2008-Sep/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2008

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Physician Leadership

14 Reasons Why Health Care Costs So Much

Margaret E. Parsons, MD

Gerald N. Rogan, MD

Letter to the Editor

A Report on Yolo County’s Syringe Exchange Program

A Posit on the Cost and Effectiveness of State/ Federal Medical Care

Bette Hinton, MD, MPH

¡Feliz Fourth!

Expanding Rehabilitation for Non-Violent Offenders

John Loofbourow, MD

John McCarthy, MD

BOOK REVIEW Teacher Cheating, Falling Crime Rates — and More

IN MY OPINION Why I Might Vote for the Democrats in November

William Peniston, MD

David J. Gibson, MD

Galen’s Four Wet Humors in Medicine and Music

Health Care Seen From a Small Clinic in Burundi

Board Briefs

George Meyer, MD

Clínica Tepati: a Student-run Clinic for Indigent Latinos

Voices of Medicine

Ryan McMahan

Del Meyer, MD

New Applicants

Classified ads

We welcome articles and letters from our readers. Send them by e-mail, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review any edits before publication. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

SSV Medicine is online at www.ssvms.org/magazine.asp The cover shows two cable cars on a San Francisco street in 2002. The original oil painting by Dr. Robert C. Lentzner measures 20 x 24 inches. Dr. Lentzner enjoys painting San Francisco street scenes — and he also has a fondness for rail transportation. “I recall a time when I traveled all around Chicago on electric trolley cars; I was about 7 years old and it was quite an adventure for me to use a single transfer for all the trolley cars used around the city during that day’s journey, with the proof of my journey being the many punched holes placed by the different conductors.

Volume 59/Number 5 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

“I enjoyed the nostalgia of riding cable cars in San Francisco. I painted a similar scene with one cable car at the same corner with different people years earlier, which my daughter has. I liked the scene so I painted another. They are quite different but I like them both.” Used by permission. All rights reserved.

September/October 2008

Sierra Sacramento Valley

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

Physician Leadership By Margaret E. Parsons, MD Recently at a community event, a physician spouse (in the official Medicare age category) mentioned that fewer physicians are engaged in community organizations than in past years. Of course, this got me thinking about physicians, community, and the varied roles we play. One of our recent SSVMS Past Presidents, Richard Pan, focused on this in his presidential year. Richard believes firmly that physicians can serve in many roles beyond just our daily patient care. During that year, SSVMS spent some time reviewing physician participation in the community, including leadership roles on both health and non-health related boards. We learned that there are many engaged in a variety of organizations and boards. There also seemed to be a cadre serving more directly in things related to family, such as coaching sports teams. We also learned there were many places where physicians had the opportunity to serve on community boards (including health-related and non-health related, such as the arts) and local elected boards, such as park and school boards. Many of those opportunities for leadership are still open. Have things changed from years past? Many outstanding physician leaders serve in so many ways. But yes, there is probably a change. Medicine is different than it was 20 or more years ago and that affects the time we have and choices we make in giving back. Volunteerism has also changed. Some board work is now done electronically and via conference call. Organizations now have many “done in a day” projects; getting longer time commitments can be difficult. All non-profit organizations are reviewing how they use volunteer leaders and develop new leaders and volunteers. Where do physicians fit in? There seem to be fewer physicians on community board lists. How are physicians serving in community

leadership? I believe that we are all leaders and develop those skills every day as we work in clinics and hospitals, whether in a small office with one physician and a few staff, a surgical team, a faculty physician at a teaching hospital, or a larger clinic team. We can bring the skills we have developed over the years to any project or board we might serve on. As one of the professions that always ranks among the highest in respect (along with the firefighters and teachers), we lead by example in our offices, on the wards, with staff, and with patients. Those of us who see children, adolescents, and young adults as patients also serve as role models. As I practice in a specialty that I sometimes call “family practice of the skin,” I enjoy hearing from parents what the “kids” are doing with their lives. This is the time of year when many of us also know young people applying to medical school and answer questions about medicine and different schools. We lead by sharing the good of medicine, even if the reality of some of the current paperwork and process of medicine frustrates us. Recently, a colleague in dermatology died of a heart attack, and I was struck by the hole in my group of organizational mentors and friends. His quiet strength was always to be thoughtful, kind and do good. Indeed, his family listed Sir William Osler’s three personal ideals on his memorial service notice: “One, to do the day’s work well and not to bother about tomorrow.… The second ideal has been to act the Golden Rule, as far as in me lay, toward my professional brethren and toward the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my September/October 2008

Part of being a physician is representing health to the community and making sure that health needs are part of other broader visions and projects.

friends without pride, and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man.”1 After returning home from the meeting where this had been shared, I looked at my bookshelves and contemplated different readings. Among the usual textbooks, I have a small group of older texts, including one by Osler. I took time to read some of the essays and found wonderful thoughts about an approach to patients and life (along with some outdated and not so appropriate to the current era). But the bookshelf I have recently turned to more consistently is the one with leadership books. I believe we as physicians need to grow and gain skills to lead in our daily lives in clinics and hospitals. We need these skills as well to advocate for medicine and our patients through medical societies and when directly advocating with lawmakers. By keeping medical societies strong, we ensure the future of medicine. And when able, these skills should be shared as well with community groups and activities, as that, too, is part of what being a physician can be. I share Past President Richard Pan’s vision of physicians on park boards, school boards, coaching kids sports, serving on agencies and commissions, and serving on other community boards even more than we already do. Part of being a physician is representing health to the community and making sure that health needs are part of other broader visions and projects. Our role as physicians brings a respect and presumed knowledge base and perspective; we have a platform and also a responsibility to be aware and work towards building pieces of the greater healthy community structure. Our title of physician brings health to the “table,” even if the “table” is a sideline cheering a child on at a sporting event. I encourage including leadership books in with medical and non-medical readings. As physicians we are always learning — that is indeed our nature. The lessons from these books can apply to many aspects of our lives as well as our role as physician leaders and our role in our communities. Some from my shelf: Good to Great for Social Sectors (Jim Collins): a short monograph aimed at leaderSierra Sacramento Valley Medicine

ship in non-profits Who Moved My Cheese (Spencer Johnson): simply written and a fast read that leaves you thinking about where you want to get to and to get outside the usual box. Tipping Point and Blink (Malcolm Gladwell): I confess I only got half way through these two before my husband snagged them for his reading, but they still made a strong impact. The Standard Code of Parliamentary Procedure (Alice Sturgis): the text makes sense of Robert’s Rules of Order and, more importantly, reviews the structure of boards and committees and their processes. A must for board leadership. Getting to Yes (Roger Fisher): the classic negotiation book. Short and to the point. It’s Your Ship (Captain Michael Abrashoff): leadership learned and applied to build a team and make it work and some interesting thoughts about best use of government VISA cards. Lincoln on Leadership (Donald Phillips): shorter than any Lincoln biography, this highlights some key leadership principles used by President Lincoln. How Doctors Think (Jerome Groopman, MD): the book everyone but physicians has been reading, so we had better know what they think of us! Renegotiating Health Care: Resolving conflict to build collaboration (Leonard Marcus, et al): the text may be approaching 15 years old, but is written by part of the Harvard team that leads seminars for health care leaders and the principles still apply. Excellent read for anyone working in health care systems, hospitals, or group clinics. New on my shelf: The Last Lecture (Randy Pausch). Any book with a section on the importance of “The Lost Art of Thank-you Notes” — and the lecture itself being a You-Tube phenomenon with over 6.3 million hits as of August, 2008 — needs to be read. I concur with the Thank-you notes being important and will see what the rest of the text holds. mepmd@ix.netcom.com 1 from Osler’s Farewell Dinner, May 2, 1905.

Letter to the Editor Praising “Demystifying Defibrillators” Dear Dr. Perryman, Today I came across your article on “Demystifying Defibrillators” and felt that I must write to congratulate you on writing such a succinct piece on this topic. Although it is necessarily of limited length, it is sufficiently detailed to provide the reader with all the important developments leading ultimately to successful in-hospital defibrillations (beyond the anecdotal) in the early 1960s, and the practical use of the machines outside of the hospital in the second half of the decade. I am the “Geddes” of “Pantridge and Geddes” who equipped an ambulance with a portable defibrillation system in January, 1966. We had first demonstrated the efficacy of a highly mobile system operating within the hospital, and with this success and armed with new information regarding the appalling mortality very early in the coronary attack, together with the hitherto undocumented lengthy delays before patients could reach a hospital coronary care unit, Pantridge (the physician in charge) suggested early in 1965 that we should “go out and pick them (the patients) up.” Although the data were compelling, there were at that time many technical and organizational obstacles to be overcome. Fortunately, Pantridge’s persuasive personality fairly easily overcame the administrative resistance and acquired financial support from the British Heart Foundation for the first year of operation, while I as the junior member of the team concentrated on finding a solution to the problem of charging a defibrillator from DC batteries and on training as many physicians as possible in CPR. You may already be aware that Pantridge in conjunction with staff of the Cardiology Laboratory developed the first ultra-portable

defibrillator weighing only 7 lbs., which was manufactured by Cardiac Recorders and was widely used in the 1970s. Sadly, my dear friend Frank Pantridge died in December 2004. I have recently retired and live with my wife near Tampa in Florida, having spent the last 19 years working as an “Arrhythmia Cardiologist” (including implantable defibrillators) in Canada. I am skeptical that a pharmacological means of preventing ventricular fibrillation on a large scale will be found, and I believe that for the foreseeable future we must be satisfied with further reducing the “coronary epidemic,” rescuing those who collapse in accessible places, and monitoring patients at times of temporary risk with implantation of defibrillators in those at permanent significant risk. Certainly, defibrillators should be placed in museums, but they will need to remain outside of the glass case for a long time to come! Once again, congratulations on your historical article which should help to keep younger generations of physicians from taking the modern AED defibrillator for granted. — John S. Geddes, MD

EDITOR’S NOTE: Kent Perryman, PhD, is a retired UCLA neurophysiologist and a member of the SSVMS Historical Committee. He has written several articles for Sierra Sacramento Valley Medicine. The one on “Demystifying Defibrillators”appeared in the July 2007 issue. He is also the creative force behind the “virtual tour” of the Sierra Sacramento Valley Museum of Medical History now available on the SSVMS website. Not only did he develop the tour, but he also took the photos it uses and he created the links to other websites for readers seeking more information. His latest project, still in the formative stages, is a virtual tour of gravesites of 19th century physicians in Sacramento’s Old City Cemetery.

