years ago, but he continued to practice in the local prison system (another area he was an early pioneer in) until recently. He died in his Florida home on September 24, 2007. I will miss George for his professionalism, leadership and friendship as will many of his colleagues, friends and former patients in Sacramento. I still picture his distinguished face blowing flames from a trumpet on a 1983 Jazz Festival Poster.

— James A. Margolis, MD

continued from page 29 best committee meetings I have ever attended.

We actually got our work done quickly enough without any electronic interruptions, and then we could all kick back and enjoy one of the nicest spots anywhere in the world. We had to boat in and out to the cabin, but that just made the meetings even better.

Quint received many honors during his life including our Medical Society’s Honor Award in 1996, the Helping Hands Award from

30

Sierra Sacramento Valley Medicine

Marshall in 2006 and the AMA’s Certificate of Appreciation for Humanitarian Service. We have a heavily used public trail in Placerville with a special bench at its eastern end. The bench is dedicated to Dr. Bonser as “The Man Who Walks the Walk.” Quint loved the Placerville Trail and really appreciated the dedication of the bench to him. I cannot think of a better way to remember the life of this excellent physician.

— Earl R. “Trey” Washburn, MD

Board Briefs September 10, 2007

October 8, 2007

The Board received a report from Dean Chalios, Executive Director of CALPAC, the California Medical Association’s Political Action Committee, regarding endorsement of candidates for public office.

The Board received a report on the Sacramento County Board of Supervisors budget deliberations concerning a reduction in healthcare services to undocumented individuals, and reaffirmed its opposition to such a reduction of medical services.

The Board also: Approved the Second Quarter 2007 Financial Statements and Investment Performance Reports.

Approved recommendations from the Scholarship and Awards Committee for the 2007 William E. Dochterman Medical Student Scholarship to provide grants to Erin Jones ($3,000), $2,000 to Elizabeth ter Harr and $1,000 to Sujan K. Sandhu.

Received a report from Glennah Trochet, MD, Sacramento County Public Health Officer, regarding a higher infection rate than other counties in California for gonorrhea and chlamydia and the county’s limited resources in educating the public about STDs. Recommended that the Child and Adolescent Health Services Committee investigate outreach efforts to get the message out to the public about STDs. Approved the Membership Report: For Active Membership — Kelly E. Burke, DO; Steven L-W. Chen, MD; Prakashchandra V. Dobaria, MD; Louis J. Giorgi, Jr., MD; Kathryn A. Glatter, MD; Bianca Harabor, MD; Marcia T. Isakari, MD; Roger E. Mendis, MD; Tammy L. Morin, MD; Joel A. Pearlman, MD; David G. Telander, MD; Virgin L. Williams, MD; Jennifer Z. Zhou, MD. For Reinstatement to Active Membership — Duva J. Appleman, MD; Peter S. Dietrich, MD; Todd M. Fisher, MD. For a Change in Membership Status from Active to Retired Membership — Dennis B. Daughters, MD. For Resignation — Philip H. Choo, MD (moved to Pennsylvania).

The Board: Approved the 2006 Year-End Audit Report.

Approved a $250 donation to the AMSA Heartbeat Run benefiting UC Davis Student-Run Clinics.

Reviewed the 2007 Nominating Committee Report on nominations to vacancies on the Board of Directors and the Delegation to the California Medical Association for 2008–2009. The report will be mailed to all active members permitting additional nominations by any active member. In an uncontested race, the sole candidate nominated to office will be considered duly elected without the necessity of vote. Election results will be announced to SSVMS membership within 30 days.

Since the November 12 Board meeting falls on a legal public holiday for Veterans Day, approved moving the November 12 Board meeting to Tuesday, November 13.

