2008-Nov/Dec - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2008

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Time Flies When You’re Working with Top People

Margaret E. Parsons, MD

SSVMS Election Results

Paranormal Wilton Pagers

Chris Sweeny, MD

The Joan Viteri Memorial Clinic Puts Down Roots

Matt Karp, MSII

Abusing Workers’ Comp

John Loofbourow, MD

Malignant Code Syndrome

Ulrich Hacker, MD

A Small Medical Clinic on the Burma-Thailand Border

Terrence Smith, MD, MPH

California’s Ambulance Services During the 1960s

Irma West, MD

Become a Volunteer

Kristine Wallach

A Posit on Universal Electronic Medical Records

New Applicants

In My Opinion The Next Mideast War Has Already Begun

David J. Gibson, MD, and Jenifer Shaw Gibson IN MEMORIAM Arnold R. Haugen, MD

Health Notes

Glennah Trochet, MD

Dr. Paul Kelly Honored for his Blood Salvage Work

The Morning Walk

Vicki Wolfe

William Peniston, MD

Voices of Medicine

Board Briefs

Del Meyer, MD

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 This oil painting by Dr. Robert Lentzner began with a series of sketches in Paris, France, of boats on the Seine with the famous Louvre Museum in the background. “I completed the painting on October 4, 1998, the day our first granddaughter was born,” he recalls. The painting is 18 by 22 inches in size. It used to hang in his office, and is now in a bedroom of his home.

Volume 59/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

November/December 2008

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2008 Officers & Board of Directors Margaret Parsons, MD President Charles McDonnell, III, MD President-Elect Richard Jones, MD Immediate President District 1 Alicia Abels, MD District 2 Michael Lucien, MD Phillip Raimondi, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD District 4 Ulrich Hacker, MD 2008 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Barbara Arnold, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Craighton Chin, MD At-Large Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Margaret Parsons, MD Charles McDonnell, MD Robert Midgley, MD Janet O’Brien, MD Richard Pan, MD Earl Washburn, MD

District 5 David Herbert, MD Robert Madrigal, MD Elisabeth Mathew, MD Stephen Melcher, MD Anthony Russell, MD District 6 Marcia Gollober, MD

Alternate-Delegates District 1 Robert Kahle, MD District 2 Samuel Ciricillo, MD District 3 Ken Ozawa, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Richard Gray, MD 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

Time Flies When You’re Working with Top People By Margaret E. Parsons, MD As the calendar year winds down, the staff members at SSVMS are busy with dues statements, planning the annual dinner, and unwinding after the CMA House of Delegates meeting. These are just some of the items from the current calendar. I continue to be impressed by the year-round activities of our SSVMS staff, physician leaders, and volunteers. Organized medicine at all levels — local, state, and national, whether general medical or specialty-specific — work in different ways to help us continue practicing in the way we believe we should to care for patients. It has been an amazing year for medicine in advocacy at both state and federal levels: Medi-Cal, health care reform, and Medicare funding issues lead the list. This work was accomplished by all levels of organized medicine and physicians participating to achieve a common goal. Through the year, SSVMS met with state and federal elected representatives on these issues. SSVMS also advocated on behalf of local patients and physicians at the county level and worked to care for those in our region through physician volunteers in county and community clinics. In conjunction with CMA, SSVMS assisted members through the transition of our Medicare payor to Palmetto this fall. Without this advocacy, the headaches, difficulties, and slow payments would have been far worse. As one of those personally affected by delayed payments for three months, I know the value of organized medicine helping to get things on track. Having attended many committee meetings over the year, I was impressed by the hard work of our physician volunteers and staff on this magazine, peer review, public health, chil-

dren’s health, history of medicine, development of CME programs, membership, SPIRIT clinic volunteers, and more. October also brought the CMA House of Delegates, and SSVMS is the largest society in the 11th District. Our delegation spoke thoughtfully and well, and our members were leaders on reference committees; Marcia Gollober chaired one committee. We had solid representation on the board from Dean Hadley and Joanne Berkowitz. SSVMS members in CMA Board of Trustees slots included Lee Snook (solo/small group representation) and Paul Phinney (large group representation). Richard Pan chaired the Council on Legislation. Paul Phinney was elected as ViceChair of the CMA Board of Trustees (see page 9). Three cheers to Paul and his hard work that has earned the respect of the CMA board and led to this key leadership role; he will have a difficult and thoughtful job as organized medicine faces challenges in future years. I personally am very grateful for, and proud of, an excellent Board of Directors and Executive Committee. Through the year, the board has had thoughtful deliberation and worked to insure that we meet the needs of members and keep an environment for physicians to best care for patients. It is a great feeling when you can finish a meeting and know that different experiences and viewpoints can be heard and discussed, and a plan brought together. And the same goes for the Executive Committee members: Drs. Rick Jones, Charles McDonnell, Steve Melcher, and Glennah Trochet