September/October 2008

A Report on Yolo County’s Syringe Exchange Program By Bette Hinton, MD, MPH, Health Officer, Yolo County This is reformatted and slightly edited report on the first 11 months of Yolo County’s syringe exchange program. On August 5, the Yolo County Board of Supervisors voted 3–2 to fund the program for another year. Yolo County has implemented both the syringe exchange program and ordinances allowing pharmacies to sell clean needle and syringes to adults, as has the City of Sacramento. Sacramento County Supervisors have consistently voted against both harm reduction programs. — Bill Sandberg On June 19, 2007, the Yolo County Board of Supervisors approved, in concept, a syringe exchange program. Start up and implementation began immediately. This report represents 11 months of program activities (August 1, 2007 – June 30, 2008). Two organizations are authorized by the health department to conduct syringe exchange in Yolo County. They are: Safer Alternatives thru Networking and Education (SANE) and Harm Reduction Services (HRS). SANE is the primary agency providing SEP services. SANE receives funds to provide services through a subcontract with the Health Department. HRS receives program implementation funds through a state grant and the health department provides syringes. The Syringe Exchange Program (SEP) is based on Harm Reduction principles. Harm reduction practice involves a prioritization of goals, in which immediate and realizable goals take priority when dealing with users who cannot be realistically expected to cease their drug use in the near future, but it does not conflict with an eventual goal of abstention. It helps the user make small and intermediate behavior changes that decrease their chance of acquiring disease through needle sharing or sexual practices, and

prevents those who may be infected with a disease from sharing it with others. Satellite Syringe Exchangers (those who make the exchanges) are the keystone to reaching the hidden drug user population. As Exchangers are recruited, they are also trained in harm reduction approaches, safe syringe exchange, and how to share this information with their network of users. As the Exchanger becomes more familiar with the program and trust is built confidentiality is preserved, and they become more able and willing to collect basic data. The SEP is a wrap-around program with other services provided by the health department. This is vital in helping users reduce their risk of acquiring or sharing blood borne diseases with others, as well as in maintaining or improving their overall health. Additional services include: • HIV/AIDS education, counseling and testing • Hepatitis C (HCV) education, counseling and testing • Safer Sex education and counseling, and provision of safer sex packets to decrease sexually transmitted diseases • Referrals to substance abuse treatment and other medical and social services • Assistance in accessing treatment/service systems • Education on injection site abscess prevention and treatment, and provision of abscess kits/supplies • Referrals to mental health services • Training for Exchangers on overdose reversal and prevention

September/October 2008

Program Data Zip Code of Residence 95605 W Sacramento 95616 Davis 95618 95637 95695 Woodland

% Contacts 59% 16% 1% <1% 12%

Zip Code of Residence 95607 95617 95627 95691 95776

Demographics Number of staff contacts with users 338 Number of staff contacts with Exchangers 288 Number of Exchangers in the program 128 Average number of people Exchangers distribute to 12/Exchanger Total number of contacts made by staff and Exchangers 1874

% Contacts <1% 4% <1% 2% 4% < 25 years 25-30 years

> 50 years

31-40 years

Male participants Female participants People of Color

61% 39% 30%

< 25 years 9% 25-30 years 7% 31-40 years 16% 41-50 years 31% > 50 years 36% Missing < 1% Age range 18 – 71 years of age Participants who report being homeless 70% Drug of Choice Methamphetamine Heroin Other

41-50 years

70% 64% 60% 50% 40%

64% 30% 6%

30%

30% 20% 10%

Number Number Number Number

of of of of

syringes distributed syringes recovered users in drug treatment because of SEP drug overdoses reversed

61,752 50,499 (82%) 4 40

Average cost to treat an abscess in clinic setting Average cost of Emergency Room visit for an overdose Excluding ambulance transport, and/or hospital admission Cost of one Hepatitis C case, medication only Cost of one liver transplant because of Hepatitis C Lifetime medical cost of one HIV case

Injection drug use is a risk factor in 32% of HIV/AIDS cases in Yolo County. The percentage is higher in women with HIV/AIDS than men. Twenty-five percent of individuals who test for HIV through the HIV Counseling and Testing program, and have a history of drug use, report they already know they are Hepatitis C 8

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Methamphetamine:

Heroin

Other

$290 $750 – $2000.00/visit

Hepatitis C and HIV/AIDS Data

$15,000–25,000 $314,000 $266,660

positive. Of the users who do not know their Hepatitis C status prior to testing, another 50% are positive.

Other Issues Start Up: This first 11 months of the program included start up activities. These include finding where users can be contacted, developing

trust with the users, and adjusting program activities to meet the needs of the users in each geographic location. It is extremely difficult to develop trust with users in rural areas. Because of the small numbers of individuals living in rural areas, it is even more important to maintain the confidentiality of the user and takes longer to earn their trust. Education of Exchangers and training in basic data collection takes time. Consequently, numbers reported here are conservative. Development of Exchangers is based on many factors: knowledge and skill level of the individual, the types of issues they encounter, how they interact with the staff member and others. Law Enforcement Involvement: Acceptance of SEPs by law enforcement is critical to the success of the program. The Health Officer presented the program at the January 17, 2008 Law Enforcement Administrators Coordinating Council. One jurisdiction has expressed concerns but has offered the opportunity for staff to give a presentation to their law enforcement staff when solutions have been found. Staff will continue to meet with various jurisdictions to coordinate services. Syringe Disposal: There have been reports of finding syringes in specific public places. Although syringes have historically been found there, it is a continuing goal of the program to have syringes disposed of properly to decrease the risk of unintentional exposure to a used syringe. Staff are working to address these concerns. Additionally, the enactment of SB 1305 September 1, 2008 creates a bigger issue for syringe disposal. It will be illegal to dispose of home generated sharps, either used by human or animal, in the trash. To address both SB 1305 and SEP disposal, a task force has begun to develop a community-wide plan for safe syringe disposal. The task force is a joint effort from the health department and integrated waste management. Alcohol, Drug and Mental Health (ADMH): ADMH supports SEP as an intermediate and proven step to help move users into

drug treatment. Treatment programs require that participants be totally free of using drugs. So combining SEPs with drug treatment sends a mixed message to clients/users. ADMH and the Health Department working together on referrals to drug treatment for SEP clients, and cross training of SEP staff, ADMH, and drug treatment agencies. Data: It is too early to determine if the program has had an impact on numbers of HIV/ Hepatitis C cases, or number of drug overdoses. This usually takes on average, 3 to 5 years before real trends are visible. We are just now able to receive data for 2007 on emergency room visits for overdoses. So the timeframes of the data are not comparable. We are working towards baseline data of emergency room visits for drug overdose, and ambulance data for transport of overdoses. We continue to work with ADMH on user data.

Over time, as the program expands to a larger portion of

Summary

this popu-

In 2006, the Trends in HIV/AIDS in Yolo County report recommended continuing targeted outreach and interventions with the injection drug user community to decrease the spread of HIV/AIDS. In 2000, then Surgeon General David Satcher said it best: â&#x20AC;&#x153;After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.â&#x20AC;? The Yolo County SEP provides the ability to reach the hidden user populations in the county. Over time, as the program expands to a larger portion of this population, the county should see a decrease in the incidence of HIV/ AIDS and Hepatitis C cases. Increased coordination with local jurisdictions and partner agencies will make the program more accessible to those who need it.

lation, the county should see a decrease in the incidence of HIV/ AIDS and Hepatitis C cases.

bette.hinton@yolocounty.org

September/October 2008

Expanding Rehabilitation for Non-Violent Offenders Proposition 5 on the November ballot, the Non-Violent Offender Rehabilitation Act (NORA), would build on the success of Proposition 36.

By John McCarthy, MD Dr. McCarthy is executive and medical director of the Bi-Valley Medical Clinic. Remember the controversial ballot initiative, Proposition 36, which was passed in 2000? It was the most significant change in public policy toward drug offenses since the â&#x20AC;?war on drugsâ&#x20AC;? began ages ago. It was passed by 62 percent of voters who expressed their discontent with drug policies that warehoused thousands of non-violent offenders, yet did nothing to foster recovery from addiction. Prop 36 mandated that offenders who pled guilty to drug offenses be sentenced to probation and mandatory drug treatment in the community as an alternative to incarceration. Parolees who were to be sent back to prison for positive drug tests were also eligible for diversion into treatment. Successful treatment resulted in dismissal of charges. Treatment failure resulted in imposition of the suspended sentence. The treatment was funded by $120 million a year from the state general fund.

The Track Record of Prop 36 In Sacramento, by the third and fourth years of the initiative, a comprehensive treatment system had been built that included outpatient recovery programs, methadone maintenance, detoxification, residential treatment, clean and sober living environments, and even some mental health care. Participants were assigned

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to the level and type of care they needed. A cooperative working relationship had been built that included the courts, District Attorney, Public Defender, probation, parole, and the County Alcohol and Drug Division, and treatment providers. Nothing of the sort existed prior to Prop 36, when the norm was revolving door incarcerations of individuals with little access to a fragmented, inadequate system of care. But when all the necessary components were in place, the Legislature started cutting the funding and major reductions in treatment resources have occurred. Now, in the 8th year of Prop 36, we are wait-listing participants for treatment, creating a real public policy crisis since newly arrested offenders cannot be incarcerated under the law. UCLA was chosen to do a comprehensive evaluation of the first five years of Prop 36. By year 4, about 50,000 offenders per year were being referred to treatment, of which 75 percent actually entered treatment. About half of these had never received any treatment in spite of an average of 10 years of addiction! One-third of participants successfully completed treatment and another 8 percent were making satisfactory progress, for an overall success of 40 percent. This is a good recovery rate considering the abysmal recidivism rate associated with incarcerations. Re-arrest rates were lower for successful completers than for those who failed to complete treatment. Treatment outcomes were

the worst for heroin addicts because methadone maintenance, the gold standard treatment, was severely underused due to widespread criminal justice biases against this treatment. Sacramento County was a major exception. All opiate users who needed methadone had access to it, and their success rates were comparable to those of other drug users in our county, in spite of an average 20 years of addiction — double the statewide average! UCLA researchers found that Prop 36 saved the California taxpayer $2.50 for every $1 spent. The number of prisons and jail days avoided by the initiative exceeded a full census of a mid-size prison and a mid-size jail. In one year, $83 million in savings accrued to the state and another $61 million accrued to counties. The researchers concluded that Prop 36 was effective for many participants, that savings were significant, and that the initiative was under funded and could be improved on.