Approved the following Nominees to the 2008 BloodSource Board of Trustees and Executive Committee: Board of Trustees — Esther M. Aw, Chris Ann Bachtel, Glennah Trochet, MD, Jeff C. Van Gundy, MD, Michael G. Ueltzen, CPA; Executive Committee — Frank A. Apgar, MD, President; George W. Chiu, MD, Vice President; Keith W. McBride, Esq., Secretary-Treasurer; Michael G. Ueltzen, CPA, Member-at-Large; Anthony Nasr, MD, Member-at-Large.

Approved the Membership Report: For Active Membership — Adam C. Duer, MD; Caron A. Houston, MD; Travis A. Miller, MD; Gurdeep S. Sahota, MD; Zachary D. Taylor, MD; Sarah L. Truong, MD; Brad J. Yoo, MD; Hua Zheng, MD. For a Change in Membership Status from Resident to Active — Gina Tobalina, MD. For Renewal of an Illness Leave of Absence — Douglas R. Schuch, MD. For Renewal of a Special Leave of Absence — Stephen K. Parkinson, MD. For Resignation — Richard K. Lee, MD. For Termination of Membership for Non-payment of Dues — Michael Ali, MD; Allison M. Dobbie, MD; H. Lynn Drummer, DO; Janos P. Ertle, MD; Taja A. Manuselis, MD; Forest H. Mealey, DO; Soni Nageswaran, MD; Kent M. Patrick, MD; Savitha K. Reddy, MD; Breanna M. Ruthrauff, MD.

November/December 2007

31

Tony Tsai, M.D.

Robert A. Equi, M.D. Arun C. Patel, M.D. Joel A. Pearlman, M.D., Ph.D. J. Brian Reed, M.D. Robert T. Wendel, M.D. RETINAL CONSULTANTS MEDICAL GROUP, INC. are pleased to announce the association of

Tony Tsai, M.D.

Retinal Diseases and Ocular Oncology practice limited to the medical and surgical diseases of the retina since 1975

www.retinalmd.com Members of the American Society of Retina Specialists

32

Sierra Sacramento Valley Medicine

Accepting New Patients for Consultation 3939 J Street, Ste. 106 Sacramento, CA 95819 (916) 454-4861

5775 Greenback Lane Sacramento, CA 95841 (916) 339-3655

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 AMAR, Arun P., Neurosurgery/Interventional Neuroradiology, UC San Francisco 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490 APOSTOLAKOS, Diane, Internal Medicine/Infectious Diseases, Univ Autonoma de Guadalajara/New York Med Col 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 BALASINGAM, Saraswathy, Internal Medicine, Univ Colombo, Sri Lanka 1972, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-2377 CARROLL, Christie L., Dermatology, UC Davis 2001, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 DUER, Adam C., Family Medicine, Mt. Sinai 2004, Sutter Medical Group, 2210 Del Paso Rd #A, Sacramento 95834 (916) 285-8100 FOY, Jon F., Anesthesia/Pediatric Anesthesiology, Univ Nebraska 1985, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4807 GARCIA, Jesus A., Plastic Surgery, Harvard Univ 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825, 2nd: 2288 Auburn Blvd., #205, Sacramento 95821 (916) 973-7357 GARCIA-FERRER, Francisco J., Ophthalmology, Washington Univ 1992, UCDMC, 4860 Y St #2400, Sacramento 95817 (916) 734-6650 GEMMELL, Peter S., Emergency Medicine, Univ New Mexico 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 HOUSTON, Caron A., Internal Medicine, Univ Texas 1991, Sutter Medical Group, 1201 Alhambra Blvd., #220, Sacramento 95816 (916) 731-7965 HUMPHREY, John S., Plastic Surgery, Tulane Univ 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5515 JERWERS, Stephen J, Internal Medicine, UHS Col Osteo Kansas City 2003, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 JONES, Sarah S., Family Medicine, Emory Univ 1996, Sutter Medical Group, 1201 Alhambra Blvd., #300, Sacramento 95816 (916) 451-4400 LI, Michael Z., Internal Medicine, Tongji Med Univ, China 1984, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 6313040 MILLER, Travis A., Allergy/Immunology/Internal Med/ Pediatrics, UC Los Angeles 1999, Capital Allergy & Respiratory Dis Ctr, 5609 J St #C, Sacramento 95819 (916) 453-8696

