2008-Mar/Apr - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2008

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE The Rewards of Mentoring

The Case Against Health Care Reform

Margaret E. Parsons, MD

David J. Gibson, MD

EDITOR’S MESSAGE Plain Talk About Our Editorial Process

Posits on Disclosure of Medical Information

John Loofbourow, MD

Under the Blanket

Participating in PQRI and Pay for Performance

J. Kent Garman, MD, MS

IN MEMORIAM Harold G. Schluter, MD

Consumer Directed Healthcare Abroad

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.

K. Gabrielle Gaspar, MD, and Sherellen B. Gerhart, MD

Voices of Medicine

Del Meyer, MD

Joseph E. Scherger, MD, MPH

Dr. Mary Cronemiller and Health Care a Century Ago

Board Briefs

Nan Crussell

New Applicants

A History of Burn Care Therapy in Sacramento

Kenya, January 2008

Hernando Garzon, MD

F. James Rybka, MD

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

Dr. Robert C. Lentzner created this 22 by 25-inch oil painting of a bridge over the American River gorge in 1983. Just before this issue went to press, he and his wife, Loretta, set off to find it again. They were directed to the Foresthill exit off of Highway 80. A ranger in the town of Foresthill sent them back to the Cool exit. After a number of twists, turns and stops, they spotted the bridge — which looks very much like it did a quarter century ago.

Volume 59/Number 2 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

Its name is the “No Hands Bridge,” according to several different groups of local residents parked by the river. But nobody could explain the name’s origin. Dr. Lentzner can be contacted at P.O. Box 2543, Carmichael, CA 95609-2543

March/April 2008

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2008 Officers & Board of Directors Margaret Parsons, MD President Charles McDonnell, III, MD President-Elect Richard Jones, MD Immediate President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD District 4 Ulrich Hacker, MD 2008 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 Craighton Chin, 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 5 David Herbert, MD Robert Madrigal, MD Elisabeth Mathew, MD Stephen Melcher, MD Anthony Russell, 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 Marcia Gollober, MD At-Large Alicia Abels, MD Richard Gray, MD Robert Jacoby, MD Sanjay Jhawar, MD Robert Madrigal, MD Connie Mitchell, MD Anthony Russell, MD Kuldip Sandhu, MD Jeff Suplica, MD Gerald Upcraft, 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 AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor David Gibson, MD, Vice Chair Robert LaPerriere, MD John Ostrich, 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 Managing Editor Webmaster Graphic Design

Ted Fourkas Melissa Darling Planet Kelly

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

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President’s Message

The Rewards of Mentoring By Margaret E. Parsons, MD Medicine is inherently a world of mentoring. So much of our shared knowledge in medicine is the legacy of oral teaching and working together to care for patients. Our first days of medical school began with senior students telling us the “ins and outs” around school. As we ascended to clinical years, we were guided by our interns and residents. Along our paths through medical school, someone inspired us in a certain specialty of medicine. We can all remember that moment: “Wow, this is what I want to be and do the rest of my life.” Joining a practice, someone helped show us the ropes through new clinics and hospital hallways. In our practice years we may be mentored in other ways, through organized medicine, hospital leadership, university politics, academic pathways, or other areas of volunteering and giving back. Part of what makes medicine so rewarding for many of us is giving back. One may think of a mentor-mentee relationship as the mentor doing the giving. Yet, the mentor often gains as much as the mentee. We see those we have worked with, talked to and advised, start to ascend their own ladders of successes. We enjoy their successes and accomplishments. Mentor-mentee relationships may be planned or happenstance. A planned relationship may involve selecting a mentor with a skill set or interest that the mentee hopes to gain. Sometimes early in a career, these may involve lab work or other more process-oriented goals. An example of these relationships at a medical school level may be helping on a project in a lab; or it may be a “matched” relationship to meet with a medical student and faculty or community physician to be a resource about the world of medicine. As we progress in our careers through resi-

dency and practice, many relationships are more of a conversational nature. However, as is often the case in the business community, many of us at this juncture of our careers can benefit as well from formal mentor-mentee relationships. A more formal relationship challenges us in early or mid-career to set goals and truly think about where we are and where we want to go with our careers and life path. However, the conversational, unplanned mentor-mentee relationship is very valuable. Often these are with someone we work with on a project or someone in a different community, or part of our own larger community that we may know through another institution, health system, or organization. Shared similar experiences are a fertile ground for discussion, thought, and guidance. Sometimes mentoring relationships are a “pass-through” as someone moves along a path. Perhaps the “match” was not the right one, and the mentor’s best gift is to arrange the connection for another mentor, or to suggest a different pathway. When a project is involved, mentors want the mentee to complete the tasks agreed to and not take on too big a project. If a mentor extends the opportunity to work on a project, write a chapter, co-author an article, or participate on a committee, it is important that the mentee meet their agreement. Responsibility and trust are a definite part of giving others a step up on the ladder. Mentoring relationships often evolve into long-lasting friendships. I write this letter as I leave my specialty society meeting where I had the wonderful opportunity to see mentors who are now friends. The former Dr. McBurney, Dr.

March/April 2008

Amonette, and Dr. Lupo of my residency years are Elizabeth, Rex, and Mary to me now. And what a joy it has been to see them as we continue to work on projects and shared goals, or tell the stories of where we are now in our lives. Former residents and young physicians who lectured in my symposium session or worked with me on committees have grown in their roles and given truly well-done lectures. They are helping insure the future of medicine will be strong and vibrant through continued committee work and physician representation on topics, including fair physician payment, health care access, and workforce, among many other things I know that my life is so much richer for these experiences and friendships. At one luncheon meeting of our specialty society, we were asked to introduce ourselves and briefly reflect on our first non-familial mentor. The answers ranged from a tennis coach who encouraged players to always strive to do their best, a high-school math teacher who pulled a student from the crowd and mentored that student (now a physician) through college applications, a physician who helped select a specialty pathway, and early career organizational guidance. Even though we were to speak of “non-familial” mentors, many recognized their parents’ faith in their reaching for high goals.

We have all been somewhere along these pathways. I believe physicians are inherently given to mentoring, as so much of medicine is taught by the conversations of rounding on wards or in clinic during our student and residency years. Rich now as I leave my meeting with many friendships affirmed and renewed, I am grateful for the modern world of e-mail that allows these relationships to always pop in and out throughout the year and across the country and time zones. Truly, mentor-mentee relations are aided by electronic communication. Do not forget For me, however, the value of a phone call or face to face mentoring is meeting to tie things back together. With the seemingly ever more busy daily part of being life of the practice of medicine, we do not want to lose this rewarding part of what is inherent a physician. to physicians. If you have slowed your practice, the joy of mentoring keeps that gift of sharing of wisdom strong. We will all mentor in different ways: as physicians, as leaders, as teachers, as advisors, as parents, as grandparents, and as friends. The benefits can extend beyond just the mentor-mentee. Shared projects, goals and visions may result in important research or publication, a successful project for an organization, or other volunteer activity benefiting a community. For me, mentoring is part of being a physician. I 17th Annual Conference on know I will always mentor Global Health Ethics and Human Rights because of the rewards of seeing a mentee succeed. GHEC: 17 Years of Alliances and Leadership in Global Health Education Yet, I know that I will Charting the course of global health education alliances always be a mentee as well, Practical Applications to Multicultural Health Issues At Home and Abroad because I hope to always Sacramento, Convention Center • Sacramento, CA • April 3-5, 2008 be learning and facing new challenges. The rewards are Jointly Sponsored by: UC Davis Office of Continuing Medical Education great on both sides of this Center for Reducing Health Disparities equation. and The Global Health Education Consortium In Co-operation with: Kaiser Permanente Kaiser Permanente Diversity Program International Federation of Medical Students Associations (IFMSA-USA)

Agenda and Registration at: globalhealth-ec.org/GHEC/Events/Conf08/Agenda.

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mepmd@ix.netcom.com

Plain Talk About Our Editorial Process By John Loofbourow, MD The editorial thrust of Sierra Sacramento Valley Medicine has been to encourage members to write about our lives in the broadest sense; to publish a story, essay, poem, painting or other artistic creation; to express an opinion or relate an experience. We try to reject self serving or commercially motivated articles from any source, and those adverse to the interests of the society. Our members take preference in this magazine; here we can be ourselves, let down our hair, or take off our white coats revealing whatever is beneath. Where else are we so welcome to do so? Our magazine is also read by nonmembers, and others who occasionally submit an article that we publish. Though we may suggest edits, we leave final decisions to authors. Revisions are most often due to space limitations, potentially libelous statements, or technical problems. With regard to dissent, we have felt that plain talk is preferable to banality and doubletalk. Therefore we accept satirical humor or sharp expression of opinion, as well as dispassionately reasoned articles. We are not fearful of an author’s passion, as it is a vital part of living. Regarding contentious subjects where there may be disagreement, we believe our members to be big boys and girls, able to give and take in print, and to understand that the expression of contrary opinion, and hearing it, are the essence of communication, and of democracy. The editorial process is briefly as follows: When articles are received by the editors, some back and forth with the authors may take place. Email makes this exchange very convenient. With the author’s consent, a draft is forwarded for review by the Editorial Committee. When

an article is approved, the editors determine those to be included in a given issue; sometimes a re-draft of an article is submitted at the last minute. When we have very little time to review it, it may be held over for another issue. At last the managing editor organizes the issue in question, taking into account time sensitive material, and the overall feel and look of the magazine. The entire process may take several months. The final steps go very quickly over about one week when the managing editor works closely, sometimes feverishly, with the graphic designer and the printer. We recently began using email to circulate proof copies of the magazine among committee members; authors can still make minor changes but it’s cumbersome and expensive. Occasionally all involved in this rather extensive review and editing process may miss an error, or something in an article that someone may find offensive. It happens. In order to minimize that likelihood, we have extended the period of time for review of articles by moving the deadline for submission up to one month before a publication date. The deadline for this, the March issue, was February 1. We hope to accumulate and to maintain in reserve enough material so that we can continue this policy. We prefer articles of less than 1125 words, but can negotiate more when space allows. For further information, or for an email copy of our Author’s Guidelines, contact editor Dr. John Loofbourow at john@loofbourow.com or 916/978-9910 or managing editor Ted Fourkas at t4kas@comcast.net, or 916/451-4862.