A Broader Impact for NORA Now we come to a new ballot initiative: the Non-Violent Offender Rehabilitation Act (NORA). It would establish a hierarchy of treatment for offenders from the juvenile justice system through different levels of adult treatment. NORA would set aside $65 million per year to bring drug and mental health care to juveniles. Drug use is embedded in a host of adolescent problems, especially family dysfunction and mental illness; treatment options for juveniles are critical to keep youth from becoming long-term wards of the prison system. On the adult side, NORA will set aside $385 million to create a continuum of care from drug diversion programs for low level offenders, to Prop 36 for mid-level severity, through to drug court for those in need of the most intensive interventions and probation monitoring. NORA allows funds to be used for treating mental illness, an important provision given the woeful lack of resources in our community mental health systems. It also changes the penalty for marijuana possession from a misdemeanor to an infraction, saving 40,000 people a year from the life-long consequences of a criminal record.

NORA would reform prison and parole policies, making rehabilitation a real priority for the Department of Corrections, and it will significantly reduce prison overcrowding by limiting the use of prison beds to punish minor parole violations. Finally, NORA sets aside $10 million a year for efficacy studies to continue using feedback from research to fine tune the system. The Legislative Analyst’s Office projects overall costs of the initiative at $1 billion, which would be offset by savings in excess of $1 billion in jail, prison, and parole costs. The Analyst estimates an additional savings of $2.5 billion in prison construction costs over the next few years. Beyond the money saved, there is the reduction in human misery and community chaos by addressing substance abuse and mental illness with effective solutions rather than the ineffective bludgeon of incarcerations. In the eight years I have worked with Prop 36 referrals to our methadone program, I’ve been appalled by stories of years of untreated addiction and mental illness. It has been very rewarding to bring health care to this troubled population. And the historical collaboration that Prop 36 made possible between treatment providers and the local criminal justice system has been one of the highlights of my years working in addiction medicine. Even if Prop 36 didn’t save a cent, this working collaborative on a chronic community problem would be worth the expense. Drug abuse is never going away. It is older than history and endemic to the human condition. It is exacerbated under conditions of human suffering and misery, of which there is plenty. With the success of Prop 36 as a model, NORA promises an enhanced spectrum of services. It would reverse the legacy of mismanagement of the past decades that gave us only exponential growth of prisons, fractured families, and uncontrolled costs. Vote for Proposition 5 on the November ballot. Our community and state will reap the benefits.

And the historical collaboration that Prop 36 made possible between treatment providers and the local criminal justice system has been one of the highlights of my years working in addiction medicine.

jmccarthy@bivalley.com September/October 2008

In My Opinion

Why I Might Vote for the Democrats in November If the Democrats win, they will expand health care entitlements and must inevitably ration health care for the elderly and cut labor costs — two things Republicans cannot do.

By David J. Gibson, MD In My Opinion reflects personal opinions of the author, not those of SSVMS, its officers or staff. Despite a lifelong identification as an Independent, I have consistently supported the Republican candidate for President and for down ticket candidates. This year, though I deeply respect John McCain, I am seriously considering changing my pattern and casting my vote for Barack Obama, the presumptive nominee at this point, and the down ticket Democrats. This change in behavior will likely startle my friends and family. How could I possibly vote for Barack Obama, a Democrat from the Frost Belt with no national security or executive experience and a voting record judged by the nonpartisan National Journal as the Senate’s most liberal during 2007? I am not changing my voting pattern because the Republicans have proven themselves, through a combination of corruption, fiscal profligacy and economic ignorance, to be incompetent at governing; personally, I don’t believe the Democrats will do any better. Rather, just as it took Nixon to open the door to diplomatic relations with China after decades of divisive debate led by the Republican Party about “who lost China,” I believe only a Democrat can tackle the joint issues of entitlement reform and public union retirement costs. Entitlement reform, particularly as it relates

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to health care, has been recognized as a critical issue for decades. As now structured, the consensus opinion is that government entitlement programs are not sustainable. Intuitive thinking has not been successful in addressing this issue. Perhaps, as an alternative, we need to explore a counter-intuitive approach. The only way to address this problem is to expand rather than restrict the various entitlement programs. These programs belong to the Democrats and only a Democrat can reform them before they destroy our economy. Sticking with the counter-intuitive approach, we are now overspending on health care in this country. America spends 15 percent of its gross national product, twice as much as any other country, on health care. Our problem is how we spend our money in the system. Democrats Obama and Hillary Clinton promised universal coverage that will include the over 47 million uninsured in this country. Unless we are willing to no longer defend the country, maintain our infrastructure, provide public protection and educate the next generation, we have no choice but to cap total health care spending and reallocate how we fund the health care system to meet this commitment. In today’s system, which is acuity-based, most of our funding goes for care during the last few months of life in custodial settings. The lobby for insurance companies, hospitals, pharmaceutical companies and various professional groups has donated the lion’s share of political

contributions to defending this acuity orientation. Expanding coverage to the currently uninsured, mostly at taxpayer expense, resonates at both the humanitarian and the public health levels. However, the current resource allocation can no longer be sustained. The only way to expand coverage, without catastrophic health care cost increases, is to alter the fundamental formula for spending. Specifically the units of service provided and the amount we pay for each service unit. If we plan to cover the uninsured who have limited access to health care, the only way to fund this expansion is to reallocate the service units we now commit to the elderly and the terminally ill. In short, we will reduce costly acuity-based service units and increase public health/primary care units. The AARP and the Medicare lobby, who favor expansion of beneficiary coverage, understand this reallocation reality but as yet have not informed their constituents. A Republican could never ration care to the elderly and dying; only a Democrat can touch this “third rail” of politics with any hope of success. The second factor in the spending equation is the cost per unit of service. Last year, the nonpartisan McKinsey Group released a report called “Accounting for the Cost of Health Care in the United States.” The McKinsey analysis determined that America overpays $477 billion per year, or $1,645 per capita for units of service delivered. The primary cost driver per unit of service is the cost of labor. Labor (physicians, nurses, technicians and non-clinical support personal) cost contributes 37.5 percent of excess spending in the hospital and 39.5 percent in the ambulatory setting. America spends twice as much per unit of service for medical labor than any other industrialized country. Only a Democrat could address the cost of labor. To provide health care services to all, we will need to reduce the reimbursement for all professional and support personal within health care by a factor of 50 percent or more. The cost of America’s health care system represents a far greater threat to the United States than terrorism. The system’s cost is destroying our economy. It has driven manufacturing to

other countries when the efficiency of our labor force is the best in the world. When the new public accounting rules known as GASB-45 are calculated for unfunded health care retirement liabilities, political sub-divisions from the federal to the local school boards across the country are bankrupt. As for entitlements, by 2030, about the midpoint of the baby boomer retirement years, federal guarantees to Social Security and Medicare will require one in every two income tax dollars. By 2050, they will require three in every four. And by 2070, these entitlements alone will consume all federal revenues. There is no argument against the urgency of the crisis we face. The health care system’s cost structure must be reformed. To extend coverage universally, the only options will be confiscatory taxation — which will drive the economy underground — or addressing the cost formula for health care. Addressing the cost formula by reducing the units of care provided to the elderly and dying and slashing the labor cost per unit of service delivered may damage the Democratic Party for generations, just as was the case with the party’s embrace of the civil rights issue, but it will represent a real service to the country. If I vote for the Democrats, I expect them to deliver on the promises they have been making. If, as now expected, this election produces one party control of the legislative and the executive branches of government, there will be no excuse for Democrats not to honor their commitment. All of the frequently cited 47-million uninsured in this country must have coverage. Incidentally, this figure includes the undocumented whose lack of health service access represents a growing public health risk. Unless the Democrats seek to intentionally damage the country, their only option will be to reform the cost of the health care system. In November, the dream of a generation of Democrats to, without opposition, set policy and govern will likely come to fruition. My only comment — they should be very careful what they wish for.

If we plan to cover the uninsured who have limited access to health care, the only way to fund this expansion is to reallocate the service units we now commit to the elderly and the terminally ill.

DJGibson@winfirst.com

September/October 2008

Health Care Seen From a Small Clinic in Burundi By George Meyer, MD I recently returned from 10 days in Burundi, an East African country previously colonized first by Germany and, after WW I, by Belgium. It lies on the eastern shore of Lake Tanganyika, the second largest lake in the world after Lake Baikal. The Democratic Republic of Congo is on the western coast of the lake and Rwanda borders Burundi to the north. Rwanda and Burundi will forever be linked by the â&#x20AC;&#x153;genocideâ&#x20AC;? of Tutsis by Hutus in 1994. Rwanda is better known because of the Hotel Rwanda book and movie. I volunteered in a small private clinic (the clinic charged $1.50 for patients to see me) where my translator (from Kirundi into French â&#x20AC;&#x201D; my French leaves a lot to be desired) was a second year medical student at the only medical school in Burundi. She was available because the medical students were on strike (it lasted 5 weeks) because their university, which gets a stipend from the government, did not give the medical students enough money to live on. Last year the faculty struck for 4 weeks over similar issues. Their medical school program is a seven year program which takes entering students from high school. The first year of classes consists of classes we would consider pre-med. The next two years are pre-clinical (the anatomy class is all theoretical with drawings, etc.; there are no cadavers). The fourth year is the beginning of their clerkships. The mornings are spent on the wards rotating on internal medicine, surgery, ob/gyn and pediatrics while the afternoons are spent in

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didactics in ophthalmology, ENT, orthopedics, etc. In the fifth year, they are responsible for a larger group of patients with more independence, having a faculty member available for consultation when requested. The sixth year is spent in three hospitals outside the capital where they have even less supervision. The seventh year is devoted to studying and passing their exams. When successful, the new doctors may go into practice.