November/December 2008

SSVMS Election Results 2009 Board of Directors President: Charles H. McDonnell, III, MD President-Elect: Stephen F. Melcher, MD Immediate Past President: Margaret E. Parsons, MD District 1, North: Alicia Abels, MD District 2, Central: Michael Flaningam, MD, Michael Lucien, MD, Glennah Trochet, MD District 3, South: Katherine Gillogley, MD District 4, El Dorado: Ulrich Hacker, MD District 5, Permanente: John Belko, MD, David Herbert, MD; Robert Madrigal, MD, Elisabeth Mathew, MD, Anthony Russell, MD District 6, Yolo: J. Dale Smith, MD 2009 CMA Delegates and Alternates District 1, North: Jon Finkler, MD, Delegate; Robert Kahle, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Margaret Parsons, MD, Alternate District 3, South: Barbara Arnold, MD, Delegate; Ken Ozawa, MD, Alternate District 4, El Dorado: Ronald Foltz, MD, Delegate: Demetrios Simopoulos, MD, Alternate District 5, Permanente: Elisabeth Mathew, MD, Delegate; Boone Seto, MD, Alternate District 6, Yolo: Marcia Gollober, MD, Delegate; Karen Hopp, MD, Alternate At-Large, Office #7: Stephen Melcher, MD,Delegate; Mubashar Mahmood, MD, Alternate At-Large, Office #8: Charles McDonnell, MD, Delegate; Gerald Upcraft, MD, Alternate At-Large, Office #9: Norman Label, MD, Delegate; Alternate (Vacant) At-Large, Office #10: Satya Chatterjee, MD, Delegate; Alternate (Vacant) At-Large, Office #11: John Ostrich, MD, Delegate; Alicia Abels, MD, Alternate At-Large, Office #12: Kuldip Sandhu, MD, Delegate; Alternate (Vacant) At-Large, Office #13: Earl Washburn, MD, Delegate; Richard Gray, MD, Alternate At-Large, Office #14: Richard Pan, MD, Delegate; Robert Madrigal, MD, Alternate At-Large, Office #15: Richard Jones, MD, Delegate; Connie Mitchell, MD, Alternate At-Large, Office #16: Michael Burman, MD, Delegate; Anthony Russell, MD, Alternate At-Large, Office #17: Janet O’Brien, MD, Delegate; Sanjay Jhawar, MD, Alternate

— a thoughtful and hard-working crowd that makes our monthly Executive Committee meetings a pleasure. Dr. John Loofburrow continues at the helm as editor of this magazine and does an outstanding job leading his editorial board with his caring and diligent style. Dr. Bob LaPerriere’s commitment to the medical museum continues to make it a well-polished gem. Over the year you may have noticed some changes if you have been by the offices. In addition to taking care of the society, we must care for our building (which we own) and the board has worked to make fiscally sound decisions. Old and leaky windows have been replaced, bathrooms updated, and stairways improved. The backbone of the organization continues to be our superior staff led by Bill Sandberg. Through the year, I have met several of the other Executive Directors from throughout the state and I am ever more appreciative of Bill and his work on our behalf. My office is just two buildings down from the SSVMS building on Elvas Avenue, so I frequently walk over to chat with Bill, sign a letter, or check on something; and I see the rapport and commitment of the staff. They are truly a wonderful team. Why do I write about all this? If you think patient care, scope of practice, fair payor policies, physician reimbursement, vaccine programs, balanced billing, public health initiatives, health care reform, physician workforce, medical education, and so many more issues are important, then join me and the rest of the board in renewing your membership. More important, please help keep our society strong by reaching out and recruiting another member. We face challenging times, and need the strength of strong medical organizations with high membership of the physician population working on our behalf. I, the board members, and the staff are available anytime to talk to prospective members. As I type my last “President’s Letter,” my appreciation goes to the organization and its members for the opportunity to have served as President. The energy, ideas, and commitment of the members have made it a pleasure. mepmd@ix.netcom.com

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Paranormal Wilton Pagers By Chris Sweeny, MD This article was adapted from an internal South Kaiser email with permission of the author.