March/April 2008

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Participating in PQRI and Pay for Performance By K. Gabrielle Gaspar, MD, and Sherellen B. Gerhart, MD Dr. Gaspar, a founding partner and CEO of Gage HealthCare Consulting, is board certified in family medicine. Dr. Gerhart, a practicing physician board certified in internal medicine, geriatrics, and palliative care, is a co-founder and President of Gage HealthCare Consulting. The Physician Quality Reporting Initiative (PQRI) began its second reporting period on January 1, 2008. This program from the Centers for Medicare & Medicaid Services (CMS) represents the agency’s transition into pay for performance (P4P) and physician profiling. Launched in July of 2007, the initiative has drawn relatively little physician attention. Many healthcare providers are unaware of the program’s intent or design. While poor visibility has likely contributed to low participation, there are other factors to consider. Many physicians are unfamiliar with the concepts of quality reporting and performancebased incentives — and the concepts themselves are rapidly evolving. Of providers aware of these trends, some hesitate to participate due to philosophical or logistical concerns. We acknowledge arguments for and against the growing trend in performance-based incentive programs, and we encourage physicians to become informed and take part in the debate. Whether or not they participate in this round of PQRI or in similar programs, physicians need to be active stakeholders in efforts for increased quality and transparency in health care.

Medicare’s Transition into P4P PQRI is a voluntary program that allows physicians and other individual providers to submit data on specified quality measures for

eligible patients. This initiative was mandated by the Tax Relief and Health Care Act of 2006 (TRHCA).1 The initial reporting period was July through December 2007 and included 74 quality measures. For the second reporting period, providers may select from 119 quality measures addressing the management of acute and chronic illness, preventative care, resource utilization, and use of information technology. The program is providerdriven, evidence-based and designed to capture data at the claims level. PQRI focuses on reporting measures rather than achieving clinical outcomes and is linked to a bonus payment for meeting reporting requirements. PQRI is part of Medicare’s transition into the P4P arena. The federal government and CMS have been moving toward a value-based purchasing (VBP) model of health care since 2001. This model attempts to measure and reward value. (Similar trends can be seen in private industry, where cost-containment is arguably as much a motivation as is improved patient care.) CMS identifies improving quality and avoiding unnecessary cost in health care delivery as primary goals of value-based purchasing.2 Medicare’s shift toward value-based purchasing is evident in several earlier CMS quality initiatives, including the Nursing Home Quality Initiative (in 2002), the Quality Initiative (2004), and the End Stage Renal Disease Quality Project (2005).3

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PQRI and Individual Physicians

PQRI…may be viewed as fair or unfair, elegant or burdensome, quality-driven or costmotivated, temporary or permanent.

PQRI stands apart from these initiatives in that it focuses on data capture at the individual clinician level. Any physician or other eligible provider with a National Provider Identifier (NPI) may participate. From the outset, the program raises concerns regarding physician profiling, difficulty, acuity adjustments, and whether quality measures can ever be translated into meaningful information about patient care. There are worries about a lack of transparency in the development of program specifics, the challenges of obtaining program information in a timely manner, and the impression that providers are required to do more work while being subjected to diminishing reimbursements. Nonetheless, PQRI should not be dismissed. It can be argued that PQRI is, in terms of U.S. healthcare policy, a unique opportunity for providers to participate in reshaping the delivery and funding of medical care. It may be viewed as fair or unfair, elegant or burdensome, quality-driven or cost-motivated, temporary or permanent. However, PQRI allows participating providers to weigh in on the important issues of medical reimbursement, best practices, cost, outcomes measurement and resource use. Clinicians can contribute in this giant experiment in national healthcare data collection. They do so by choosing measures which are relevant to their practices and patients, giving a good faith effort to report on those measures, providing feedback to CMS and related parties on the design and relevance of the measures, and publicly commenting on the value of the provider feedback reports and bonus awards. The development of a meaningful quality measurement system will require committed efforts from all stakeholders in health care, and it is extremely important that health care providers be involved.

Physician Profiling CMS has been unapologetically increasing its efforts to identify and reward quality medical care. Inherent in its shift toward VBP is using tools and programs for promoting better quality while avoiding unnecessary costs.

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The agency notes that these include “explicit payment incentives to achieve identified quality and efficiency goals such as pay for reporting, pay for performance, gain-sharing, and competitive bidding.” The programs mentioned earlier illustrate this effort. PQRI is the first large scale CMS provider program. Participation involves reporting on selected measures using codes that indicate performance of certain clinical tasks or administration of therapies premised on evidence-based medicine. Included are mechanisms for clinicians to report without penalty when a clinical action has not been completed or documented. With regard to the bonus, providers are measured on their level of reporting rather than directly on patient care, even though data on the latter are being captured. Presumably, this design allows for program revisions before actually attempting to measure and reward “performance” or “quality.” In this way, PQRI is more accurately a “pay-for-reporting” than a pay-forperformance program. While P4P programs in the public sector have focused on the hospital or organization level and are recently shifting to the individual provider, private industry has been using them for decades. Many insurers have incentive programs that assign bonuses based on patient satisfaction surveys, laboratory values suggestive of effective disease management, and other proxy measures of clinician performance. For example, Hill Physicians Medical Group paid $32 million in performance compensation to participating physicians in 2006, up from $13.5 million in 2003.4 Similarly, Blue Cross of California announced a distribution of $69 million in physician bonus incentives in August 2007. 5 Despite the increasing availability of performance and quality-related data, there is little to ensure the accuracy or proper use of such information. There are controversies surrounding the use of physician performance data, including lawsuits against third party payers. A notable example is the suit filed in November 2006 by physicians and the Washington State Medical Association against Regence BlueShield. The plan was accused of

unfairly dropping over 500 providers from its preferred network in that state due to poor ratings in the “quality and efficiency of their practices.”6 This policy allegedly affected over 8,000 patients and their physicians. The American Medical Association joined the case, and when Regence discontinued its use of a Select Network the following month, it was noted to be “a good first step toward eliminating arbitrary measures that do not accurately reflect physician quality.” Fortunately, the need for standardized measurement of provider performance is gaining recognition. While the debate on these issues will likely continue, we can expect to see more physician rating systems made public without guarantee that they will be fair or accurate. While the landscape still offers relatively more ranking systems for hospitals and organizations (such as hospitalcompare.org, or healthgrades. com), individual physician profiling is clearly a growing phenomenon. Physician profiles are only useful if they are reliable and accurate, yet there is little research which demonstrates that existing programs are either. This is largely due to a lack of standardization in quality data measurements. Few studies have been done which have the necessary adjustments for risk and large enough numbers of participating providers to produce useful data. The literature has yet to show that outcomes for patients can be consistently linked to measurements of physician actions in the clinical setting. Clearly, for health care incentive programs including PQRI, the value of data depends ultimately on their translation into meaningful changes in practice. Inherent in this process is the capture of appropriate data and accurate interpretation, followed by the development and implementation of viable policies.

Using the Data Assuming that the measures for PQRI 2008 address a fair sampling of clinical issues and corresponding appropriate clinical actions, there remains the question of how the data will be used. This is perhaps one of the greatest obstacles. In general, the data obtained may

have a negative impact on physicians as an artifact of program structure, or it may be used to discourage clinical resource use. Providers are also concerned that measures may fail to account for patient acuity, effectively penalizing those who take care of more ill and complicated patients. While acuity is being addressed in other CMS programs in the inpatient setting, it is not a factor in current assignments of the bonus in PQRI, and it remains unclear how the issue will be addressed in later iterations of the initiative. Concerns about physician profiling, however, are both immediate and substantiated. The PQRI feedback reports will be provided directly to the practitioner in a confidential manner for the 2007 and 2008 reporting periods, but it is expected that data in later years will be public domain. In the meantime, we have an opportunity for our profession to promote continuous quality improvement. Physician profiling may seem inconsequential in the current environment, but the trend is toward increased profiling by payers and awareness by consumers. As a profession, our failure to participate in an objective and critical manner may leave us with misleading statistics and potentially damaging clinician rating programs. On the other hand, participation in efforts to increase quality and high reliability in health care delivery can be empowering for practitioners and may lead to improved outcomes for our patients.

Concerns about physician profiling, however, are both immediate and substantiated. The PQRI feedback reports will be provided directly to the practitioner in a confidential manner for the 2007 and 2008 reporting periods,

kggaspar@gagehealth.com sbgerhart@gagehealth.com

but it is

1 MEIA-TRHCA final rule on PQRI 2008. http://www.cms.hhs.gov/ physicianfeesched/downloads/CMS-1385-FC.pdf. 2 CMS public communication regarding Hospital Acquired Conditions and Present On Admission initiatives (HAC-POA), 3 Quality Initiatives General Information, Centers for Medicare & Medicaid Services http://www.cms.hhs.gov/QualityInitiativesGen Info. 4 Way beyond Vitals. Hills Physician Medical Group 2006 Annual Report. 5 Bluecross of California Pays Out Over $69 Million in Physician Bonus Incentives. August 24, 2007 BlueCross Website Press Room. http://www.bluecrossca.com 6 Regence calls off flawed physician profiling. Statement attributed to: William G. Plested, MD, AMA President. www.ama-assn.org/ ama/pub/category/17128.html

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expected that data in later years will be public domain.

Voices of Medicine The growth industry of diagnostic codes, and when consultants go too far.

By Del Meyer, MD

#@&%! that 5-Digit Number “And Now-A Minute with Andy Rooney (With Apologies to 60 Minutes)” by Stephen Kamelgarn, MD, discusses the ICD-9 codes, in the December issue of The Bulletin of the Humboldt-Del Norte Country Medical Society: Dontcha just hate little five digit numbers. I know I do. Little numbers that comprise the ICD-9 — this three pound paperback book I’m holding in my hand. (Camera pans into Andy fanning the pages of a huge tome) A five digit code that supposedly encompasses the full gamut of medical diagnoses that may ever have entered the mind of humankind. Isn’t that a bit of hubris, thinking we can classify all diseases with a five digit code? But people keep trying. Here’s an example: 711.4 Arthropathy associated with other bacterial diseases. The fifth digit is Code for the underlying disease, as: diseases classifiable to 010-040, 090-099, except as in 711.1, 711.3, and 713.5 leprosy (030.0-030.9) tuberculosis (015.0-015.9) Excludes: gonococcal arthritis (098.50) meningococcal arthritis (036.82) It’s nice to know that we can separate out tuberculous arthritis from gonococcal arthritis. It also makes no sense at all: is leprosy 030.0? or is it 030.9? or is it somewhere in the middle? What happened to the 711.4 code, which was the original number I looked up? When the folks keeping track of the numbers were mostly medical people (and actually understood this stuff) those five digits were (and still remain) an important way of tracking diseases and disease trends. But somewhere along the line the bean counters and the insurance ‘droids