Should they want to specialize, they must spend two years in the interior of the country serving as generalists. Most specialties require three years of training. Public health is a big part of the governmentâ&#x20AC;&#x2122;s medical focus. A couple of years ago it decided that all child births, even C-sections, would be without cost to the mother. In addition, it is said to have a good, clean water supply as of November 2007. Falciparum malaria is still a major problem in Burundi, with the peak incidence during the early part of the rainy season in January and February. The female to male ratio of malaria reported from this clinic is about 1:1 until the age of 15, after which there is a male predominance of 2:1 and 3:1 for severe cases â&#x20AC;&#x201D; I presume because the men are more exposed. Onchocerciasis, a filarial illness known to cause river blindness, is common outside of the capital. There are ongoing efforts to control the disease with the same meds given to our pets to prevent heartworms (one pill gives protection for 6â&#x20AC;&#x201C;12 months). Although not a problem from Lake Tanganyika, schistosomiasis is common in the rivers of Burundi. Hepatitis B and C are common in Burundi, and there is no ability to treat these diseases. I saw a gentleman with hepatitis C whose GI doc told him he needed to go to India for treatment ($3,000). AIDS is a major problem. The country is mostly Christian (predominantly Catholic) with a small, but visible, Muslim community. Homosexuality is not acceptable in Burundi. One young unmarried patient I saw for weight loss complaints was suspicious for AIDS, but we could not discuss it. I asked for a CBC, but he chose not to even have that performed (AIDS testing is available without cost at government clinics). Tuberculosis is also a common problem, but I had no chance to pursue further information. The experience was eye opening. I am looking forward to my next, not yet planned, medical adventure.

These photos were taken by Dr. Meyer during his Burundi visit. The originals are in color, and can be viewed with this article at www.ssvms.org. In the photo on the previous page, , bike riders hold on to the back of a tanker going up hill. A second photo features a pile of green and red wheelbarrows for sale. The third photo, of a fabric shop, is relatively drab in black and white, but striking in full color.

geowmeyer1@earthlink.net

September/October 2008

Voices of Medicine Shutting down: instructions at the last stage of life, and reflections after closing a practice.

By Del Meyer, MD

A “Good” Ending Drs. Wendi Joiner and Tim Nicely discuss “The Last Stage of Life Project in Humboldt County,” in the The Bulletin of the HumboldtDel Norte Country Medical Society, April 2008. What is a “good” death? This is only identifiable in the perspective of the patient and the patient’s loved ones. How can we consistently provide this last service to our patients, our neighbors? Communication and coordination in the last stage of life — whether this is a few weeks or many years — are the key. Communication is a personal skill set and coordination means a system including the wide variety of persons and facilities providing services. A diverse group sponsored by the IPA has been meeting to discuss issues related to last stage of life (LSL) care in our community since October 2006. The IPA LSL Project Committee includes clinicians, representatives of all levels of local health care facilities and emergency medical responders. A common concern is that systems are not in place to ensure that patients’ wishes are consistently carried out due a lack of coordination and communication, especially between levels of care. According to a recent survey, eight out of ten people say it is “very” or “somewhat” important to write down LSL wishes, but only 36% actually have written instructions. As a result, needless and unwanted interventions happen during the last six months of life, causing unnecessary stress and expense for patients and their families alike. The Mission of the Last Stage of Life (LSL) Project is to ensure that all residents of Humboldt

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County have their choices known and preferences honored regarding the nature and intensity of last stage of life care, support and services. The vision of the LSL Committee is to help the members of our community have a good death according to their own values and preferences by creating a collaborative system within and between all levels of care — home, RCF, SNF, acute hospital, emergency transport — to honor and implement documented patient preferences. The choice of a common documentation for clinician orders regarding CPR, antibiotics, artificial nutrition/‌hydration and hospitalization has been a key focus of work. The Physicians’ Order for Life Sustaining Treatment (POLST) form has been selected as the tool by which patient’s LSL care preferences will be communicated within and between facilities. In November 2007, the Humboldt IPA received a grant from the California HealthCare Foundation to assist with implementation of the POLST. We became part of a statewide Coalition working with the California Coalition for Compassionate Care to implement the POLST in California, based on a model in use in five other states. This group gives us a forum by which we can share ideas, materials, and experience with others across California… To read more about the coalitions, plans, and the POLST forms, go to www.humboldt1.com/~medsoc/ images/bulletins/APRIL%202008%20BULLETIN_ for%20web.pdf

Thoughts After the Unthinkable Anne French, MD, writes about “Collective Health” in the summer 2008 Sonoma Medicine, of the Sonoma County Medical Association. I’ve done what was once unthinkable — I

closed down a 45 year-old solo family practice in the fall of 2006. My father ran the ship for 42 years. I came along to experience this rare dying breed for a mere three years, and then decided it was time for hospice. Ever since residency, I’ve had the sense of holding my breath, waiting for the medical system to collapse entirely, so that it can rise anew and become a viable system that truly cares for the health of our nation. When I was mired in the muck of a frantic 16-hour day filled with hundreds of detailed tasks, often involving significant liability for people’s health and lives, it felt impossible to be part of the solution. My original decision to take over my father’s practice took me by surprise. I left my salaried position at the Sonoma County Indian Health Project and was propelled headlong through a crash course in small-business ownership, practice management, and being the sole provider for not only 3,000 patients, but also five employees. I learned the reality of partial and delayed reimbursements from the insurance industry, and of productivity-based income. To avoid compromising my ideal of quality, I limited the number of patients to 18–20 per day. This limit allowed me to break even, but I was still working 80 hours a week. It’s taken some retrospection to realize that I was running a private nonprofit. I loved the autonomy of solo private practice, I loved practicing my own blend of allopathic and integrative medicine, and I loved my patients. But I knew the pace was not viable, and that I was at high risk for burnout. I also could not tolerate any more incursions on my time or my income. I was getting paid for only 50% of my time and effort. Sure, my patients were happy, but the workload and the financial equation were not sustainable. I currently work for the State of California, at the Sonoma Developmental Center. I’m on hiatus from private practice, with a strong desire to protest our current system. As long as I continued to contract with insurance companies, I was part of the problem, not the solution. I was allowing these companies to further exploit the medical system, by accepting their

corrupt contracts and their delayed payments. Needless to say, a year and a half after closing my practice, I am still owed tens of thousands of dollars by the insurance companies, which still require labor-intensive redundant paperwork to refile and contest my unpaid claims… The total amount of money going into our health care system is phenomenal, more than any other country in the world. In a typical insurance company, administrative costs range from 20% to 30%. These rates compare unfavorably with Medicare and Kaiser, whose administrative costs are less than 10%. The multiple layers of separation between patient and physician are not benefiting anyone except the insurance industry, which continues to rake in huge profits. Meanwhile, physicians and hospitals struggle to survive, and patients receive mediocre and substandard care for an ever-increasing price tag… Many of the common arguments against universal health care continue to be recycled in repetitive campaigns to play on our fears of long lines, less choice and substandard care. Isn’t that what we already have? We can create a viable, competitive new system that we actually want to use. We’re a creative country (although a bit constipated at the moment), and we could use some of the benefits of our capitalist society (such as competition) to create a universal health care system that fills us with pride, not fear. The power and strength of the pharmaceutical and insurance lobbies is clearly stamped on our current medical model. The only way to revamp medicine is to have physicians and patients take back ownership of the system. In fact, if we don’t find our voices, the “solutions” will continue to be dictated by industry lobbyists and politicians. The balance of power must be restored, and a set of checks and balances needs to be applied to the drug and insurance companies, just as they are currently applied to individual physicians. The entire article can be read at http://www. scma.org/magazine/scp/sm08/french.html

We’re a creative country (although a bit constipated at the moment), and we could use some of the benefits of our capitalist society (such as competition) to create a universal health care system that fills us with pride, not fear.

DelMeyer@MedicalTuesday.net

September/October 2008

14 Reasons Why Health Care Costs So Much By Gerald N. Rogan, MD Dr. Rogan practiced emergency medicine for 7 years, had a “medical home” private practice for 18 years, directed Medicare B in California for over 6 years, and now consults on health care issues. The federal government and California may initiate significant health care “system” changes during the next few years. “System” is in quotes because what we have is a crazy quilt of disjointed programs. Anderson1 and others found that the U.S. spends about 150 percent of what care should cost, compared to the cost per person in countries that offer similar quality. In 2007, we spent 16 percent of our gross domestic product (GDP) on health care, up from 14.6 percent in 2002, while the French spent 9.7 percent of their GDP. About a sixth of our population has no illness/injury insurance. Frontline of PBS recently featured elements of the health care systems of the United Kingdom, Canada, France, Switzerland, Germany, Japan, and Taiwan.2 Each has a health care system that delivers health care for everyone — but with remarkable differences. AARP Magazine in July/August lists several reasons why health care costs so much. I review each item, make comments, and rank with 1 to 5 dollar signs the potential achievable savings were health care reform to lower these costs. 1. Malpractice insurance premiums: 1975 tort reform in California lowered premiums to 37th highest of the 50 states. Tort reform in all states would lower doctor costs by 25–30 percent3 and overall costs by 0.5 percent. RANK: $

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2. Defensive medicine costs: “Defensive medicine” is a pre-emptive effort to lower the risk of a law suit and a potential plaintiff judgment for negligence by ordering diagnostic tests not medically necessary based on scientific evidence. Some docs claim it is the community standard to test, to defend against a potential law suit. For others, the “need to defend” is a thinly-veiled excuse to obscure the conflict of interest inherent with test self-referral. An adequate history, exam, and documentation are the best defenses against a malpractice law suit. The cost of defensive medicine includes the cost of unnecessary tests and treatments, plus insurance payout for legal defense and malpractice awards included in #1. RANK: $$ 3. High Collection Costs: The cost to bill insurance is about 8 percent of collections for a primary care physician, because the average bill is small. One specialist reports his cost is 2–14 percent of collections, depending on the insurance plan. These costs are much too high. In France, a primary care physician bills much like a car rental — with the patient’s health insurance card via a hand-held transmitter. Insurers do not require diagnosis codes to determine medical necessity of an evaluation and management (E&M) service. For auditing E&M services, insurers use volume and level of service, not diagnosis. In France, the patient pays the primary care doctor and insurance reimburses the patient. Direct patient payment would constrain insurance payment delays and improper reductions of individual claims. RANK: $$ 4. Unnecessary Services: Patients receive too many unnecessary tests and treatments.