When I first moved to Wilton, the pager sang merrily all hours of the day and night. There was a pager company change a few years ago and I had to turn in my old, reliable, constantly whining pager for a new one. That was the end of my wireless connection from the hospital to my house. I went through a few pager changes without success until I was handed my current pager which is so large it has been tested for illicit steroid use twice. It has so many functions and buttons on it that it requires a bound manual in three languages to explain its many wonders. I must confess that just the last two weeks I have been experimenting with the function buttons on it very much at random; I fear these manipulations are the underlying cause of the current national financial crisis and market crash. I can now get about 50 percent of my pages at home. The remaining 50 percent go zipping by my house at the speed of em waves and are hitting cows in Nebraska. This constant bombardment of the cows by my pages is probably what is making them all face north, so that the pages hit them in the flank rather than the face. For a while I was mystified as to why I could get pages in San Francisco, but not in Wilton. Even more intriguing was that my very large new multifunctional 1080i high def 7.1 surround sound mp3-ready blue ray pager would not work in the hospital. I was forced to obtain a second pager for the hospital, while using my giant pager at home. Even after 25 yrs of carrying one of those

little plastic sadists around, I still get an adrenaline surge whenever it goes off, and it takes 10 minutes for my vital signs to return towards normal. Now I have two of them which has led to a host of comical situations. I have my home pager at work and my work pager at home, or both pagers or neither, or one going off in my locker in the OR all day while the other sits mute and smug in my pocket like a wicked step sibling determined to get me in trouble. I am highly overeducated and reflect the Peter Principle to its extreme by rising well beyond my level of competency mostly through guile and hush money. So Iâ&#x20AC;&#x2122;m beyond the extremes of my coping abilities. I finally took a final drastic step, the step which has never failed me in any situation, any crisis, any problem. I gave up. I live with my two pagers and they constantly play their tricks on me. I no longer complain about them. After six months other people also stop complaining. This still doesnâ&#x20AC;&#x2122;t explain why I could probably get pages on the Sea of Tranquility, but not in Wilton. I have concluded that the problem is not the pager system at all. The problem is Wilton. It is either paranormal in its origin, (a curse, a hex, an ancient burial ground); or infested by extraterrestrials practicing shutting down earth communications before invading, (Dave Manske comes to mind);or quark leakage from Rancho Seco, the reportedly decommissioned nuclear power facility, splicing together humans and animals creating scorpion creatures with anger management issues.

I finally took a final drastic step, the step which has never failed me in any situation, any crisis, any problem. I gave up.

ChrisSweeny@kp.org

November/December 2008

The Joan Viteri Memorial Clinic Puts Down Roots The student-run clinic that formerly used a cramped RV to treat patients now has a home in Sacramento’s Oak Park.

By Matt Karp, MSII Matt Karp is one of seven co-directors of the Joan Viteri Memorial Clinic, a UC Davis student-run free clinic treating IV drug users and sex workers. The last time an article written by a Joan Viteri Memorial Clinic co-director appeared in these pages, back in 2004, our clinic still had wheels. That’s not to say that the wheels have fallen off the bus (although from some of the stories told, that wouldn’t be a surprise), but that the co-directors before us saw the wisdom of spending our ever-rising RV maintenance fees more directly on patient care. We thus put down roots in Oak Park, sharing a building with the Harm Reduction Services (HRS) needle exchange program detailed in Dr. Glennah Trochet’s report in the July/August 2008 issue. While we still find ourselves apologetically explaining our dearth of mobility at fundraising events, the added stability has greatly assisted our patients in (a) being able to find us every weekend and (b) not having to undergo a physical exam in the cramped confines of a mid-size recreational vehicle. Being next door to a needle exchange has allowed us to expand our outreach while staying in one place, an added benefit of the nowlegal exchange programs in the City of Sacramento. Working with HRS,

we get referrals from patients who use the needle exchange throughout the week. Additionally, because of HRS’s excellent reputation with the intravenous drug user community, we get a leg-up on gaining the trust of a population that is skeptical of the white coat and stethoscope crowd. As co-director Sally Graglia writes, “We want to build relationships of trust, communication, and understanding with the hope that in the future we will be advocates for our patients — that when they ask for resources to change their lives, when their personal lives will enable them to change their lifestyle — they will have us to help them.”