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and the government bureaucrats hijacked those five digits for their own nefarious purposes. Now those same five numbers have taken on a life of their own and have become a tyranny. Nothing moves anymore without that five digit code accompanying it; and they’d better be the right code, or you can forget it… “I’m sorry doctor, the patient’s insurance plan doesn’t pay for the code ‘V77.91; Screening for Lipoid Disorders.’ I’m afraid the patient will have to pay out of pocket.” This, despite the fact that the American Colleges of Everybody say that all adults should be screened for this problem at age 40, or whatever. “I’m sorry doctor, you’ve only put down 493, the first three numbers. We need the fourth and fifth.” Do they really need to differentiate “extrinsic” asthma from “intrinsic” asthma to pay for a nebulizer? Not only that, but the online reference I’ve been using www.icd9cm. chrisnendris.com doesn’t even carry 493 out to five places. “I’m sorry doctor, Incontinence, ICD 788.30, doesn’t qualify your patient for adult diapers. We need a code for why the patient is incontinent.” Does it matter? The patient has a problem with his/her bladder, and just needs the damn diapers, for goodness sake!… When did we allow this to happen to us? As medical costs rose, the insurance industry, out of a sense of their perceived necessity, intruded more and more into our autonomy and our ability to advocate for what is right (as opposed to what is cost effective). We found our time slowly being chipped away, as slowly, relentlessly more and more forms and insurances started demanding that we supply the appropriate code, and now we can’t put a halt to it as more and more of our office time gets taken up

by having to look up and provide the appropriate damn code. It’s become a growth industry unto itself. Just Google ICD-9 and see how many hits one gets: dozens of web sites devoted to telling us the appropriate code for whatever ails us. Our mailboxes (both email and snail-mail) are flooded with junk mail, advertising “coding” conferences, so that we may make the best use of these abstruse codes to obtain, or heaven forbid, increase reimbursement. This must be a financial boon to the companies putting on these dog and pony shows…. I guess that it is nice to know that I’ve found some part of the economy that’s profitable and growing. When I get out of medicine I can always get a job as a coding consultant. The entire article is at www.humboldt1. com/~medsoc/images/bulletins/DECEMBER%2020 07%20BULLETIN_for%20web.pdf

They Want What? Lytton W. Smith, MD, editor of the Orange County Medical Association’s Bulletin, urged “Dare to Say No!” in the December 2007 issue. A presentation on peer review and medical staff issues became a discussion on insurance contracting. While at the California Medical Association House of Delegates, members of the Solo and Small Group Practice Forum (SSGPF) invited me to attend a presentation by Howard Lang, MD, dealing with peer review and medical staff issues. The evening evolved into a self-confessional discussion about insurance contracting. At the House of Delegates, the SSGPF represents physicians practicing alone or in a small group of four or fewer. The CMA has more than 8,000 members fitting that category. Other practice forums include the Medium Group Practice Forum (5 to 150 doctors), the Large Group Practice Forum (150 to 1,000) and the Very Large Group Practice Forum (1,000 plus). After a short presentation about a messenger model developed in Los Angeles County, various members spoke about dropping contracts. The sharing of personal experiences with contract termination has become chic. The solo practitioner sitting beside me made the observation

that he felt like an Alcoholics Anonymous meeting erupted. “My name is H-----, and I terminated my contracts!” In response, knowing sighs from attendees filled the room. Those still afflicted with insurance contracts listened in admiration… Now shift to the floor of the House of Delegates. We learned that legislation had been passed to study the peer review process in California, and that the Medical Board of California had contracted with Lumetra to perform the assessment. Further, we learned that medical staff offices across the state had received letters from Lumetra demanding confidential peer review information. What? They want what?!? Calls from medical staff offices to chiefs of staff and medical staff attorneys ensued. What information could, should or would be released? Was this information about peer review protected by SB* 1157? Most hospitals collect reams of data about peer review. Physicians participating in review of other physicians assumed SB 1157 protected them from discovery. Hospital administration feared that exposure of cases with severe criticism of patient management could lead to increased legal liability. Who pays for the collection, copying and mailing of confidential patient and peer review data? Faced with another unfunded mandate from the state, what would medical staffs do? Could they dare to say no? The House of Delegates passed a resolution requiring that the CMA legal department immediately look into the legality of the Lumetra demands…. It’s not that we physicians are a bunch of naysayers. We gladly say yes to proven innovations, evidence-based medicine and new surgical techniques. Yet over the past 20 years, demands by insurers, legislators, regulators and even specialty boards have increased physician angst — and in that environment we must dare to say no. The article is at www.socalphys.com/article/ articles/625/1/OCMA-Viewpoints---Dare-to-SayNo/Page1.html

Further, we learned that medical staff offices across the state had received letters from Lumetra demanding confidential peer review information.

DelMeyer@MedicalTuesday.net * Actually Evidence Code section 1157.

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Dr. Mary Cronemiller and Health Care a Century Ago By Nan Crussell The author is a former Sacramento Bee reporter (then Nan Nichols) who now runs her own accounting and web design business. Dr. Cronemiller was her great grand aunt. “Give me health and California is a pretty good place to make money. But give me sickness such as I have seen here and hell can’t be far off,” wrote a weary goldrush pioneer in 1850. “No place can hardly be worse for a sick man than California.” Indeed, thousands of men, women and children traveled across the American continent to reach the alluring California gold country in the mid1800s. They faced scurvy, outbreaks of contagious diseases, typhoid, cholera, mosquitoes, food shortages and even death in their search for a better life. However, upon their arrival “out west,” many found not gold but sickness and few doctors or hospitals to help them. Often they had no money to pay for care when it could be found. One young doctor determined to make a difference in that gloomy 19th Century California medical world was Mary M. Cronemiller. Her father, Oliver Hazard Perry Cronemiller, was among those pioneer travelers who came to Sutter’s Mill to look for gold and to work. In 1852, Oliver (named for his father’s own military hero and fellow militiaman Commodore Oliver Hazard Perry of the War of 1812 fame) gathered his young bride, Maria, and departed the mid-west, traveling by covered wagon across the continent seeking a better life in California.1 The Cronemillers bore their children there

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— William, Nathan, Emma, Mattie, Jenny and Mary — amid the gold fields along the Sacramento and Yuba Rivers. Mary, the youngest, was born in 1862. According to Cronemiller family lore, young Mary fell in love with a physician, but for whatever reason, they did not marry. So she vowed “to become every bit as good a doctor as he was.”2 She became determined to provide better medical care for those in need than had been available in her father’s day. Mainstream medicine in that time often employed such measures as bloodletting and purging, the use of laxatives and enemas, and the administration of complex mixtures such as substances including opium, myrrh, and viper’s flesh. These treatments often worsened symptoms and sometimes proved fatal. Mary believed there must be a better way to treat the sick. The concept of homeopathy was rising to the forefront around this time. It was a controversial form of complementary and alternative medicine created in the late 18th century by German physician Samuel Hahnemann. It encompassed a more natural form of medical care. Patients of homeopaths often had better outcomes than those of mainstream doctors. Homeopathic treatments, even if ineffective, would almost surely cause no harm, making the users of homeopathic medicine less likely to be killed by the medicine that was supposed to be helping them. Hahnemann also advocated various lifestyle improvements to his patients, including exercise, diet, and cleanliness. These ideas seemed plausible to Mary and other doctors of her time,

and are widely touted today. Intrigued, she returned from California to her father’s mid-west homeland and enrolled in the Hahnemann Medical College of Chicago, School of Homeopathy. She graduated in the class of 1890. In 1891, Dr. Mary Cronemiller opened her medical practice at 815 10th Street in Sacramento. While her beginnings were in homeopathy, they eventually led her to a wide variety of general practice, delivering babies at home being a common call. She tended those from all walks of life, from Sacramento’s Crocker family and the Gladding family of Lincoln to hundreds of others from Dixon to Yuba to Folsom and beyond. She travelled by horseless carriage — an impressive sight in that time, according to her great nephew, Robert McNairn Jr. of Sacramento, whom she delivered in a homebirth on Jan. 1, 1919. “Aunty Doctor drove a black electric car that steered with a handle. She took it to the 20th and M Street Electric Garage where it would be plugged in.” The influence of Sacramento’s pioneer physicians went far beyond caring for the sick and injured. In particular, Dr. Cronemiller, who practiced medicine in Sacramento from 1891 until 1919, was president of the local homeopathic group. She was active in the women’s suffrage and temperance movements, but was best known for her charitable and missionary activies on behalf of the Central Methodist Church. One of her cash receipts book from 1900 to 1905 is a treasure of Sacramento area history showing paid accounts and their prices, as well as those who traded work and embroidery for medical care. Among her heirlooms is a tiny embroidered silk slipper which she removed from an adult Chinese woman in Sacramento; the woman’s bound feet, meant to be a sign of beauty and class, resulted in a life of crippling pain and debility. Dr. Cronemiller refused to put the slipper back on. A receipts book includes the name of Marion

Crocker. That could have been Marion Phyllis Crocker, whose grandfather, Clark Crocker, helped build the Central Pacific Railroad. (According to the Marin Independent Journal of December 24, 1988, Marion Phyllis Crocker died in San Francisco at age 98. During her adventurous life, she had flown in an early flying boat, ridden a pony 102 miles in 14 hours, driven an ambulance in World War I, and later worked to create the United Nations.) Dr. Cronemiller’s newspaper obituary in October 1920 says that “Besides attending fami-

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Dr. Cronemiller’s favorite mode of transportation was her electric car. She refused to return the Chinese slipper below, picture in its actual size — 3 1/2 inches from front to back.

A portrait of Mary Cronemiller, and her headstone at the Old Sacramento City Cemetery. Her receipt book includes an entry for Marion Crocker, perhaps a member of the famous Crocker family.

lies of the poor gratis, she often sent them food and clothing. When she gave up her practice, Dr. Cronemiller destroyed books containing the accounts of scores of families financially unable to reimburse her for professional services.” While she was seen by her patients as a breath of fresh air for her kind and tender care, she may have had a more fatalistic outlook on her own world. Inside the front page of one of her receipt books, she copied this poem:

Mary Cronemiller died in 1920 at the age of 58 and is buried in the Pioneer section of the Old Sacramento City Cemetery, alongside her mother, Maria, and her father, Oliver. According to the burial records at the cemetery, about 55 doctors are interred there. Only six were women. Her simple headstone aptly reads “She lived for others.” quikword@mcn.org

Two Crosses by Helen M. Richardson We bear about a little load of care, And call it trouble, when the heart is young; Before Pain’s anguish from our lips hath wrung The cry that sends us to our knees in prayer. We stagger ‘neath the crushing weight of woe and call it discipline, in after years; When faith hath taught us, through our blinding tears, His best beloved must crucifixion know.