Brownlee (AARP)4 blames the patient, whereas I blame everyone — advertising, the “glamour” of tests and treatments5, patient expectations, doctor willingness to test instead of treat based on history and exam, and excessive reimbursement for imaging and certain treatments. The best example of too many tests is an ankle x-ray for a suspected sprain. Percussion against the sole of the foot will exclude a significant fracture. Follow-up after three days of splinting will confirm the absence of a fracture. Another example is an MRI for low back pain of short duration without certain “red flags,” which will not differentiate disease from health. Cardiac computed tomographic angiography (CTA) is more frequently performed in recent years with many tests self-referred. Yet clinical utility is uncertain, especially for asymptomatic patients. Medicare recently proposed CTA coverage only for selected symptoms and requires additional evidence to prove clinical utility.6 A Sacramento hospital system recently advertised virtual colonoscopy via direct mail, yet the California Technology Assessment Foundation (CTAF) did not find evidence the test improves health outcomes in persons of average risk.7 Most Medicare Part B restrictive local coverage decisions (LCDs)8 were created to control excess test and treatments ordered or provided by those physicians who do not follow medical science. Self-referred tests, particularly imaging studies, have increased twice as fast as all other physician services between 1999 and 2003.9 We spend a disproportionate amount on cancer care. Patients have unrealistic expectations, are willing to take large risks, and often want chemotherapy with small benefits. Doctors do not tell hospitalized patients they are dying 39 percent of the time, and some 20 percent to 40 percent of patients receive chemotherapy within 14 days of their death. RANK: $$$$$ (AARP estimates $500 billion wasted.) To the AARP list of costs, I add 10 more: 5. Fragmented acute primary care: About 80 percent of the patients seen in an emergency department could be seen in a physician’s office if it were open every day, including evenings until 9 p.m. Emergency departments are too

expensive to diagnose and treat problems that are not potentially life-threatening. Primary care physicians are underpaid and, therefore, unavailable during evenings and weekends. Emergency departments are overcrowded largely because primary care is not available when needed for urgent, non-emergent problems.10 RANK: $ 6. Fragmented long-term management of complex cases: Too many patients have no “medical home.” Primary care physicians who provide “medical home” services coordinate the care, direct consultations to specialists, monitor inter-specialist referrals, are on-call, and oversee hospital inpatient activities.11 Concierge docs provide this service for a fee. Disease management companies are, in part, a reflection of the need for primary care physicians to increase efforts to manage chronic disease. For example, primary care physicians do not always follow end-stage disease patients after referral to a specialist. Now that family medicine is the least popular specialty with residents, some insurers are paying monthly fees for medical home services that may save unnecessary costs or improve quality. MedPAC is studying monthly supplemental reimbursement for medical home services for Medicare. RANK: $$ 7. For-profit illness/injury insurance companies: Blue Cross and Blue Shield of California began as non-profit. For-profit health insurers must pay dividends and high executive salaries, which reduce physician fees. Non-profit insurance is a less costly product for comparable physician reimbursement. I propose every person should have the opportunity to buy a non-profit insurance product, either an individual plan or a group plan. RANK: $$ 8. Medicaid payment too low: Mainstreaming Medicaid patients is an unfulfilled myth. A primary care physician cannot cover practice expenses with Medicaid reimbursement. The solution is to deliver primary care through government-sponsored public clinics, not private offices. RANK: $ 9. Medicare has rewarded low quality: Medicare has been “paying for performance”

September/October 2008

About 80 percent of the patients seen in an emergency department could be seen in a physician’s office if it were open every day, including evenings until 9 p.m.

We will not have “Medicare for everyone,” i.e., a single payer program. Reforms can focus on a return of not-for-profit “mutual” insurance, guaranteed insurance continuation, and insurance portability.

for many years. The worse the performance, the more Medicare has paid — for complications and additional tests when care is suboptimal. Now the Centers for Medicare & Medicaid Services (CMS) is trying to pay more for better care. Doctors should help find ways to measure and reward quality, by helping and not fighting CMS. RANK: $ 10. Preventive care: Immunizations, infant care, and pre-natal care provide long-term high value outcomes and can be provided as a public service through health department sponsorship where needed. For adults, most primary preventive care is through personal lifestyle choices. Preventive care through physician service interventions is mostly secondary and tertiary: early detection of cancer and prevention of disease complications. Insurance coverage for secondary prevention for adults is less important than assuring affordable coverage to finance treatment of illnesses and injuries. Tertiary prevention is disease management which returns us to the “medical home.” RANK: $$ 11. Hospital advertising: The need for and propriety of hospital advertising troubles me. Instead of glossy directly mailed magazines, billboard ads and other promotional costs, hospitals should post on the Internet their DRG prices and their discount from retail programs for the uninsured. RANK: $ 12. Pharmaceutical costs: We appear to pay double the cost of drugs in Europe, based on my anecdotal purchases in France. The time has come for group purchasing for all insurers, including Medicare. Drug company field representatives do not exist in Europe. RANK: $$ 13. The cost of labor: David Gibson previously published an analysis of the cost drivers in health care.12 Do physicians charge too much for some services? Compare the average annual income of a radiologist to a primary care physician, and physicians as a group to other professionals for the same stress and hours of work. RANK $ 14. Social cost drivers: Many social issues negatively impact health care costs and health status, including community design (too scattered), cost of gas (too low), public transporta-

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tion (too little), non-carbon based energy (too little), consumerism (overvalued), news and TV shows about violence (overemphasized), eating too much, exercising too little during day-today life, and U.S. culture (too violent, egocentric, and fearful13). These are not problems physicians can solve in their role as personal healers. RANK: $$ In the next several years, we may collectively guarantee, through our government, that an individual who can document no break in insurance can purchase an individual high deductible illness/injury PPO-type insurance product at a reasonable price. We will not have “Medicare for everyone,” i.e., a single payer program. Reforms can focus on a return of not-for-profit “mutual” insurance, guaranteed insurance continuation, and insurance portability. Government should assure access to reasonably priced, continuous insurance coverage for illnesses and accidents. Reform must re-establish the central role of the primary care physician. Price transparency will support consumer driven health care. I hope this article prompts you to write our leaders to help guide them as they attempt to improve our health status through changes in system organization, financing, and delivery. jerryroganmd@sbcglobal.net 1 http://content.healthaffairs.org/cgi/content/abstract/24/4/903 2 http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/ countries/ 3 AARP cites the Congressional Budget Office 4 Shannon Brownlee; Why does Health Care Cost So Much?; www.aarpmagazine.org, July, August 2008. 5 http://www.sacmag.com/media/Sacramento-Magazine/ December-2007/Top-Doctors/ 6 http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo. asp?from2=viewdraftdecisionmemo.asp&id=206& 8 http://www.ctaf.org/content/general/detail/535 9 http://www.cms.hhs.gov/mcd/results_index.asp?from2=results_ index.asp&contractor=28&from=’lmrpcontractor’&retired=&n ame=National%20Heritage%20Insurance%20Company%20 (31140,%20Carrier)&letter_range=4& 9 http://www.medpac.gov/publications/congressional_testimony/031705_TestimonyImaging-Hou.pdf 10 http://www.calphys.org/assets/applets/er_report_web.pdf 11 http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File. tmp/022107medicalhome.pdf 12 http://www.ssvms.org/articles/0501gibson.asp 13 Bowling for Columbine

September/October 2008

A Posit on the Cost and Effectiveness of State/ Federal Medical Care “Economy and effectiveness of State/Federal health care like Medi-Cal and Medicare would be greatly improved by providing more compensation for primary care, and reducing compensation for procedure-intensive care.”

AMONG 134 RESPONSES, 80 agreed, 47 disagreed, and 7 commented without agreeing or disagreeing. Posits are contentious state-ments, usually overly simplistic, intended to en-courage discussion among our members. The results are not a valid poll, and the opinions do not reflect the views of the editors, or the SSVMS Board of Directors. Commentary follows:

This ‘either or’ approach just doesn’t make sense.

“Tightening up on eligibility would help immensely in slowing down the drain on the system. The widely held historical inequities between compensation for primary care and specialty care have already been addressed. Further change in the balance will merely serve to make specialty care even more difficult to obtain. The 90-day ’global rate’ for procedural charges needs to be relegated to antiquity as in many cases, a procedure oriented specialist can receive higher overall compensation by charging consultation and serial follow-up rather than charging for the procedure itself.” — Clifford C. Marr, MD “We live in a society where primary care medicine is not valued; our society values procedure oriented specialties, even though most of the health care is provided by primary care.” — Vong M. Lee, MD “This ‘either or’ approach just doesn’t make sense. It is obvious that the powers that be are using the ‘divide & conquer’ approach on physi-