November/December 2008

The seven co-directors of the Joan Viteri Memorial Clinc, all second year medical students at UC Davis: From the left, Mikel Matto, Melissa Loja, Sally Graglia, Rasna Sandhu, Jordan Lilienstein, Dan Stein and Matt Karp.

The Joan Viteri Memorial Clinic is now located at this site.

In the past year, our clinic has grown in more ways than one. Our physical space has grown exponentially, since all we had to do was add one exam room to the two existing. Combine that with the addition of adequate air conditioning and last year’s addition of solid walls and, from our perspective, we’re practicing limited resource medicine while living the life of Riley. We’ve begun to offer the hepatitis A/B vaccine to our patients free of charge, and we’ve already seen nearly a hundred new patients this year, moving the total number of individual patients in the 10 year history of the clinic past the thousand mark. When I tell family members or friends that I work in a clinic that targets drug users and prostitutes, it invites a certain quizzical look. More forward people just blurt out, “But why?” We all have our reasons of course, but first: it’s not about us. I mean that seriously. As medical students, we spend such long afternoons in simulated interactions with actors playing patients, groping and stumbling playing doctor (talking about how we’re feeling, how we’re reacting to the patient, how we’re projecting ourselves), that it is very easy to forget that it is not about us. It is, of course, about the patient. This is no more at the forefront of the mind than when a medical student confronts one of the hardest of physician duties: being the bearer of bad news. In our clinic, this often takes the form of informing patients that they have tested positive for hepatitis C. As medical students, we often get caught up

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in our own “act”: to convey the news accurately, to explain complex odds and treatment options to an emotionally distraught patient, to try to explain how bad, or not bad, the case may be. It can be overwhelming, it can be a burden; but it is, of course, nothing compared to the burden the patient carries. All this is to say that, while we certainly have our individual reasons for working at Joan Viteri Clinic, the reason is the same as why we got into medicine in the first place. Our patients are just like any other patients: they need us. As another co-director, Melissa Loja, writes, “I want to be the kind of doctor who can give care without judgment, to a population that is devastatingly underserved with few advocates.” As co-directors, we oscillate between idealistic optimism and the realistic difficulties of the population we treat. Luckily, medical students are never short of the former. Co-director Dan Stein loves “knowing that I’m delivering healthcare to someone whose only other option is the emergency room, where they can often be treated as fringe patients with fringe needs, and perceived as people whose worth is diminutive.” Harm reduction is the keystone of this approach. Thus, co-director Jordan Liliestein writes that “our role in harm reduction is to keep our patients alive and healthy long enough for them to find their way out of their addictions. Even if they fail, it makes them no less human, and no less deserving of the best care we can provide to them.” Abscesses are the primary reason many of our patients come in, only to disappear until the next infection. During that time, we try to treat them for their immediate problem as well counsel them on the risks of sharing needles and of not cleaning injection sites. Abstinence is always the goal, but never to the point that it is a barrier to care. This is especially important considering that our patients, just like any others, get all sorts of diseases completely unrelated to IV drug use. Thus, one of the advantages of optimism: being able to see past the drugs to treat our patients. This article was written in a large part to

provide an accounting of our clinic and its philosophy to the greater Sacramento and Sierra medical community. As co-director Mikel Matto puts it, “I get to provide healthcare to a group of people that are often forced to go without. And in doing so, I learn how to represent this group’s needs and challenges to other physicians and those in the community with less exposure.” We are constantly trying to educate both ourselves and the greater medical community on approaches and needs specific to this unique population. However, many of the physicians’ goals are not so different with these patients than any others: patient compliance, behavior modification, risk reduction. Come February, we will hand the reins of the clinic over to a new class of co-directors. They will no doubt make their own improvements; more importantly, they will gain real experience with patients who, in so many ways, present many of the same challenges that we all face in the practice of medicine. The patients and medical students at the Joan Viteri Memorial Clinic would appreci-

ate your help as physician volunteers; because we are an official student-run clinic, malpractice is covered through UC Davis. Please see our website at http://cim.ucdavis.edu/clinics/joan/ index.html for more information. karp.matt@gmail.com

Dr. Paul Phinney Elected Vice Chair of CMA’s Board of Trustees We are pleased to announce that Dr. Paul Phinney, Past President of SSVMS (in 2003) and CMA Trustee representing the Very Large Medical Group Forum, was elected Vice Chair of the CMA Board of Trustees following this year’s House of Delegates meeting. Dr. Phinney was in a contested election with two other trustees, and he has been campaigning since the 2007 House of Delegates. This election puts Dr. Phinney on the CMA Executive Committee and on the track to even greater responsibilities within the CMA if he so chooses. Congratulations to Dr. Phinney! — Bill Sandberg