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1 “Descendants of Johann Martin Cronemueller” provided by Dennis Coupe and rootsweb.com. NOTE: Oliver’s father, Martin Cronemiller (1794-1848) was an intimate friend of Commodore Perry, by whom he was presented with a medal for gallantry in action during his service as a colonel in the War of 1812, specifically the Battle of Lake Erie. This medal is still preserved, a valued family relic. 2 Clara McNairn Nichols, Dr. Mary Cronemiller’s great niece

A History of Burn Care Therapy in Sacramento By F. James Rybka, MD During the 19th century Sacramento was not spared from major fires. There was one in the 1850s that destroyed about two-thirds of the young city, and this led to the use of bricks, rather than wood, in reconstruction. The vast majority of fires were accidental, but ever since biblical times, military conquests have often been followed by retributive arson, such as the burning of Atlanta by the Union Army in 1864. Sacramento had its own ugly story some years later when the Chinese community, located then near today’s Amtrak station, caught fire and the Sacramento fire department was ordered to let it burn. Furthermore, the Chinese burn victims who ran from the inferno were not allowed to go to hospitals.1

Treatment 100 Years Ago One hundred years ago, burn victims in Sacramento were treated certainly no better than in the larger cities back East. By today’s standards, they were uniformly primitive across America. In our SSVMS Historical Library, such treatment is found in “Textbook on Surgery” written in 1891 by a New York surgeon, Dr. John Wyeth. He found that the victims of major burns usually died from shock (“collapse”) within two days. According to Wyeth: Pain relief. Relieve pain “by the administration of morphia hypodermically, or some form of opium by the rectum or stomach. Stimulation with whisky or brandy by enema, or by the mouth, is also indicated to prevent collapse…. “The use of both opium and alcohol should be made with a certain degree of caution, for there is danger from a too profound narcosis

from the former, while alcohol in excess will unnecessarily add to the fever of reaction…” Grafting “When an extensive area is to be grafted over, the method of Thiersch should be employed… [also,] Pieces of skin taken from a healthy man six hours after death by accident, cut into a great many small pieces and laid upon a healthy granulating surface will become revitalized” (although eventually rejected).2

Modern Therapies The survival rate from major burns improved dramatically with fluid, electrolyte and colloid replacements during the 1930s and 1940s. This brought many victims through the shock phase, but, too often, they then died from infection some weeks later. Around this period, the mortality from a 50 percent burn was about 50 percent. Another major breakthrough has been the use of silver in wound care. Silver had been used for centuries as a disinfectant for water. The American settlers routinely placed a silver dollar in barrels of liquids to avoid spoilage. More recently, NASA used it to maintain water purity on the space shuttle. The silver ion apparently kills micro-organisms instantly by blocking the respiratory enzyme system, but has no effect on human cells. Prior to 1960, colloidal silver solutions were used in burns. Silver sulfadiazine has been used since the 1970s. Today’s senior plastic surgeons may have seen their professors cut split-thickness skin grafts freehand using a Humby knife, which is like a long straight-edged razor. This required considerable skill, and also an assistant to keep March/April 2008

the skin taut. But it was inexact, time-consuming, and difficult to use for large grafts. Certainly, one of the most valuable surgical instruments in burn care has been a relatively simple one, the electric Brown dermatome. It has a gauge to accurately determine thickness, requires less manual dexterity, and can be used, not only to rapidly obtain long sheets of grafts, but also for debridement of eschars, particularly in deep second degree, or partial thickness skin loss.

Local Burn Care in the 1970s In the 1970s, most of Sacramento’s plastic surgeons had one or two burn victims a year under their care. There was no “burn unit” then so large burns were managed in local hospitals. This required “special nurses” around the clock, strict isolation precautions, and daily dressing changes with application of silvadene. Although the nursing staff was excellent, it nevertheless amounted to a staggering amount of care for just one patient. One drug used 100 years ago is still used actively today — morphine. I recall its nearmiraculous power from one burn disaster in the 1970s when two men were horribly burned at Aerojet. They were cleaning a rocket fuel tank when an explosion occurred. One victim died within minutes after arriving at Mercy San Juan Hospital. The other seemed hopelessly burned, screaming uncontrollably in pain until we were able to give him a bolus of morphine intravenously. This relaxed him immediately and dramatically, and he became almost euphoric. Then, there was perhaps an hour during which he spoke to his family and divulged some information to an inspector about how the accident happened. However, despite all our efforts, he became weaker, was given the last rites, thanked us for our care, and lapsed off to die in peace. Another case I recall says something about laws governing flammable clothing. The long dress of an 11 year-old girl from Rough and Ready was engulfed in flames at a campfire, causing third degree burns of both legs and thighs. We treated her at the Sacramento Medical Center and she survived. (Our colleague, Dr.

One drug used 100 years ago is still used actively today — morphine.

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John Osborn, who was in training then, will remember her.) In collaboration with an obstetrician, we used human amnion as a temporary biologic dressing. At this time, there was a recent federal law requiring flame-retardant clothing for children. One would think that such a bill would have sailed through Congress, but the garment industry put up a terrific fight which it lost only after the pediatricians and AMA weighed in. However, adult garments were not covered by the law and, in this case, the dress had originally been her grandmother’s. Plastic surgeons have historically been involved in burn care because that specialty developed techniques of debridement, skin grafting and reconstruction. However, acute burn care has now developed into a specialty of its own following research at the Brook Army Hospital in Texas, as well as centers in Boston, Cincinnati, Galveston and elsewhere. The Shriners hospitals have contributed greatly to this research.

Burn Units in Sacramento today In 1974, the University of California at Davis opened its burn unit at the Sacramento Medical Center and, thereafter, most of the major burns of the area were taken there. In fact, there is now a law requiring paramedics to take major burns to a Level 1 Trauma Center, UC Davis Medical Center being the only one in our area. At present, it has a census of about 12 patients, mostly adults, who come from all over central and northern California, except for the Bay Area. In an emergency, it could handle more. In 1997, the Shriners Hospital of Northern California vacated its facility in San Francisco and moved to a beautiful modern hospital on the UC Davis Medical Center campus. Aside from the care and research that this facility has given to children with burns, it is all the more remarkable in that the costs, which are huge, are underwritten by the Shriners of North America. Only four of the 22 Shriners Hospitals in the US, Mexico and Canada have a burn unit, and Sacramento is one of them. It has a census of approximately 14, but could have a capacity of 30 to 40 if a disaster occurred. It cares for

children under age 18 with both acute burns and those needing subsequent reconstruction. They come from all over the western United States, as well as a few from Mexico. General surgical residents from UCD and San Joaquin General Hospitals rotate through the units and manage acute care, while plastic surgery residents are involved with reconstruction. The nursing staff is specialized and skilled in all aspects of burn wound management. Although no large burn disaster has yet hit Sacramento, the area does have contingency plans on how to handle such an event. From the 9/11 attack in New York, it has been estimated that, had the towers not crumbled but stayed erect as infernos, the US would have had to suddenly handle about 2,000 major burns. The American Burn Association has a computerized clearing house to determine which facilities could suddenly handle increased loads. We are fortunate indeed to have as the chief of both burn units, Dr. David Greenhalgh, a Professor of Surgery at UCD, who has devoted his professional career to the care and research of burns. Today, in addition to using the patient’s own skin as grafts, and temporary dressings with cadaver (allograft) or pigskin (xenograft), a new advance has been the cultivation and growth of the patient’s own skin. This can be accomplished experimentally; in about a month, there may be enough new skin grown to cover one’s back, let us say. This is done by cultivating the dermis (fibroblast) layer separately from the epidermis, and then using the two as a “sandwich.” Dr. Greenhalgh said that this skin cultivation is still experimental, and not yet approved by the FDA. Fighting for one’s life after a major burn is one of the most exhausting burdens a human body can face, so it is no surprise that those in top shape to begin with have the best chance to survive. Today, it is not unusual to see a previously robust patient with a 90 percent burn stay alive in our units. However, even with the best of wound care, there are many hazards remaining with major burns, such as pulmonary problems, infections,

and phlebitis. Finally, there is multiple organ failure (MOF), an insidious syndrome that has been seen with increasing frequency over the last two decades and which is now responsible for 50 to 80 percent of deaths in surgical intensive care units around the country. The causes of this are still being worked out. It must be inappropriate to use the metaphor, “passing the torch” when discussing burn care. Yet, I know I speak for the senior Sacramento surgeons by imparting to Dr. Greenhalgh how comforted we are that he is here, and supported with such an energetic, young team. We wish him every success in the future. jimrybka@hotmail.com 1 Beckner, Chrisanne, “Sacramento’s Chinatown” 6-28-07, www. newsreview.com/sacramento 2 Wyeth, John, A, Professor of Surgery, N.Y. Polyclinic Hospital, “Textbook of Surgery” pg 93-95, Appelton, New York, 1891.

View from the roof of the Tuesday Club during the fire of September 11, 1950. Courtesy of the Sacramento Archives & Museum Collection Center.

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The Case Against Health Care Reform By David J. Gibson, MD and Jennifer Shaw Gibson In January, the Senate Health Committee drove the final nail in the coffin of the Schwarzenegger/ Núñez medical insurance proposal. The plan would have required Californians to hold private insurance and would have subsidized the premiums for those who could not afford them. Even though financing of the current health care system is crumbling, there are a number of sound reasons for the Senate’s rejection of the reform proposal. Some important lessons can be applied as the debate moves to the national level. “Universal” health care is a major Democratic issue in the presidential campaign.

The cost for a massive new health care obligation is both unknown and problematic It became evident during the California debate that state funds would not match the growth in program costs. This painful fact has also been our experience with Medicare. According to the recently released report by the Medicare Trustees, the program’s unfunded liability has grown to $74 trillion — five times that of Social Security. According to the Congressional Budget Office, health care spending for Medicare is on a course that will crowd out all other government programs. This represents a catastrophic miscalculation of future costs. Furthermore, Medicare is progressively failing to financially protect existing beneficiaries.