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cians to avoid putting any additional funding into these 2 vital programs.” — Earl Wolfman, MD “This one is long overdue.” — Deane Hillsman, MD “I think Primary Care does a lot of work/ is held to a high standard/not compensated as well, which is why there are fewer providers.” — Renée A. Nelson, MD “Time taken and expenses, i.e., malpractice insurance, must be continually re-evaluated to provide fair compensation for both primary and procedural care.” — Katherine Gillogley, MD “…I doubt that simply paying more for primary care and less for procedure intensive care would improve matters for long. After all, primary care people can become as addicted to profit as politicians, specialists, and technocrats. “As I see it, one way to effectively control costs in a government paid system is to take systemic decisions out of the hands of professionals and pols, and put the whole system into a receivership, like a bankrupt financial institution. The receiver would have authority and responsibility to make the system honest and economically sound but could not compel anyone to participate. Therefore would need to act in a way that achieves consent. What he could do, however, is to innovate and circumvent the oppressive bureaucracy…— John Loofbourow, MD “The crisis in primary care is real. We need

to reward doctors for thinking about patients, not windmilling them every 15 minutes or so and not for doing technical procedures. Should we ever get universal health care there will be no one around to see patients in order to get them to the procedurists.” — George W. Meyer, MD “To quote H.L. Mencken: ‘For every complex problem there is an answer that is clear, simple, and wrong.’” — Thomas J. Curran, MD “Regardless of what is done in the realm of compensation for procedures, compensation for primary care must be increased. All one needs to do is to speak with current Internal Medicine residents. Whereas previously about 50 percent practiced some form of primary care after residency, now only about 20 percent choose that path. Since many of these young physicians are carrying massive debt from their training, they have little choice but to choose a specialty in which they will be adequately compensated and have a reasonable prospect of repaying their loans. The result is a current and even greater future shortage of primary care physicians. In such a scenario, who will perform the unglamorous tasks of preventative medicine, discussing advance directives, and listening to the ’worried well’?” — Mark Blum, MD “This action would improve ’Effectiveness’ but probably have little effect on ’Economy.’ “The data clearly show that application of primary care services have a measurable effectiveness on aggregate population-based health outcomes as well as individual health outcomes. Those data for much ‘procedure intensive care’ show little effectiveness on population-based outcomes but attractive outcomes for individuals on a case-by-case basis in both length of life and quality of life. For instance, screening for breast cancer has reduced the death rate for breast cancer among women in California by some 27 percent — a measurable population-based outcome. Similar outcomes for immunizations, hypertension control, diabetes control, and other ‘primary care’ modalities are quite attractive. Outcomes with some ‘procedure intensive care’ may have a disease prevalence (too few patients) insufficient to move the populationbased indicators. Preferentially moving this cost

center as proposed would probably enhance the outcomes indicators. “The data also clearly show that our quiteeffective application of professional standards in the primary care setting have little to no effect on ‘economy’ as measured by amount of money spent in the medical care system. The industry is quite adept at leveraging additional cost centers regardless of changed patterns of illness and death. For instance, in the 1950s we successfully eradicated polio (vaccine) and rheumatic heart disease (penicillin), yet saw the costs of medical care continue to rise and rise. The same thing happened with application of other primary care modalities (other vaccines, other antibiotics) and indeed the 12 percent decrease in cancer rates in California over the past decade with our successful Tobacco Control Program (adult smoking prevalence cut from 23 to 14 percent). “The battle for the soul of our industry does not pit these two groups against each other for reimbursement rates — primary care vs. secondary and tertiary care (’procedure intensive’). Our professional part in this equation is ‘effectiveness’ where we are quite successful; the industry’s part is ‘economy’ where they have been too successful — to the despair of many.” — Donald O. Lyman, MD “The other important alignment of incentives [is] to pay for quality and better outcomes; improved health; risk adjusting [for] the populations.” — T. Warner Hudson, III, MD “MDs are trying to make more by performing many unnecessary procedures.” — For-Shing Lui, MD “I personally feel that medical coverage is medical coverage. Categorizations are what make providers money hungry. If an individual needs to have primary care/procedure together (with procedural care) or one without the other, both need to be compensated. There is ’free’ nothing. Someone pays and it is usually us, ’the tax paying citizenry.’ If we truly are a government of, by and for the people, then together we need to put a lid on it.” — Elisabeth Mathew, MD “Decreasing state/federally funded compensation for procedure-intensive care is not the answer; for most of these specialists can afford

September/October 2008

The crisis in primary care is real. We need to reward doctors for thinking about patients, not windmilling them every 15 minutes or so and not for doing technical procedures.

Unless you can prove the specialists are overcompensated for the hours worked and the acuity of the patients and complexity of the procedures, they should not be made the target for improving the primary care providers’ income.

not to see these patients in lieu of the private sector. However, I do agree that primary care docs should receive more compensation for what we do.” — Anthony W. Russell, MD “Pay is too low for everyone — even if PCPs get paid well, we are unable to refer to specialist because of low pay = inadequate care.” — Kenneth Corbin, MD “We physicians have been for too long playing the fool and agreeing to the zero sum game of the ‘fixed pie’ fraud. This was foisted on us early in the managed care days. The concept is simple: get physicians to fight one another for a fictitious and arbitrary ’fixed pie.’ While they are fighting, preferably one segment against the other, the real money is siphoned off and out of health care. I believe that the unbelievable profiteering that I read about comes out of this ’pie.’ Where else can it come from? So we can continue to beg Washington not to cut our Medicare rates too much, fight over geographic distributions of moneys, sue the governor to stop Medi-Cal cuts because of the ’fixed pie.’ Remember when Medicare paid 20 percent of the UCR fees? Now Medicare is the ceiling, not the floor. The problem is not redistributing the ’pie’; the problem is unreasonable compensation for services rendered across the board. Primary care has been undercompensated for as long as I can remember. It would really be nice to concentrate on patient care, which is what we do best, instead of fighting to stay in business. I spend over half of my day doing administrative work to stay in practice. Much of this is related to insurance coverage issues. What’s wrong with this picture?” — Lee T. Snook, Jr. MD “Robbing Peter to pay Paul is not a strategy that will work. Specialists/proceduralists practices are already full; is paying them less going to motivate them to work harder or try to recruit additional partners? I think not.” — Sidney Yassinger, MD “…When the primary care providers can do what the specialists can do or provide the same services, then they can expect part of the specialist’s compensation. Unless you can prove the specialists are over-compensated for the hours worked and the acuity of the patients and

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complexity of the procedures, they should not be made the target for improving the primary care providers’ income. There is not data that suggests ’economy and effectiveness’ of health care is improved by more highly reimbursed primary care.” — James E. Boggan, MD “Medical reimbursements are deplorable. Why would a physician work for so little money? With that said, I think caring for a percentage of Medi-Cal patients should be mandatory, or there could be incentives. Something so the people who need medical care most are not left to the wolves because of bad government policies and for-profit insurance.” — Tracy L. Burns, MSII “If that happened, the primary care physicians can take care of the sicker patients by themselves!” — W. Randy Martin, MD “Procedure intensive care is already minimally reimbursed. Further reduction will severely impact access.” — Roseanne Pevec, MD “Many procedures are under compensated already. There is a need to reduce payments for unnecessary care and repetitive charges for fraudulent care by phantom clinics.” — Forrest L. Junod, MD “The state and federal government agencies need to provide better compensation for ALL those who provide care for these patients. Just increasing Primary Care compensation isn’t going to help the patient who needs to see a specialist if they (the specialists) aren’t going to be fairly compensated and, therefore, can’t or won’t see the patient.” — Monique Burnette Hanible, MD “Agree with first part, disagree with reducing compensation for procedure-intensive care.” — Robert C. Lentzner, MD “Radiology charges should be in Procedure Category.” — Colin P. Spears, MD “Increase Medicare, leave procedure compensation the same.” — Joseph Lash, MD “When are we going to stop this competition among different specialties in medicine? We all play critical roles and this fight among ‘cognitive’ and ‘surgical’ specialties seems ridiculous.” — Steven C. Patching, MD “We only need to look at all the other devel-

oped nations that manage to provide universal coverage (through a variety of different mechanisms) AND achieve better health statistics than ours, all of them while spending less per capita than we do. What they have in common are systems which are much less specialty and procedure intensive than ours, and reimbursement schedules with much smaller discrepancies between generalists and specialists.” — Francisco Prieto, MD “Increasing payment for primary care is essential, unless we turn it over to midlevels and society lowers its expectations. However, the issue is not primary care vs ’procedure-intensive care’ but rather it is raising payment for E&M services. The nonprocedural and limited procedural specialties such as endocrinology, rheumatology, and neurology, to name a few, are short-changed by the current system. However, lowering payment for procedures will simply result in more procedures, or the panel of participating providers in certain specialties (in certain markets) will diminish to the point of inadequacy. “So, we should raise payments for E&M and keep procedural payments at the current, already unacceptably low to many, levels. Obviously if you combine this with an objective of ‘universal coverage’ it will cost more. The message to society: ’be prepared to pull out your wallet and pay your taxes...or your premiums.’ If we don’t do this, we will witness the further deterioration, including unavailability to the middle classes, of healthcare in this country.” — Ralph E. Koldinger, MD “No one wins with this scenario, except the government bean counters.” — John R. Tucker, MD “The notion of somehow improving the effectiveness of health care by restricting specialty care to those who receive support via governmental agencies but augmenting reimbursement for the primary care physician to this same group is the most egregiously preposterous notion I have been the victim of for years.… The most obvious area of improvement in the economy and effectiveness of health care in our society…would be to provide a better quality of education to this

physician group so they would recognize serious and potentially debilitating disease processes early by personally taking a good history, doing a thorough physical examination then arriving at a specific diagnosis instead of throwing antibiotics or steroids at them or submitting them to random scanning. In my experience, one of the biggest problems that I see is the delay in diagnosis brought about by the lack of access of patients to the doctor due to lack of their ability to pay. Part of our moral obligation as physicians is to see everyone independent of their ability to pay. If providing more money to primary care would assure a longer contact time with all patients by these practitioners and a more astute understanding of uncommon disease processes to which they may become afflicted, it may be justified. But to ration access to the specialized care and new technology that has made the major contributions to medicine in the last half century is preposterous.” — Paul Donald, MD “[I agree because] Primary care is the mainstay of prevention and control of disease.” —Richard S. Isaacs, MD “…a dollar spent on prevention is worth hundreds to thousands later, but we simply can not refuse to compensate for procedures when they are necessary.” — Kelly A. Sharrar, MD “Difficult to assess the impact on decreased comensation to specialists ’procedure-intensive care.’ I do not know if paying more to primary care leads to improved care.” — Henry L. Kano, MD “Why not increase primary care compensation, and make NO change for several years in compensation to specialists doing many procedures?” — Catherine E. Moizeau, MD “…Primary care has always been the triage center and their compensation is so vastly undervalued. We should increase compensation to primary care and trust in doctors to judiciously request appropriate procedures when required. Administration of the programs is the problem and the bureaucracy in charge should be pared down drastically since they have so far been ineffective.” — Jose Ma C Leuterio, MD “And last but not least: This is a joke, right?” — Robert T. Wendel, MD

September/October 2008

No one wins with this scenario, except the government bean counters.