November/December 2008

Abusing Workers’ Comp By John Loofbourow, MD These observations about an abusive physician were originally told to me by a former patient, a person I have known for decades as very reliable. We are friends. I know his family, his life story. I found his assertions significant enough to invest considerable time and trouble to confirm them. I will not reveal process, or name names, places or times. Frankly, it’s likely no one will ask me to do so; no journalist, no legislator or watchdog agency will care. Why? Because the facts merely reflect an unwelcome but well documented aspect of human behavior: We cheat for profit when unlikely to be caught — when within the letter of the law, even though clearly abusing its intent and our own professed professional, societal and moral principles. We usually do so not by stealing money, but by abusing a process. I relate this story not to suggest new laws or to berate a respected colleague, but to make this point: When more than two principal parties are involved in medical care, any of them is sometimes able to abuse the others. Physicians and insurance providers are capable of bullying, or cheating, and some patients are as well. While abuse can take place when physician and patient are one on one, each added participant makes matters worse. (I won’t consider lawyers and the courts, here, even though the added complexity and dysfunction these other players bring is very significant.) The dismal outcome with only three parties is obvious enough, for example, in Workers’ Compensation injuries, where the parties subject to abuse are: The powerless patient whose injuries are severe and who cannot economically or emotionally

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tolerate months or years of delays, denials, and referrals. Meanwhile physicians and the insurance carrier profit from the same endless ”care.” He may lose his mortgage, his car may be repossessed, and his family disintegrate during this cruel process. If he seeks legal help, all too often the severely injured worker becomes powerless in three hostile arenas rather than two. The powerless physician who can’t justify or afford a practice designed to deal with pre-authorizations, tactical denials, delays in payment, and continually changing heavy administrative burdens. It becomes economically and emotionally tempting for this doctor to abandon a well known patient, turning “comp” cases over to a workers’ comp specialist of some sort. The powerless insurance carrier that is abused by patients who make false claims and are willing to stubbornly milk the system. This is a kind of medical blackmail that threatens ever increasing medical and legal costs. The insurance carrier can also be abused by medical practices artfully organized to systematically plant and harvest fees, sometimes in naked collusion with patients. The situation below is one where the insurance carrier is abused, although in this case the patient is not a participant.

Mr. X’s Complaints Mr. X and his wife enjoy good general health; they have a large, close family, and own a modest but comfortable home. Mr. X worked at heavy labor for 38 years, developing severe incapacitating back problems not amenable to surgery. By age 54, after thorough workup, his condition was judged permanent and stable. In such workers’ comp cases, the patient can elect either a lump sum settlement without medical benefits, or lifetime coverage for injury-

related medical care. Realizing he would require ongoing medical care for his back, Mr. X chose paid medical care instead of a lump sum settlement. Now retired, he also receives Medicare and Social Security benefits, so his middle class medical situation is, altogether, satisfactory. With medications he is able to walk, stand, or sit for up to a half hour, can lift light objects from waist height, can reach, bend, and twist with limitations. He sleeps in three or four hour shifts, remedicates, and in that way totals about 7 hours sleep plus a 1 or 2-hour daytime nap. He stretch-exercises as prescribed, and walks a half hour twice daily. This has been his life for about 6 years, without significant change. He projects the image of a successful, contented patriarch, uncomplaining, a rather wryly stoic but cheerful man who has struggled, and won his battles with, and for, life. Nonetheless, when we spoke recently he complained rather uncharacteristically about his medical care. I quote, while taking literary, but not factual, liberties: Mr. X: “First, I have to make a two hour drive every month to get pain medication refills. I’m told the doctor can’t call or write a prescription to be filled in my home town.” JL: “That may be part of the effort to control drug abuse. So many patients sell their hard drugs that pain docs now do unannounced drug testing to confirm medication is actually taken.” Mr. X: “Even so. That does seem, well, stupid. It’s a hardship for me. I have to stop the car, get out, and walk around twice each way. Why can’t the prescription be sent to my local pharmacy or sent there, say, by fax?” JL: “To win the war. On drugs.” Mr. X: “Yeah, right. Good luck with that. You don’t think it helps the doctor’s bottom line if I come in every month?” JL: “Maybe…I suppose.” Mr. X: “There is another war I fight myself; can’t seem to win even a battle. Do you know how many EMGs I’ve had within these last two years? Sixteen! They steal another hour or so of my time, and are not fun. You ever had one? I don’t think they are all really needed. The last time, I tried to refuse. I did refuse! The doctor,