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Retiree out-of-pocket expenditures for premiums, deductibles and co-pays for parts B and D of Medicare will consume 29 percent of the average Social Security benefit check this year.1,2

Poorly designed reform does more harm than good. The health reform legislation closely resembled the far-reaching (and disastrous) energy “deregulation” scheme of 1996. The bill was worked out in private negotiations and dropped into the hopper near the close of the session. The Assembly Appropriations Committee conducted a pro forma hearing and gave partyline approval, even though few on the committee or those in the Assembly knew the contents of the bill. There was no financing component for the $14.4 billion expansion of health care coverage called for in the Assembly bill. It was highly likely that requiring employers to pay 1 percent to 6.5 percent of their payroll to fund this initiative violates long-standing federal law, as courts have held in other states. Furthermore, the $14.4 billion price tag by the Schwarzenegger administration was not credible. The Massachusetts mandated universal health-care plan is generating costs 20 percent over budget. The tab will likely run $619 million for the current fiscal year, $150 million over budget, and could increase $350 million next year. Massachusetts has learned it costs twice as much to insure people than paying for the sick who show up in hospitals. The “universal” promise of the Massachusetts initiative is also in question. That state has exempted almost 20 percent of uninsured adults

who don’t qualify for subsidies from mandated coverage, because it is too expensive. The board overseeing the plan has approved cuts of 3 to 5 percent in reimbursements for healthcare providers caring for those in the subsidized plan. The suggestion is the cuts will bring reimbursement in line with Medicaid. So, one might reasonably ask, why all the hoopla about reform? Just expand Medicaid. Unfortunately, as reality dawns, we would discover that this approach would provide the uninsured with coverage but no providers to care for them.3 Dan Walters, political writer for the Sacramento Bee, observed in a column last December that it is inexplicable “that the governor and the speaker would push an incomplete, unclear and legally questionable health plan, especially when they face a budget deficit of over $14 billion.”

Despite political posturing and misleading polls, the electorate is not ready for reform On its face, revamping health care should be a political winner. Voters see two fundamental problems with health care. First, it costs too much: 74 percent in a recent Democracy Corps poll say they are dissatisfied with the cost of health care, a number matched in a Kaiser Family Foundation poll from 2006 (80 percent). Second, 70 percent of voters believe the number of uninsured people is a very serious problem, according to a New York Times poll. A strong majority believes health care is a top domestic priority — 55 percent, according to the Times poll — and 64 percent believe the federal government should guarantee health care for all Americans. This appears to create an environment for sweeping reform that state and national politicians have consistently misread. Their interpretation is based on the fact that 90 percent of Americans say the health care system as a whole needs change — 54 percent say “fundamental change” is necessary, and 36 percent say the system should be “completely” rebuilt. Just 8 percent believe the system needs “minor

changes.” But the picture changes dramatically when questions shift from the systemic to the personal. Americans are generally satisfied with the care they currently receive. In the Times poll, 77 percent of Americans are satisfied with the quality of their care; 82 percent say the same in the Democracy Corps poll, compared with 89 percent in the Kaiser poll. Why this seeming contradiction? As was the case in 1993, reforms face a backlash if they threaten — or appear to threaten — the health plans of insured Americans (who generally vote and pay the taxes for government programs as opposed to the uninsured, who do not). Polling shows how quickly opinion can turn. The 64 percent majority in the Times poll that believes the government should guarantee health insurance for all shrinks to 48 percent if a universal program were to raise their own health insurance cost. The 60 percent willing to pay higher taxes to insure everybody shrinks to 49 percent when a $500 price tag is attached to it. In the Kaiser poll, 56 percent say they prefer a universal plan — covering everyone with a system like Medicare — over the current system. However, that number drops dramatically if it includes higher premiums or taxes (35 percent), waiting lists for nonemergency treatment (33 percent), limited choice of doctors (28 percent), or if it excludes certain treatments (18 percent).

An evolving crisis of uninsured is a myth4

As was the case in 1993, reforms face a backlash if they threaten — or appear to threaten — the health plans of insured Americans…

Despite claims of a health insurance crisis, the proportion of Americans without health coverage has changed little in the past decade. In the past decade, the number of people without insurance increased by 3.5 million, while the number of Americans with insurance increased by nearly 25 million. Approximately 75 percent of uninsured spells last one year or less. Although immigrants (including naturalized U.S. citizens) make up slightly less than 12 percent of the population, they make up 27 percent of the uninsured. Overall, the total

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Reforming the way we pay for health care is infinitely easier than actually reforming the health care delivery system.

number of uninsured rose slightly, from 15.3 percent of the population in 2005 to 15.8 percent in 2006. In 2006, according to Census Bureau data, more than 84 percent (250.4 million) of U.S. residents were privately insured or enrolled in a government health program, such as Medicare, Medicaid and the State Children’s Health Insurance Programs. Up to 14 million uninsured adults and children qualified for government programs in 2004 but had not enrolled, according to the BlueCross BlueShield Association. Nearly 18 million of the uninsured live in households with annual incomes above $50,000 and could likely afford health insurance. Here is reality — over the past 10 years, the ranks of the uninsured in households earning $50,000 to $75,000 increased by 49 percent, while households earning above $75,000 increased by 90 percent. Nearly 18 million uninsured Americans live in households with annual incomes above $50,000, and could likely afford health insurance. So, who are the uninsured? For the most part they are young; almost half are between the ages of 18 and 34. Nearly three-quarters of the uninsured describe their health as “excellent” or “very good.” More than two-thirds have at least some college education and about half earn middle-class incomes. Mandating coverage for this non-utilizing group represents a massive transfer of wealth from the working young to pre-retirement boomers. Rushing to replace the current system with a new government-led initiative based on a crisis myth is ill advised.

The focus is on shortcomings of the current system; a “universal” system is presented as glorious and problem-free The death of 17-year-old Nataline Sarkisyan is a classic example of damming the current system. She died on December 20, 2007, after Cigna initially denied her coverage for a liver transplant, citing insufficient evidence that the procedure would be safe or effective. Jeffrey Kang, Cigna’s chief medical officer, observed

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that “it is highly unlikely that any health-care insurance system, nationally or internationally, would have covered this procedure.” After her death, candidate John Edwards advocated a government-run health plan open to all Americans, rather than the current system in which insurers decide on patient eligibility. Implicit was a government system that would have paid for this and all other experimental procedures. But no government-based plan anywhere in the world lives up to such a grandiose promise. Comparing an imperfect present system with a “perfect” future system is populist demagoguery at its worst. Reforming the way we pay for health care is infinitely easier than actually reforming the health care delivery system. Implying that an expensive new health care entitlement program can be financed by increasing taxes only on the wealthy does not compute. The government, from the national to the local levels, is bankrupt and will be unable to meet existing health and retirement benefits. The private sector is evolving new and more efficient systems for health care financing that would only be impeded by a massive new entitlement program. At some point, candidates running for office need to pay heed to what we have learned. To ignore that will be a grave mistake. DJGibson@winfirst.com David Gibson is a senior partner and Chief Medical Officer at Illumination Medical, Inc., a health care consulting and medical management company. Jennifer Gibson is an economist specializing in evolving health care markets as well as a futures commodity trader specializing in oil and gas.) 1 A baby born this year can expect the same costs to absorb nearly 70 percent of future Social Security benefits at age 65. 2 Since Social Security benefits will have to be cut 25 percent by 2041 unless taxes are increased, today’s newborns are facing a future in which the cost of health care will have gobbled up the entire Social Security program. 3 The recent withdrawal by Sutter Roseville from the MediCal program is an example. 4 Source: Devon Herrick, “Crisis of the Uninsured: 2007,” National Center for Policy Analysis, Brief Analysis No. 595, September 27, 2007.

Posits on Disclosure of Medical Information 1. It is unethical for a physician to disclose a patient’s medical history for contractual or commercial reasons. 2. A physician is ethically obligated to withhold medical information except when required by law or the patient. 3. I never lie in the best interest of a patient.

There were more than 360 responses to these related posits, with 31 comments that appear below. A majority of respondents agreed with all three posits. That said, the posit statements might have been improved if it were clearer that they referred to demands from insurers like Blue Cross — insurers to which contract physicians provide medical information that could indicate a patient erred or lied on an insurance application. One commentator notes that the relationship between an insured and the insurer is a business contract, which requires honest disclosure of medical history or risk; this business contract is quite different and separate from the physician-patient relationship. Yet a panel physician, or preferred provider, also has a business relationship with the insurer and, therefore, enters two conflicting contracts, one ethical and professional, and the other legal and commercial. To judge from this survey, many of our colleagues feel determined to ignore the contract with the insurer, and to honor the implied ethical contract with the patient. Nonetheless, another comment points out, in Workers’ Compensation cases, physicians apparently find no difficulty providing otherwise privileged medical information to the insurer; in this instance, we honor the business contract. On lying in the best interest of a patient, the predominant sense of the commentary is

“I never lie even when I don’t tell the truth!” Nicely and truly said! — J.L. Posits do not necessarily reflect the views of SSV Medicine, the Medical Society, or Board of Directors. “I don’t lie but I may make a decision on what to disclose.” — Donna DeFreitas, MD “OK with patient’s full knowledge and consent. Re lying: Sometimes I try very hard to obscure the truth.” — Donald Brown, MD “Sins of omission count as lies, in my opinion.” — Sage Wexner, MSI “Lie is too strong of a word. I may not totally disclose everything if I feel complete disclosure can work against a patient.” — Robert Ruxin, MD “We have no legal or ethical relationship with anybody but the patient…. {So I agree] unless requested to do otherwise by the patient. Re lying: When asked for information we are signing off that we are being truthful. We don’t owe our patients a lie.” — J.J. Rabinovitz, MD “Workers’ Comp is an exception to the first posit. Re lying: There are different ways of presenting information!” — Dorrit Ahbel, MD “On lying: I do not know how to interpret this statement. But, I agree that one should not lie.” — Don Macko, MD “I could imagine a scenario when a physician is ethically obligated to withhold medical information even when required by law.” — Michelle James, MD

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“Sometimes I try very hard to obscure the truth.”

“The best answer is not to lie at all, as the patient then knows of your veracity when you speak.”