¡Feliz Fourth! By John Loofbourow, MD My cousin’s pool is a few decades old, and the plaster began to flake. So she sent out for bids. To her surprise an out of town bidder was far and away the most competitive. It was a major commercial pool operator who was finding little work in among its usual big customers. It appears that although pool work is scarce, and many companies are laying off experienced people or going broke, this one decided to respond as in the saying, “When the going gets tough, the tough get going.” I imagine it felt there is no better time to expand than when the competition is in trouble. So it enormously widened its area of activity, and focus, and advertized aggressively, both to keep the best people working and to seize the moment by taking a calculated risk. Building or even replastering a pool is not a simple matter to be accomplished by a visit or two to Home Depot. It is an orchestrated series of specialized ‌‌‌‌‌‌‌ tasks which must be independently and collectively completed — correctly. Every step is critical to the final result. The work began in the heat of July last year. The pool was drained. The old plaster was removed. One morning, 12 men appeared to sandblast the tile, and to chip and jackhammer away the plaster down to reinforced cement beneath. The accumulated plaster was raked up and shoveled into wheelbarrows. The wheelbarrows were muscled up a plank to poolside, and then about 75 feet to a truck. There, at last, was an electric lift to move the loaded wheelbarrows up to the truck bed. It was a 10 hour job in July heat. Next was the application of plaster. An entirely different crew of 8 men sprayed the plaster onto

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the pool, in several applications, and worked the material again and again until it was perfectly smooth, formed, and set up. Before, after, and in between these two major efforts were visits from supervisors, and various jobs done by plumbers, electricians, and technicians. What was most curious and impressive was this: The most timely and reliable crews consisted entirely of people who could not speak English well or could not speak it at all. A few years ago in January, a huge eucalyptus tree fell from the south side of our creek, destroying four very old olive trees. The eucalyptus was at least 120 feet high, and 9 feet diameter at the base; three great resinous trunks bearing leafy sails defied the storm. On losing the challenge, the fallen tree roots and base nearly totally blocked the creek. That week the roiling brown water was high; it was raining heavily day on day, yet the authorities informed me the tree was not theirs (and neither was the creek). So I had a commercial tree company remove it. The job required the bone-numbing work of 10 men, over two days. They stood with raging creek water up to their waists, wielding four-foot chain saws, cut and then carried the heavy green 100 pound chunks of eucalyptus on their backs through the fast water, up the banks, and across 150 feet of more shallow water to a truck. The race and origin of these men was obvious. Most were very young. I didn’t ask about citizenship, or work status. I felt only kinship, admiration, and enormous gratitude, wistfully recalling my own youth, and my own foolish, fierce pride in doing heavy work alongside grown men while ‘knocking’ almonds in the dry dusty north valley heat. Afterward, there was a great void in my back yard. The forest was simply gone. In an act of

faith, I planted several fruit trees. Now, by each 4th of July, one little tree throws off hundreds of sweet fruit. Is it a prune or plum? Whatever it is, the recurring luminous blasts of sweet life is like Independence Day fireworks. I confess to my own prejudice in regard to immigrants, the result of personal life experience. I lived for a year in a Chihuahua mining town as a child. I worked with and interpreted for braceros as a young man. I worked in Spanish-encrusted fields and almond orchards every summer for many years. I interned in the Panama Canal Zone. I practiced in Woodland where I was the only Spanish-speaking physician in the entire region at the time. Then, aware of the life of migrants, I spent 8 years organizing and operating migrant and East Yolo clinics. My wife is from Chile and, when we were

married, I felt the need for a master’s degree in Spanish Literature, because I knew how to swear and lie in many dialects but knew no literature, history or grammar. These experiences marked and changed my life. As one result, it seems to me that the immigrants of all sorts who continue to risk life and health to seek better lives in the U.S. are our national life’s blood. Those floods and storms leading ultimately to the planting of fruit trees, and now the annual July explosion of sweet fruit thrown up from the dead tree beds speak to me of the significance of recurring floods of immigrants who continue to create and recreate this most fortunate nation. So on Independence Day l like to send forth this metaphoric greeting: Feliz 4th!” john@loofbourow.com

Send Us a Caption

A View from Medical Reception

This view in a medical reception area — of a man in a snake’s coils — is one of several cartoons by Gary Williams depicting absurd reception or waiting room scenes. We invite any reader with a sense of humor to send a suggested caption to webmaster Melissa Darling at mdarling@ssvms.org. There is no prize. But if we get some good replies, we’ll publish the best ones.

“I’m sorry, sir, your health plan covers animal bites, but not animal constrictions.”

September/October 2008

Book Review

Teacher Cheating, Falling Crime Rates — and More By William Peniston, MD FREAKONOMICS: A Rogue Economist Explores the Hidden Side of Everything, Steven D. Levitt and Stephen J. Dubner, Harper Collins, New York, 320 pp, $27.95, ISBN: -13:978-0-06-123400-2 (rev. ed.). Since I know practically nothing about economics, I suppose I’m the ideal person to review this book. Especially since co-author Levitt (the economist) “professes little interest” in “monetary issues” and blustered with selfeffacement. ”I just don’t know much about the field of economics,” and “I’m not good at math. I don’t know a lot of econometrics, and I also don’t know how to do theory. If you ask about whether the stock market is going to go up or down, if you ask me whether the economy’s going to grow or shrink, if you ask whether inflation’s good or bad, if you ask me about taxes — I mean, it would be moral fakery if I said I knew anything about any of those things.” Levitt sees economics as “a science with excellent tools for gaining answers but a serious shortage of interesting questions.” He has the ability to ask such questions and his “abiding interests are cheating, corruption, and crime.” So some of the more interesting topics in the book are about cheating by schoolteachers and sumo wrestlers, similarity of the Ku Klux Klan and real estate agents, and the causes of falling crime rates. I found the chapter on the falling crime rate one of the most interesting. In 1989 crime was about at its peak in the United States. During the previous 15 years violent crime had risen 80 percent and was a major concern nationwide.

During the early 1990s, the crime rate began falling at a sudden and rapid rate which left the “experts” confused for years. The explanations published in newspapers were numerous, there being seven that were more frequently named and an additional more than four theories recorded. In his analyses of the seven, Levitt was able to find only three that had a significant effect on lowering the crime rate. I found this section of the book rather confusing in that he doesn’t discuss the seven most popular explanations in an orderly manner, with a presentation of data and a firm statement about the reasonableness of the explanation. He does start out doing that with what he calls a “fairly uncontroversial one: the strong economy.” He quickly disposes of this as an important factor in a short paragraph that does present significant data. But the next explanation, increased reliance on prisons, is pushed aside by “flipping the crime question around” and asking, “Why had it risen so dramatically in the first place?” What follows is over three pages of an interesting discussion of this subject including two pages about the lack of effectiveness of the death penalty, for which some data are presented. But in this section there is only the statement that “harsh prison terms have been shown to act as both deterrent and prophylactic,” which is accompanied by no data. Despite these perceived shortcomings Levitt provides convincing data that the decriminalization of abortion was a major factor in the

September/October 2008

Nominations for SSVMS Awards SSVMS is seeking nominations for its most prestigious awards, to be presented at the Annual Meeting in January 2009. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must have been in practice for at least 15 years, and may be active, retired or hold an administrative position The Medical Honor Award is presented to a member, who is currently practicing or retired, whose high achievement has resulted in a contribution of great significance to medicine or community health in the El Dorado-Sacramento-Yolo region. The candidate must be member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send nominations to the Scholarship & Awards Committee, SSVMS, 5380 Elvas Ave. #100, Sacramento, CA 95819. The deadline is November 1, 2008.

decline of crime in the United States. A study attempting to measure the academic progress of more than 20,000 children from kindergarten through the fifth grade is presented in the chapter “What Makes a Perfect Parent.” The acquired incredibly rich set of data were subjected to “the economist’s favorite trick: regression analysis” which is described as more art than science. Although I never learned what “regression analysis” is (I should have “Googled” it!), I found it and the chapter on children’s names and what they tell about the parents almost as interesting as the one on the crime rate. The epilogue suggests a result of reading the book may be finding “yourself asking a lot of questions.” It also repeats the suggestion that, if “morality represents an ideal world, then economics represents the actual world.” This is the “Revised and Expanded Edition” of the book and contains some 92 pages of “bonus” material from the New York Times Magazine and the Freakonomics Blog. peniston@mcn.org