MUDIE, Dawn A., Emergency Medicine, Univ Texas HSC 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 PHAM, Kelly H., DO, Radiology/Nuclear Medicine, Ohio Univ Col of Osteopathic 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6187 REZAC, Mark A., Ophthalmology, Jefferson Med Col 2000, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5100 ROBINSON, Seth P., Pulmonary/Critical Care, Univ Virginia 2001, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 SAHOTA, Gurdeep S., Internal Medicine, Ross Univ, Dominica 2004, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 SHARRAR, Kelly A., Family Medicine, UC Davis 2004, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 SIEGNER, Scott W., Retina/Ophthalmology, Wayne State Univ 1992, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4357 SKOLNICK, Tracy M, DO, Internal/Palliative Medicine, Philadelphia Col of Osteopathic 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 977-7017 TAYLOR, Zachary D., Internal Medicine, Tulane Univ 2004, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

THOMPSON, John F., DO, Family Medicine, Univ Health Sciences Col of Osteopathic 2003, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5200 TOLLEFSON, Travis T., Facial Plastic Surgery, Univ Kansas 1998, UCDMC, 2521 Stockton Blvd., #7200, Sacramento 95817 (916) 734-8169 TRUONG, Sarah L., Dermatology, Wake Forest Univ 2001, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 6312488 TSAI, Wesley J., Internal Medicine, Med Col Wisconsin 2002, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 9735000 VIDOVSZKY, Tamas J., General Surgery, Semmelweis Med Univ, Hungary 1988, UCDMC, 2221 Stockton Blvd., 3rd Fl, Sacramento 95817 (916) 734-2443 WILLIAMS, Virgil L., Radiology/Neuroradiology, Loyola Univ 1973, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 YOO, Brad J., Orthopaedic Trauma Surgery, New York Med Col 2000, UCDMC, 4860 Y St #3800, Sacramento 95817 (916) 734-5878 ZHENG, Hua, Internal Medicine, Shanghai Railway Med Col, China 1990, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

The Debut of our Continuing Medicial Education Activity On Saturday, November 3, the continuing medical education activity, “Doctor, Is It Really ADHD? ADHD Pretenders” was presented by the Sierra Sacramento Valley Medical Society. Designated for 3.5 AMA PRA Category 1 Credits™ and facilitated by Charles Maas, MD, MPH, the activity featured four speakers who presented information on how to recognize, differentiate, diagnose, and treat common ADHD pretenders and confounding issues, such as Anxiety, Post Traumatic Stress Disorder, Bipolar Disorder, and Learning Disabilities.

Using a five point scale, the 38 attendees rated the activity a 4.29 (between “very good” and “excellent”). They reported that their comfort level differentiating between ADHD pretenders went from 2.90 (between “uncomfortable” and “neutral”) prior to the activity, to 4.14 (between “comfortable” and “very comfortable”) upon completion of the activity. Their ability to demonstrate medically appropriate treatment strategies for non-ADHD mental health issues went from 2.69 (again between “uncomfortable” and “neutral”) to 3.79.

We were very pleased with our first outing as a Continuing Medical Education provider and look forward to future activities. If you have suggestions for any topics to fill gaps in medical education, please contact Kristine Wallach at 453-0254.

November/December 2007

33

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.

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.

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

Free Standing Medical Office, South Sacramento. 1500+sf. Completely renovated. Your neighbors are allergist, dermatologist and physical medicine specialists.

Call: (916) 425-7998 Medical Buildings-Mercy San Juan Hospital.

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

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

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

Contact Liz: (916) 275-3747.