“I cannot say I have never told an untruth to get appropriate therapy for a patient.” — Sydney Scudder, MD “I have an opinion but it does not fit into a yes/no format. An insurance policy is a business contract. If one party enters into the contract under false pretenses, the business (not the clinical) relationship is void. This question mixes business and clinical issues. These issues exist in separate universes. Re lying: If the information is relevant to honesty in a business or professional setting, disclosure is not unethical.” — David Gibson, MD “The Blue [Cross] letter was an insult to medicine and some kind of sanction should be undertaken because of it, even though they withdrew it. Re lying: Sometimes a ’white’ lie is appropriate; e.g., if I saw a teenager for acute situational depression that resolved, I might recommend that he might respond to a pre induction questionnaire requesting if he has been treated for a ’mental illness’ with a denial.” — James Margolis, MD “I agree in general. However, under certain, rare medical circumstances, if withholding medical information is life threatening and prevention is possible for the patient … as a physician, I should be ethically obligated to take proper action and practice prevention. Re lying: [A] ’lie’ is never best interest.” — Kamer Tezcan, MD “The law has no right to demand a patient’s medical information. Re lying: Only if the patient has an incurable disease, I withhold that information from him/her and call the closest relative to decide how to handle the situation.” — Leslie Bernstein, MD “Re lying: This question is too broad for a simple response.” — Deane Hillsman, MD “Re lying: I have not, but can see how some would.” — John Belko, MD “Not sure what is meant by contractual/commercial reasons.” — Claudia DeYoung, MD “Re lying: Poorly worded: does that mean I never lie, because doing so is in the best interest of the patient, or I never lie even to protect the best interests of the patient. The best answer is not to lie at all, as the patient then knows

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of your veracity when you speak.” — Richard Gray, MD “Re lying: It is best not to lie in most situations and honesty is the basis for a good relationship with patients.” — Forrest Junod, MD “Re lying: Question is unclear.” — John Thompson, MD “General comment on the posits: My patient is my only client. I am her/his representative, the only ombudsman she or he is ever going to have in this managed care ’health chain’ dominant world. The insurer is interested in…making as much money as they can.... The ‘patient’ and physician-employee are only vehicles — means towards that end. ‘Third party’ goals are antithetical to the healing and health-enhancement goals that are supposed to guide physicians… insurers will do all they can to not pay a bill, pay as little as they can, make it difficult to get care/tests/medications, etc. — to place as many roadblocks as their busy little VPs can come up with. SOooo...since so many others are doing all they can to deny care, I will do all I can… if that means bending the insurer’s obstructive rules: so be it!” — Michael Goodman, MD “[I agree] unless the life of the patient is at risk. Re lying: This is really a loaded question. I think there are lots of situations where it isn’t in the best interests of [a] patient’s medical condition to provide full disclosure to certain requestors that are overcome by patient direction to do so. There are also different contexts; are we talking about their health best interests or financial best interests, or other interests?” — Thom Atkins, MD “I don’t understand the question. Withhold medical information from the patient, the public, the law? It is not clear.” — Ralph Herrera, MD “Re lying: I have omitted details.” — Sherellen Gerhart, MD “Re lying: Does withholding information constitute ’lying’? — Adrienne Hall, MD “On lying: I may soften a diagnosis if I feel it will impact the patient to his accelerated detriment.” Paris Royo, MD “The actions by Blue Cross are invasive, insulting and, in all other ways, personally and professionally offensive. This doesn’t even

address their egregious lack of HIPAA compliance!” — Dennis Ostrem, MD “Re lying: [Agreeing] I assume this means lying in general, meaning lying to the patient and lying for the patient to their family, friends and partners.” — Stephanie Yan, MS I “I assume this is in reference to releasing info to an outside source as opposed to another treating colleague/staff person. Re Lying: I’m not sure I understand the statement but I took it to mean I would not lie just because it benefits the patient. This does not imply that I would breach confidentiality, as that is my primary commitment. If put in a compromising situation, I would simply not answer if that is what would protect my patient’s confidentiality. — Virginia Joyce, MD “Privacy of a person’s life is primally important for numerous reasons and should never be divulged to entities that shirk their fiduciary responsibilities and, if we do, we become accomplices in this ’business’ madness and scandal. I agree [to] demands by the pt as it is the pt’s situational biography. I disagree (on the

legal requirement to provide information)…. On lying: I try my level best not to lie under any circumstance for anything, anybody or any reason.” — Elisabeth Mathew, MD “I assume we are not talking about insurance companies who routinely get this information.” — Thomas Curran, MD “Physicians also have an obligation to public health, which may take precedent over an individual patient. This is my issue with our HIV consent laws.” — William Lewis, MD “The statement can be interpreted to mean I never lie BECAUSE it is in the best interest of the patient. Or I never lie WHEN it is in the best interest of the patient (i.e., I will lie when I feel it is in the interest of the patient to lie).” — KuLiang Yu, MD “I would never lie to the patient about their medical status and would let them decide whether and to whom they give their information. If they asked, I would sit in on the talk they have with their family etc. to make sure correct information is passed on.” — Shereen Zakauddin, MD

March/April 2008

Under the Blanket By J. Kent Garman, MD, MS Dr. Garman was President of the Stanford Medical Staff, and is a past President of the California Society of Anesthesiologists. He now lives in Folsom. This article appeared in the April 2007 Stanford University Medical Staff Update and was reprinted in the Summer 2007 CSA Bulletin.

…in an instant I went from being as healthy as possible for 67 years to the victim of a potentially lethal cancer.

I’m going to waive my HIPAA rights, whatever they may be, and tell you what I saw on the other side of the syringe, scalpel, oxygen mask, and the rest of the gadgets we physicians use with patients. It’s a personal story, but I hope it transcends the self-indulgent hospital tale we all prefer to avoid. My professional and personal worlds collided and gave me some thoughts as a practitioner. In February I responded to an advertisement seeking normal controls for an MRI study sponsored by vascular surgery. Since I was older than 55, without aneurysm or spinal cord disease, I was eligible to have a free MRI of my abdominal vasculature. What a deal. Why would I not do this? (By the way, they may still need some “normal controls.”) So, I signed up and got the contrast injection MRI. When the researchers finished the study, I learned I was no longer a “normal control.” First, the good news was that there was no obvious adenopathy or renal vein invasion. My CXR was normal. The bad news: I had a large (6–7 cm) left renal cell carcinoma, and in an instant I went from being as healthy as possible for 67 years to the victim of a potentially lethal cancer. Symptoms? I had no hematuria (the most common symptom). I did have left back pain, more severe after working a full day in the OR, but otherwise, I had nothing that would have made me seek medical help. So, in late February, I elected to have surgery and underwent a radi-

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cal left nephrectomy. The final cell type turned out to be a chromophobic carcinoma instead of the more common and more lethal clear cell carcinoma. But before that answer came down, I learned a number of things about Stanford patient care delivery: in the clinic bed, but not bedside.

Customer Satisfaction I was very impressed with the efficiency and attention I experienced in the Stanford Clinics and from the outpatient labs. The new facilities in the Cancer Center are especially impressive. And the personnel all seemed to enjoy their jobs.

Internet Access Why can’t we finally have access for patients? We have the wireless infrastructure, and surely our need to communicate while hospitalized remains stronger than ever. Also, Lucile Packard Children’s Hospital has had free Internet access for a year for patients and visitors.

Protocol Compliance Lying in bed, you focus on funny things sometimes, so I wondered just how well the protocols we are being taught to follow are being carried out. I had time to watch the nurses and aides wash their hands, and generally compliance with our hand hygiene protocols was excellent; in fact, almost compulsive. Are we as physicians doing as well, showing leadership? Another current patient safety rule calls for checking patient identification in two ways — usually a wristband check and a verbal inquiry as to name or birth date. I may have missed a double check or two when I got my meds, but my mental scorecard ticked off full compliance with the labs.

Noise and Sleep and More The complaints I’ve heard from other patients seemed to be true. I was in a double room converted to a “private room” by installing a plywood panel and door so thin you could easily hear quiet conversation on the other side. And overall, the alarms going off continually, conversations, footsteps, motors and the like persistently inhibited any attempt at solid sleep. But the distractions didn’t stop there. I had the misfortune to wear compression boots from foot to knees. These inventions of the devil at first seem like a good idea (after all, who wants to get DVT?). However after several hours, the constant inflation deflation cycle coupled with the noise of the compressor motor started to drive me crazy — not to mention contributing to sleep deprivation. The incessant noise, however, is a serious problem, and perhaps we should take a look at some corrective measures. I was placed on a hydromorphone PCA, and at least this component of my stay was quiet — but only at first. I was offered from 0.2 to 0.4 mg of hydromorphone with a lockout of 10 minutes and no basal rate. This is where the rubber hit the pavement for me as I transitioned from anesthesiologist to patient. Although I should know better, I hit the button whenever I felt any pain. I became confused and had a number of very bizarre dreams and nightmares. Yet, whenever I awakened, I hit the button again. Then it got noisy. Strangely, I discovered that whenever I took off or lost my nasal oxygen cannula, the pulse oximeter alarm would go off and wake me up. Fortunately, I could stop the alarm by keeping my nasal oxygen cannula in place. The next morning I felt absolutely terrible — confused, disoriented, nauseated, with pain. That’s when I figured out that PCA was to blame, so I decided to stop using the device. Things cleared rapidly after I made that decision. But even after discovering the truth about PCA, I continued to play doctor. I turned the pulse oximeter around so I could see it. My saturations were not good. On room air, my sat would drift down to the mid 80s. With supplemental oxygen, they came up into the mid 90s. If I used the incentive spirometer vigorously

(and that hurts), I could get the room air sat into the low 90s for a short time. It took me concerted effort with deep breathing for several hours to get rid of the atelectasis I had developed during the night and maintain room air sats in the mid 90s. Good thing I know what I’m doing, I guess. Most patients would simply lie there and be miserable. Interestingly, a recent article by the Anesthesia Patient Safety Foundation points out a high incidence of morbidity caused by hypoventilation with atelectasis, hypercapnea, and respiratory acidosis from the effects of PCA and epidural narcotics. The APSF says that monitoring oxygen saturation with a pulse oximeter gives a false sense of security when supplemental oxygen is administered. The O2 sat will be OK, but everything else is going south. The bottom line is that the APSF will probably recommend that exhaled CO2 monitoring should be added to pulse oximetry as mandatory monitoring for postoperative patients receiving narcotics. Unfortunately, our technology is not quite good enough yet to do this well on nonintubated patients. Playing doctor on myself probably contributed to stress, but I’m convinced the stress would have been worse if I had remained ignorant. Think of the anxiety a patient without a medical background must feel. Trust the doctor? Easier said than done when you are feeling terrible in a noisy bed. So after one night as an inpatient, I decided if I were to get some sleep, I’d have to leave. Fortunately, I was able to do so.

VIP Status—The Red Blanket

Playing doctor on myself probably contributed to stress, but I’m convinced the stress would have been worse if I had remained ignorant.

Stanford gave me a red blanket, telling everyone who came in my room and saw it that I was a “VIP” patient. While I felt honored, my caregivers weren’t so sure this was a good idea. Some of the nurses and others asked if the blanket meant they should treat me better or differently, and if so, whether this sent the right message to patients. Maybe this concept needs to be evaluated.

Nurses and COWS I have only the deepest appreciation for the

March/April 2008

nursing staff and nursing aides I came in contact with. They all were genuinely concerned and helpful. However, they did seem to be struggling with the new wireless mobile data entry devices, called COWS, which they wheel from patient to patient to use in lieu of carrying a clipboard. Fancifully, I imagined we could put a bicycle seat and pedals on the COWS so the nurses could maneuver them more easily.