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Galen’s Four Wet Humors in Medicine and Music The following is reprinted from program notes of a San Francisco Symphony concert earlier this year. Symphony No. 2, Opus 10, FS 29 By Carl August Nielsen, 1865-1931 “It was held that physiological imbalance (produced by an excess of one of the humors, for example) would be reflected in bodily illness and in exaggerated personality traits. Thus, if a person had an excess of blood...he was expected to have a sanguine temperament, be optimistic, enthusiastic, and excitable…. Too much of a humor called black bile (congealed blood from the spleen) was believed to produce a melancholic temperament. The term melancholia literally means black bile, and there are literary allusions to venting one’s spleen. When someone was oversupplied with yellow bile (the yellowgreen gall secreted by the liver and stored in the gall bladder), he was held to become choleric… angry, irritable, and to view his world with a jaundiced eye…. Finally, with an abundance of the humor called phlegm (as secreted in the throat), people were supposed to become stolid, apathetic, and undemonstrative…grow phlegmatic.” Encyclopedia Britannica. Shortly before his death Nielsen wrote the following program notes for his symphony, The Four Temperaments, translation by Harald Knudsen: “The first movement, Allegro collerico, starts impetuously with a theme that develops with another little theme on the clarinet and rises to a fanfare leading to the second subject, which sings very expressive, but is soon interrupted again by violently shifting figures and rhythmic jerks. After a pause the second subject, ff, unfolds itself with greater breadth and strength which gradually pass away, when the development begins; here the above-

mentioned material is worked, now wildly and impetuously, like one who forgets himself, now in softer mood, like one who regrets his irascibility. Lastly comes a coda (stretto) with vehement passages in the strings… “The second movement is meant to be a complete contrast to the first. I don’t like programme music, but perhaps it may interest my listeners to know that during the preparatory work I thought of something like the following: I visualized a young fellow [who] was uncommonly lovable…. He was about seventeen or eighteen years old, with sky-blue eyes, confident and big. In school he was loved by all, but...he never knew his lessons. But it was impossible to scold him, for everything idyllic and heavenly in nature was to be found in this young lad…. His…inclination was to lie where the birds sing, where the fish glide noiselessly through the water…. I have never seen him dance; he wasn’t active enough for that, though he might easily have got the idea to swing himself in a gentle slow waltz rhythm, so I have used that for the movement, Allegro comodo e flemmatico, and tried to stick to one mood, as far away as possible from energy, emotionalism, and such things. Only once is there a forte. What’s that? Did a barrel fall into the harbor from a ship, disturbing the young chap lying on the pier dreaming? Maybe. So what? In a moment everything is quiet again: the lad falls asleep, the world dozes, and the water is again smooth as a mirror. “The third movement tries to express the basic character of a heavy, melancholy man, but here as always in the domain of music, the title or program is only a pointer. After a bar and a half of introduction, the theme begins, drawn heavily towards a strong outcry of pain

September/October 2008

Too much of a humor called black bile (congealed blood from the spleen) was believed to produce a melancholic temperament.

— an ad from the collection of the Sierra Sacramento Valley Museum of Medical History

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(ff); then comes, on the oboe, a little plaintive sighing motive, that slowly develops, ending in a climax of lamentation and suffering. After a short transition there is a quieter, resigned episode in E-flat major. A long, somewhat static passage now follows, at the end of which the parts intertwine like the threads of a net, and everything subsides; then suddenly the first theme breaks out with full force, the various motives sing together, and the whole moves to its close, where it sinks to rest. “In the finale, Allegro sanguineo, I have tried to sketch a man who storms thoughtlessly forward in the belief that the whole world belongs to him…. There is, though, a moment in which something scares him, and he gasps all at once for breath in rough syncopations; but this is soon forgotten, and even if the music turns to minor, his cheery, rather superficial nature still asserts itself. All the same...the final march, though joyous and bright, is yet more dignified and not so silly and self-satisfied as in some of the previous parts of his development.”

Board Briefs July 14, 2008 The Board: Received an update on the California Medical Association’s sponsorship of AB 214 which, if passed, will establish a new diversion or physician wellness program for California physicians. Authorized the Executive Committee to implement, if necessary, a reimbursement program to assist members who may be adversely impacted by an extended delay in the passage of a California state budget, and a resulting delay in Medi-Cal payments. Reviewed a request from the California Medical Association to schedule a MiniInternship Program sometime in the Fall for CMA employees interested in spending a half or full day with a physician. The program will help facilitate a better understanding about how physicians spend their day and give the participant a broad perspective on the practical, business and clinical side of medicine. Tabled for further discussion publication of the 2009–2010 Pictorial Membership Directory. Approved the Membership Report: For Active Membership — Manoj Agarwal, MD; Julieta DominguezJones, MD; Michael A. Haight, MD; Alex J-C. Liou, MD: Sandra L. Schank, MD; Katharina M. Truelove, MD; Jeffrey L. Young, MD. For Reinstatement to Active Membership — Kristie A. Bobolis, MD; Ron E. James, MD; Aaryan N. Koura, MD; Taja A. Manuselis, MD; Ali Tajlil, MD; Robert S. Treat, MD.

For Retired Membership — Elaine P. Silver, MD. Serving as the Administrative Board to the Community Service, Education and Research Fund (CSERF), the Board authorized staff to renegotiate the SPIRIT Project contract with Sacramento County. The contract authorizes CSERF through its SPIRIT Project to provide volunteer physicians and other health care providers to treat patients in the county-run clinics. Also, the Board approved expansion of the SPIRIT Project to The Effort, a community health center serving the uninsured and underinsured in the Sacramento area.

September/October 2008

Clínica Tepati: a Student-run Clinic for Indigent Latinos By Ryan McMahan, Executive Administrator, Clínica ‌Tepati The author is a pre-med student at UC Davis. Founded in 1974 as a response to the indigent Latino community of Sacramento County lacking basic health services, Clínica Tepati is devoted to providing basic primary care and knowledge to help patients make informed choices to improve their own lives and those around them. As an advocate for this ill-provided community, Clínica Tepati continually searches for resources to help its efforts to decrease health disparities. In addition, physician volunteers provide clinical exposure, hands on experience, education and mentorship that nurture and motivate students to achieve their personal best, and encourage them to continue their professional work with the Latino community and other underserved populations. Clínica Tepati operates under a three-part mission of health services, education and advocacy. The clinic provides basic health care services and health education to over 1,000 patients annually, the majority from the underserved Latino community of Sacramento. Undergraduate and medical students — there are Jesus Perez MSIII goes over his plan for a patient with an undergraduate student at the clinic.

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now 60–70 volunteers — learn from first-hand clinical experience in a respectful environment that fosters educational exchange and helps each student become a conscientious, compassionate individual. Additionally, Clínica Tepati provides both students and patients with positive role models and mentors working as healthcare professionals. Volunteers go beyond providing standard care to become advocates for recent immigrant patients by serving as both linguistic and cultural interpreters and providing a voice for these individuals. In recent years Clínica Tepati’s quiet tradition of providing free, culturally competent care has been increasingly threatened. The loss of our pharmaceutical budget has caused hardship for our vulnerable patients and our clinic. We are struggling to find other ways to cover their medications.

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. — Glennah Trochet, MD, Secretary HAIGHT, Michael A., Pediatrics/Gastroenterology, Loyola Univ 1983, UCDMC, 2516 Stockton Blvd., Ticon II, Sacramento 95817 (916) 734-3750

REISS, Mimi E., Family Medicine, UC Davis 2005, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

TAGORE, Kuldeep S., Gastroenterology/Hepatology, Creighton Univ 2001, Sutter Medical Group, 2801 K St #502, Sacramento 95816 (916) 733-8730

MURRELL, Karen L., Emergency Medicine, Southern Illinois 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

SCHANK, Sandra, Psychiatry, Univ Nebraska 1991, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

TRUELOVE, Katharina M., Family Medicine, Tulane 2000, Marshall Family & Internal Medicine, 5137 Golden Foothill Parkway #120, El Dorado Hills 95762 (916) 933-8010

grateful patients each Saturday. As physician volunteers, our preceptors oversee and teach medical students throughout the patient’s visit, and get the rewarding opportunity to work with the underserved. Clínica Tepati, located at 1500 C Street in Sacramento, is open Saturdays from 9 am to 4 pm. For more information on how you can become one of our preceptors, please contact Ryan McMahan at the email address below. rymcmahan@gmail.com

Unlike other student-run clinics, Clínica Tepati has no permanent home and operates solely out of the generosity of the Capital Health Center. As Sacramento’s budget crisis continues to ravage primary care services, our patients’ medical home is uncertain. Despite these and other obstacles, Clínica Tepati has kept its doors open every Saturday to make our patients healthier and happier. We simply could not keep our doors open without the continued support and enthusiasm of our dedicated physicians, who come in to teach students and care for about two dozen

top left: Dr. Andrew Burt, a volunteer community physician, listens to Elisheva Danon, MSIV, present patient information. above: Five undergraduates working in the clinic meet in the lab area. From the left are Fatima Zelada, Betzabel Ortiz, Norma Monico, Kaylan Christianer, and Ryan McMahan.

September/October 2008

Classified Advertising

Positions Available PART-TIME PHYSICIANS for urgent care center. Hours flexible. BC/BE in FP, IM, EM preferred. Competitive compensation and malpractice paid. Kim Marta, MD. The Doctors Center, 4948 San Juan Ave., Fair Oaks, CA 95628. (916) 966-6287. BUSY PRIMARY CARE CLINIC in Midtown area seeks PT and FT MDs. Multi-lingual staff. Competitive Compensation. Please call (916) 275-3747 or fax resume to (916) 760-0837.

Office Accreditation We’ll prepare your office for licensure, general anesthesia or conscious sedation with any accrediting agency. Contact Outpatient Settings at (530) 758-3324 www. outpatientsettings.com

Office Space For Lease: Medical Office Space at 9717 E.G. Florin Rd., Elk Grove, 1785 Sq Ft, 5 Treatment Rooms, Large Reception Room and Business Office, Private Office, X-ray Dark Room and Laboratory Space. Call: 916-479-1827 West Sacramento Medical Office Space to Rent. Conveniently located. 1-4 exam rooms, 600-1000 sf. Full services available. Contact Liz: (916) 275-3747.

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

• • • • • • •

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

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

Membership Has Its Benefits!

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

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

Billing & Collections

Athenahealth 1-888-401-5911

Car Rental

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

Clinical Reference Guides-PDA

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

Collection Services

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

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

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

Office Supplies

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

Practice Management Supplies

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

Electronic Claims

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

Healthcare Information Technology Products

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

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

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

HIPAA Compliance Toolkit

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

Investment Services

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

Magazine Subscriptions

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

Notary Service/Free to Members

Medical Society (916) 452-2671

Security Prescription Pads

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

Professional Publications

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

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

Back by Popular Demand: A Magical Medical History Tour The final lecture of the Sierra Sacramento Valley Museum of Medical History is a Magical Medical History Tour. Faith Fitzgerald, MD, an internist, Professor of Medicine and Assistant Dean of Humanities and Bioethics at U.C. Davis, presents cases of famous people, their illnesses, their accomplishments and associated interesting things. Her talk is at 7 p.m. November 5, at the Medical Society, 5380 Elvas Avenue. It is free and open to the public, but reservations are needed to ensure seating. Call 452-2671.

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partnership

whatdrivesyou? A commitment to excellence. A passion for the art of medicine. A basic desire to heal. Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL.

(800) 652-1051 www.norcalmutual.com

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