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

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

Cute, 750 sf available in shared medical office. Ideally located in East Sacramento across from Mercy Hospital. $1.50/sf. Call L. Wytrzes, MD - 916-761-5521.

HIPAA Compliance Toolkit

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

Investment Services

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

Magazine Subscriptions

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

Notary Service/Free to Members

Medical Society (916) 452-2671

Security Prescription Pads

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

Medical Practice (Ophthalmology) in Roseville has space available immediately to sublease. Fully equipped. 1200 square feet. Available Mon., Tues., Wed., Fri., and alternate Saturdays. Rent very reasonable.

Please call Lucia at 510-525-2600. Send email to: lsalvador@elliseye.com.

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

34

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

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

A 7.9 Earthquake in Peru

By Hernando Garzon, MD On August 15, a 7.9 magnitude earthquake hit the coast of Peru, killing at least 337 people in Ica, 265 kilometers from the coast and 165 kilometers south of Lima, Peru.

SSVMS member Dr. Hernando Garzon, who works in Emergency Departments at Kaiser North and Roseville, was part of a medical team dispatched to the devastated area. Some of his emails and photos follow.

Aug 19, 2007 7:03 a.m. Currently in transit in El Salvador. Expect to arrive in Lima in 6 hrs.

Aug 20, 2007 Met with the ministry of health, and made contact with 4 other local relief agencies (Caritas, Red Cross, Salvation Army...)

Hired a 4WD vehicle and driver. Acquired local medications to supplement the trauma supplies brought from the U.S. Plan to head down to Ica (the hardest hit city where most relief efforts are centered) at dawn tomorrow.

Aug 23, 2007 View of one camp from the stadium bleachers; 3,000 people in the camp and 7,000 outside.

Population of the affected area is over 1 million, centered in three cities of 300K, 300K, and 170K each.

The poorest living in the simplest housing were affected the most. Spent the last 36 hrs in the earthquake impact zone and have scoped out various cities and towns — sometimes navigating roads covered with rocks. Met with the health minister for the country and the region.

As expected things are chaotic and information is patchy and unreliable.

Have finally started to see some patients.

Some have injuries from the earthquake, but most have the expected illnesses of impoverished people living in poor conditions — respiratory and GI illnesses.

Ran a clinic today in an area not previously serviced by medical teams. Between two doctors and a paramedic we saw 100 people — mostly elderly or young. Lots of respiratory disease.

Moderate amounts of post earthquake trauma follow-ups.

My Spanish is invaluable.

In a big earthquake, aside from the destruction and injury, the chief feature is… dust which rises like a cloud over populated areas because of destruction of buildings. A Twin Tower cloud rising up from the earth.

September 4, 2007 Have finally made it home. Thank you all for your support! I would say our mission was successful. We did some very useful work, helped by running mobile clinics to remote areas, while completing our primary assignment which was medical needs assessment. After two weeks it seemed time to end our medical presence, as the in-country resources seem adequate to handle the current medical needs.

There is still a lot of disorganization in the

November/December 2007

35

government’s response to the disaster, and still much work to do for the rebuilding process, but the emergency medical need has lessened significantly. Relief International still has a person there and will send others to work on projects related to rebuilding schools.

As with most events that don’t affect our daily lives, the media coverage has now significantly lessened about Peru and the aftermath of the quake. But for those who were affected, it is still very real, and very difficult, and it will take years to get back to a ‘normal’ daily life.

Here [see inside back cover] is a before and after picture of a church where 100 people died during the earthquake Hernando hxgarzon@gmail.com

36

Sierra Sacramento Valley Medicine

partnership

whatdrivesyou?

A commitment to excellence.

A passion for the art of medicine.

A basic desire to heal.

Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL.

(800) 652-1051 www.norcalmutual.com

NORCAL is proud to be endorsed by the Sierra Sacramento Valley Medical Society as the preferred professional liability insurer for its members.