Psychological Impact The biggest impact of my hospitalization was psychological. I have had deep thoughts about what to do with the rest of my life, accompanied by a fair amount of depression and fatigue. I’m more optimistic now that my diagnosis is actually quite favorable. An earlier than previously planned retirement from clinical medicine may be in the cards, since I have discovered that daily high

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stress in the OR is not necessarily a good thing. Coming face to face with your mortality is a real eye opener. More important, I hope that I can transcend the clichés and truly be more empathetic with the experiences patients have. I hope I can find ways to put that knowledge to work in practical ways that will incrementally improve the hospital experience for those patients who can’t read a pulse oximeter. They’re scared in a noisy environment and trust us to do what’s right both on a hospital-wide basis and in the patient room itself. We need to make sure we do just that. Thanks very much for reading. Go ahead and use my thoughts to apply to your more general musings and discussions. I welcome your comments about this article.

In Memoriam

Harold G. Schluter, MD 1920–2008

My very good friend, Harold G. Schluter, MD, died in Nehalem, Oregon, on January 12. I knew Harold since 1949, when he moved to Sacramento after his obstetrics-gynecology residency at Mary’s Help Hospital in San Francisco. He joined the practice of his uncle, Hans F. Schluter, MD. “Honas” was one of Sacramento’s most esteemed physicians in the early 20th century. Harold was born in Pendleton, Oregon, where he grew up on his parents’ large wheat ranch. His undergraduate work was at the University of Oregon and his medical degree from the University of Michigan Medical School. His internship was at the Multnomah County Hospital in Portland. He was a diplomate of the American Board of Obstetrics-Gynecology. Harold’s first office was a small home on Alhambra Blvd., because in those years medical office space was hard to find. In 1952, Dr. Robert L. Range joined him, and they practiced together for 37 years — interrupted in 1954– 56 when Harold, a Navy reservist, served at Whidbey Island, Washington. He delivered over 6,000 babies here, and was loved by his patients and respected by his colleagues. I first met him at Sacramento County Hospital. He was my attending physician during my first deliveries there. One day three of us interns invited him to join us in our quarters for a card game, which he assumed would be bridge. He lost to the lowly interns that night in a game of poker, and the amount grew in the telling. From that day our friendship grew. He loaned me his office two afternoons a week while my office was being constructed. He was a warm, gentle, caring man. Harold had numerous interests, many dating back to his days on the wheat ranch. He grew peaches, figs, kiwis, and specimen orchids in two greenhouses in his back yard. He and

his wife won so many awards for their orchids and arrangements that, in embarrassment, he stopped entering shows. An intense interest was wine. He owned six acres of chardonnay and pinot noir grapes on a mountain top near Saratoga, and was an investors in the nearby Mount Eden Vineyards along with several other Sacramento doctors. I remember warmly a large party he gave there to celebrate the year’s grape harvest. A kid goat was barbecued on a long wooden spit over an open pit of coals. For several hours we took turns rotating the spit by hand. The smoke got in our eyes, but we were rewarded with only the best wines on that day — and on every other day of his life that he Harold G. Schluter, MD served wine. Harold was a master at blind tastings; he often could name the grape, the vineyard, and sometimes even the year. Harold and I called our years of practice the Golden Years. We felt among us a deep professional comradeship. Every year we had a Founders’ Day banquet of the medical society. One of the best was in 1968, its 100th anniversary. Harold served on the committee that secured Danny Thomas for the evening’s entertainment. In those years, doctors had time each morning for coffee together at the hospitals after rounds. There were warm exchanges about friends and families, life and medicine, wit; a few curbstone consultations thrown in. Harold and Margaret were married over 64 years and had two children, Hans and Karyn, and a grandson, Robert. They remain my very good friends. I miss Harold and those golden years of medicine. — John M. Babich, MD

March/April 2008

Consumer Directed Healthcare Abroad By Joseph E. Scherger, MD, MPH Dr. Scherger is clinical professor of family medicine at UCSD. This article is from the Editor’s Column, October 2007 issue of San Diego Physician, published by the San Diego County Medical Society.

Medical tourism is the hottest new sector in the travel industry.

A new medical magazine arrived in the mail. Big deal. Then I took a look at it. Issue 1 of The International Medical Travel Journal. I was flabbergasted by what I found inside. I knew that places like India were attracting “medical tourists” from the United States for less expensive surgeries and other treatments. I was not prepared for what I found inside, and I would like to share with you a sampling of articles and current offerings. Singapore aims to attract one million medical tourists by 2012 through the efforts of SingaporeMedicine [www.singaporemedicine. com], an initiative of the Economic Development Board of Singapore, Singapore Tourism Board, and International Enterprise Singapore. In 2005, the number of visitors who came to Singapore expressly for healthcare reached 370,000. A growing number of medical and surgical specialists offer a complete range of consultative and treatment procedures. Medical travel agents are standing by to help you. Vietnam opened its first medical-travel resort, Medicoast [www.medicoast.com], in February 2007 in the popular seaside town of Vung Tau. The resort offers pediatrics, obstetrics, eye surgery, orthopedics, nutrition advice, general surgery, and cosmetic dentistry. Tourism officials in Thailand are optimistic the number of medical tourists will reach two million by 2011. The Thai medical-travel

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industry has several advantages: “First is the quality of doctors, second is price, and third is that patients do not have to wait to see a good doctor.” The South Korean government and private hospitals are collaborating to attract overseas patients. The priority target for international patients is Korea’s advanced techniques in LASIK operations, Oriental-medicine treatment, plastic surgery, backbone surgery, artificial fertilization and implant treatments. India and Taiwan are relaxing visa restrictions to help promote medical travel, and the options are extensive and rapidly growing. Turning from Asia to Latin America, a recent San Diego Union Tribune reprinted a Miami Herald article about Americans traveling to Panama, Mexico, Costa Rica, Columbia, Argentina, and Chile. The article states that United Nations figures show that travel and tourism is now the world’s largest industry at $4.4 trillion, more than defense, manufacturing, oil, and agriculture. Medical tourism is the hottest new sector in the travel industry. This is not just about Americans traveling abroad for less expensive medical care. Annually, about 50,000 British patients travel out of the United Kingdom to escape long waiting lists and out of fear of contracting hospital infections. The most popular destinations are India, Hungary, and Turkey. In Germany, a new website is offering “e-auctions” for medical treatment: www.arzt-preisvergleich.de. The site asks patients to post how much they have been quoted for a treatment from one physician, allowing other physicians to offer to beat the price. When physicians compete, you win!

A new Irish Internet start-up [www.reva healthnetwork.com] describes itself as a matchmaking site for those interested in having medical treatment in other countries. If you want to avoid the Third World, try Switzerland. The five-star diagnostic center, The Diagnostic & Prevention Center (DaP) in St. Moritz [www.dap-center.ch], claims to be the first European medical resort of its kind. DaP offers a range of packages to suit each client’s needs. Clients are expected to come from all areas of Europe, particularly Italy, Germany, and the United Kingdom. Like with Swiss banks, strict confidentiality of results will be maintained. The list goes on: Bahrain, Dubai’s Healthcare City, Israel, South Africa, and even (this will make you smile) Iran. Not to be totally outdone, the United Kingdom’s largest private hospital, London Bridge Hospital [www.londonbridgehos pital.com], is getting into this. Of course this type of activity has been going on in the United States for many years. Cleveland Clinic [www.cleveland clinic.org] and Mayo Clinic [www. mayoclinic.com] have large international caseloads. New York hospitals advertise all over the world. I have witnessed the efforts of the University of California medical centers. But the problem in the United States is our prices for medical care. Despite the higher costs for almost everything in Europe, healthcare costs run about half that of the United States. In the Third World, pockets of excellence can operate at a small fraction of U.S. prices. What about accreditation and liability? These issues are being covered. Our own Joint Commission [www.jointcommission.org] now accredits international hospitals and facilities. Interestingly, India added Australian hospital accreditation as an option. The quality international centers make transparent their liability coverage, and patients can purchase their own policies to guar-

antee the results. The days of rich Arabs coming to the United States and paying top dollar are coming to an end. The world is rapidly becoming flat for quality medical care. The private healthcare market in the United States facilitates Americans going abroad for care. With the rise of consumerdirected healthcare, and patients paying more of the costs, medical travel is likely to steadily increase unless we can be competitive at home. Health insurance plans in the United States are even beginning to cover medical travel since the costs are lower. As our patients think about traveling abroad for care, we should seize the opportunity and become a destination for medical travel. Think of those HMO and PPO rates we accept. Many people in the world will pay much better.

The world is rapidly becoming flat for quality medical care.

jscherger@CUSD.edu

“It looks like another case of parking rage.”

March/April 2008

Board Briefs February 11, 2008 The Board approved the Auditor’s recommendations regarding updates to SSVMS policies relating to general housekeeping and accounting procedures. Upon the recommendation of the BloodSource Board of Trustees, the Board approved the appointment of Brenda Crum to the 2008 BloodSource Board of Trustees to complete the term vacated by Judge Morrison England. Approved the Membership Report: For Active Membership — Anna A. Barber, MD; George T. Bolton, MD; Michael p. Carroll, MD; Emery L. Chen, MD; Howard H-V. Dinh, MD; Natasha W-Y. Fine, MD; Benjamin L. Franc,

MD; Mark C. Gorrie, DO; Ingvild G. Lane, MD; Kimberly E. Laurenson, MD; Donald P. Lombardi, MD; Erin B. Marcin, MD; Stacey A. Nakano, MD; Julie R. Wei-Shatzel, DO; Tony Tsai, MD; Byron F. Vandenberg, MD; Karin K. Wertz, MD; Christine (Cong) Zhang, MD. For Reinstatement to Active Membership — Ravinder S. Khaira, MD For Retired Membership — Diamond Kassam, MD; Stephen R. Shapiro, MD; Margaret Upson, MD. For Resignation — Samir Narayan, MD (moved to Michigan); Douglas W. Pepin, MD; Alisa M. Sabin, MD; Yelena Y. Sergeyeva, MD (moved to Orange County); Sabina Tahera, MD.

March/April 2008

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. â&#x20AC;&#x201D; Glennah Trochet, MD, Secretary BARBER, Anna A., Pediatrics, Univ Washington 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

LANE, Ingvild G., Internal Medicine, UC Los Angeles 1998, Sutter Medical Group, 1020 â&#x20AC;&#x201C; 29th St #480, Sacramento 95816 (916) 733-3777

BOLTON, George T., Radiology/Musculoskeletal Radiology, George Washington Univ 1989, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

SHEEHY, A. Macduff, Cardiology, SUNY Buffalo 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5282

DINH, Howard H-V, Cardiology, SUNY Stony Brook 1999, Regional Cardiology Associates, 3941 J St #260, Sacramento 95819 (916) 736-2323

WERTZ, Karin K., Pediatrics, UC Davis 2003, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4802

THIRUNAVUKKARASU, Bhuvaneswari, Internal Medicine, Madras Med Col, India 1997, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5237

FINE, Natasha W-Y, Family Medicine, St. Louis Univ 2001, Sutter Medical Group, 1201 Alhambra Blvd., #335, Sacramento 95816 (916) 731-7770 FRANC, Benjamin L., Nuclear Medicine, USC 2000, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300

UPPAL, Hartej S., Internal Medicine, Guru Nanak Dev Univ Med Col, India 1992, Sutter Medical Group, 1020 â&#x20AC;&#x201C; 29th St #480, Sacramento 95816 (916) 7333777

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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) 7600837. Part-Time Internist/FP needed to help with screening and medical management of obese patients during rapid weight loss. Week-day evenings. Must be familiar with diabetes, hypertension and lipid management. We pay malpractice insurance premium. Please email: julie@weightmanagement.net or fax CV to (415) 771-3528, Att: Medical Director.

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March/April 2008

Kenya, January 2008 “How are things in Mathere?” His single word answer says it all: “Unbearable.”

By Hernando Garzon, MD These edited emails were sent by Dr. Garzon while in Kenya with Médecins Sans Frontières, or Doctors Without Borders. Parentheses (like this) are the author’s; brackets [like this] were inserted by the editors. See the inside back cover for color photos. Wednesday Jan 8. The MSF “Emergency Response Team” has been staffed by three Kaiser E.D. docs and ”operational” since October.… Their first true ”activation” of this team is for the current impending crisis in Kenya. It happens that I am ”first up” this month for them, so I have been asked to go (alert yesterday, green light today, travel tomorrow). I have been asked to fill a position as Medical Coordinator...to establish what MSF has to do to prepare for the potential deterioration [and] civil unrest which has occurred as a result of the elections in December. I will initially be in Nairobi and focus on the needs of the slums [there]…. There is potential to travel to western Kenya which is the other area impacted by the civil unrest. I depart tomorrow morning (Jan 9th) at 9 a.m.; Mission duration is up to 4 weeks. Wednesday morning, Jan 16, Nairobe, Kenya. We have gotten through the first day of Parliament without much incident. Today is the first of three days of planned protests by the opposition party. I have spent a couple of 16 hour+ days touring through the Mathere slum, visiting potential sites to set up clinics with consideration for both accessibility for patients and security for the team, visiting area hospitals, putting together trauma first aid kits to include sufficient medi

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cal supplies to treat 70–100 victims, and I have spent many hours in Nairobi traffic. The slum in which we are working in more mixed than most, with neighboring areas of differing ethnic origin…people will have difficulty getting through one neighborhood to another to seek help or shelter. Different ethnic tribes are at risk from each other, and pro ODM (the opposition party) supporters who protest are at risk from the police who are known to use excessive force to quell crowds. 6:30 p.m.: Political Situation: Everything is pretty tense. The police shut down the city center and quelled almost all rallies. Three people where shot (dead) in the slums by police. Some peaceful demonstrations and some minor violent ones throughout the country. Just a few hours ago the president suspended parliament (which he supposedly has the power to do), so who knows what this will cause overnight. MSF work: The day was quiet, for the most part…. We saw about 50 regular patients in the HIV clinic and 7 victims of violence, some treated and discharged, but three sent to the hospital for major fractures and head trauma.… One of the national staff here is an amazing young man who is a vital link between the MSF program and the local community in the Mathere slum.… [I asked him:] “How are things in Mathere?” His single word answer says it all: “Unbearable.” Thursday Jan 17…was not like the relatively peaceful day before. The morning started slowly, and I had a chance to help the MSF clinic with their usual business of seeing HIV and TB patients. I joined the Field Coordinator for the Mathere slum MSF clinic and two other staff in driving the clinic ambulance into the slum to

retrieve patients who had missed their appointments and were reportedly too ill to get out of their beds. While I have heard about and seen pictures of the Nairobi slums, nothing can really prepare you for the lives that people endure [there]. The squalor, poverty and suffering are unimaginable. The ambulance can only drive up to a certain area, and from there we have to enter the slum on foot because there are only narrow, muddy, stench-filled alleys between the corrugated metal boxes called homes. We were able to repatriate an HIV and a TB patient who were quite literally dying in bed, too weak to get out of their dark metal boxes. 20 percent of the slum population is HIV positive. We couldn’t continue that repatriation because we soon started hearing stories of shootings in the slums. I have already seen a number of articles in the news detailing the numbers of casualties, and can tell you that they are at best inaccurate. The police were in force quelling demonstrators even before they got to assembly points (better to suppress crowds that way instead of after they form). We saw violence of two types — civilian vs. civilian beatings and stabbings, and police vs. civilian shootings. In total for the afternoon we saw: • Two gunshot wounds to the head • One gunshot wound to the abdomen • One gunshot wound in the arm of a 5 year-old who was hit when a bullet went through the wall of his shanty • And at least a dozen beatings with lacerations and orthopedic injuries. After stabilizing the patients, we sent the majority to the hospital. From the early part of the day, Robert Frost's words kept on recurring for me in my thoughts: A voice said, Look me in the stars And tell me truly, men of earth If all the soul–and-body scars Were not too much to pay for birth Monday, January 28 12:08 a.m. We had three relatively quiet days in Nairobi, but…over the weekend there has been much violence in an area about 50 miles from Nairobi [Nakuru], with at least 90 dead and hundreds injured,

houses [and] people burned alive, and a monastery with people seeking safety under siege by rival tribes and protected by police. A small team from MSF-Spain has been trying to help in one of those area hospitals, where they have received over 160 injured, with 90 of these requiring surgery. MSF-Spain’s team is mainly a primary health care team…so they have asked MSF-France to take over that hospital. We have already requested a separate 6-person emergency team to staff that project separately (from what we are already doing in Nairobi and in the western part of the country). We have also ordered another metric ton of medical supplies to arrive in 48 hrs. Later this morning we [our coordination team] is making a trip to the area to assess the situation in person. While it has been relatively quiet [in Mathere]…we have still had a small number of critical cases, [with] significant injuries from the routine violence of the slums and other serious medical cases (see below). The U.S. RN who arrived three days ago has started work. Vivian Reyes, who is an E.D. physician from S.F. Kaiser arrives here on the 30th, and as it appears that this program in the Mathere slum will continue, we are also looking to hire a local doctor, nurse, and additional other staff. Over the weekend we saw: 1. A man with a tension pneumothorax from a stab wound to the chest, which had actually been sutured the day before at a local clinic. When he presented, the sutured wound was raising and falling with his respirations. He had clinical signs of a tension pneumothorax, and a needle to his chest nicely decompressed the tension. 2. A woman 35 weeks pregnant with seizure and elevated blood pressure (eclampsia) who we referred to the hospital after stabilization. 3. A man with extensive third degree burns sustained when he had a seizure at home and knocked down his cook-pot, setting fire to his house. 4. A woman who was refused entrance to a maternity clinic because she had no money to pay, [and delivered] her child in the street. We came upon her while riding our ambulance, but the infant was already dead. March/April 2008

The ambulance can only drive up to a certain area, and from there we have to enter the slum on foot because there are only narrow, muddy, stenchfilled alleys between the corrugated metal boxes called homes.

I have been given the nickname “the tailor” (in Kiswahili, of course) because of all the suturing I’m doing or teaching the other doctors and nurses to do.

5. A number of infected wounds, already several days old, many of which had been seen and sutured at outside local clinics; many of these are staffed by pharmacists or people with even lesser training.… We treated for infection,…and sutured them secondarily — something we rarely do in the U.S.... I have been given the nickname “the tailor” (in Kiswahili, of course) because of all the suturing I’m doing or teaching the other doctors and nurses to do. My own medical misfortune: I woke up on Saturday to the sudden onset of fairly severe right flank pain. What a lovely time to get my first kidney stone. Anyway, a trip to a local [western] hospital, a CAT scan, about 25 mg of morphine and about 5 hours later, and I was pain free (being fortunate to have passed the stone that quickly). Because of all the pain medication I had to sleep away much of the afternoon, but was back to my usual self by dinner and back to work by Sunday. Yes, I am more vigilant about hydrating now. …It is difficult to get a sense of where, when or how bad the violence may flare. Several people who know Kenya well are concerned that the violence will return to Nairobi, and as we make preparations to send a new team to Nakuru, the area affected [last] weekend, we are also continuing to staff the Mathare slum in Nairobi. It is really a 16 hour a day job to process all the information, and make adjustments to our game plan almost on an hourly basis. Such is the work in situations like this. My replacement has been requested, but with all the turmoil of the weekend it now appears that I will not get to leave early.… As hard as it is to stay and work in this current environment, it will also be difficult to leave. Saturday, February 05 7:24 a.m. [Later on the morning of the 28th,] I was dispatched (with 3 others) to a town 60 miles north of Nairobi where violence had been reported the night before and one doctor in a rural Ministry of Health Hospital was caring for 30 trauma victims by himself.… We arrived around 5 p.m., and were up until around 4 a.m. working a ward

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with 27 trauma victims – four major head injuries, one patient with severe third-degree burns, two patients with collapsed lungs, and multiple fractures from beatings and gunshot wounds. One pt, already deceased on our arrival, remained covered on the floor between two beds all night. We had only two local nurses, and no housekeeping. The blood stains on the floor remained well into the next day. Because of the safety risk, we could not evacuate the sickest patients until the following day. It was, to say the least, a surreal experience. With national health care staff arrivals the following morning we were able to come back to Nairobi. This day alone could be a rather good novella. The violence in Nairobi has remained minimal, and we have had a number of slow days in the clinic here (thank goodness). While the number of cases in this clinic has not been great, we have continued to see some rather severe trauma from the routine violence that persists in the slums.... What began as an 8 person emergency team (4 here in Nairobi and 4 in the western part of the country), has now grown to 21 foreign staff and 12–15 national staff. We have not only increased coverage for the Nairobi team, but have also increased coverage for the team in the west and staffed a mobile team that is ready to go to any location necessary. Vivian Reyes (an S.F. Kaiser Emergency physician) arrived a few days ago and is working as part of the Nairobi emergency team. My replacement arrives tomorrow, on the same day I leave. This has been my last formal day of work. I depart from here tomorrow evening, with a one day stop to ”debrief” with MSF and then home by the evening of the 8th. In a deployment where I have largely been witness to unimaginable violence committed by humans on other humans, it has perhaps been a saving grace for me that today our Nairobi trauma clinic delivered a baby. While I was not there at the time, I will gladly take all of the hope that this new life symbolizes, and make it my own. hxgarzon@gmail.com

Scenes from the slums of Nairobi, taken in January.

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