who never actually has seen me for the past two years because I always see a nurse, actually appeared. In the flesh. He was pissed because I didn’t want another EMG. Said I had to do it because I am due to see the orthopedist again soon. Claimed the other specialist insists on another EMG. But I am never going to have surgery; nothing has changed; and the ortho guy has never mentioned EMG studies to me. But I gave in; you know why?” JL: “No. Why?” Mr. X: “Because I am completely dependant on my medication to live a relatively decent life.” JL: “So? Change doctors.” Mr. X: “I’m afraid to. The next might be worse, and the process of changing is threatening.” JL: “You know, you didn’t have to do the 16th EMG. Why do you think there were so many EMGs?” Mr. X: “ That’s easy! The test is expensive. It is done by a technician employed by the doctor. And most important: It doesn’t yet require pre-authorization. The doc just wants me to cooperate while he crawls through a lucrative loophole.” JL: “ But you are getting satisfactory care, aren’t you? I’d just count my blessings. Don’t let this situation upset you.” Mr. X: “Maybe. But this particular blessing? It sucks.” Preauthorization is an imperfect remedy, yet is justifiable when a devotion to gain overrides reason, logic, and principle. Transparency is the only medicine that works well in these situations. When transparency is lacking people can justify anything, and may do so, until Kapow! They are outed. The Redding cardiac procedure abuses, the latest banking crisis, the mortgage meltdown, and the ongoing activities of our Congress are just a few instances of this generic problem. Typically, when caught we usually can find something or someone to blame. Like the devil made me do it. Yes. The devil within.

“Do you know how many EMGs I’ve had within these last two years? Sixteen!”

john@loofbourow.com

November/December 2008

Malignant Code Syndrome By Ulrich Hacker, MD We recently had a meeting with our hospital’s coding auditor to bring us up to speed on coding. For a good hour and a half we discussed how to code. We did learn a lot. There was a list of new codes from the CDC website — 10 pages. Among many that seemed straightforward, there were others that were less so — such as 24 (TWENTY FOUR!!!!) codes for headaches, 30 codes for migraines, 10 codes for “exfoliation due to an erythematous condition involving” from 10–19 percent up to 90 percent or more “of body surface.” And this was only a selection of new codes! I am sure that somewhere on the surface of the planet there will be physicians in need of each one of those codes. I also know that there are unfortunate patients suffering from each one of the afflictions described. However, I had codes coming out of my ears after this meeting. I needed to put some order to this crazy world of numbers, put a face on it, and some human emotion into it, AND let off some steam. Here’s the result (with my apologies and all due respect and sympathy to patients suffering from these problems).

A Visit with Dr. Eye C.D. Nyne, MD Jacob Creutzfeldt (046.11) came to visit his Doctor, Eye C. D. Nyne, MD. He stated he had Hungry Bone Syndrome (275.5) probably brought on by an ORTHOpoxvirus-infection (059.0). The doctor’s initial reaction was that the patient must have Dysplasia of Anus (569.44) to think he had Hungry Bone Syndrome (275.5); it was much more likely that his symptoms were due to Monkeypox (059.01), which had morphed into a Yatapoxvirus-infection (059.20) likely brought on by Yaba Monkey Tumor Virus

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(059.22) and yada yada yada double-o-seven. The patient complained that the doctor showed Partial Androgen Insensitivity (259.52), accused him of Acute Graft-Versus-Host Disease (279.51), and developed a Primary Thunderclap Headache (339.43). This was followed by a Short Lasting Unilateral Neuralgiform Headache With Conjunctival Injection And Tearing (339.05) whereupon the doctor remarked that his working diagnosis now was Pingueculitis (372.34), possibly complicated by Plateau Iris Syndrome (364.82). His recommendation for treatment included Prophylactic Use Of Aromatase Inhibitors (V07.52). Jacob Creutzfeldt (046.11) stuck his nose up at this suggestion and slapped the doctor, giving him an Acute Post-Traumatic Headache (339.21), which evolved into a Chronic PostTraumatic Headache (339.22) once everyone had calmed down. Not being able to deal with his Hemicrania Continua (339.41) alone, the patient called in his friends, Gerstmann, Straeussler, and Scheinker (046.71) to help him. As they put their heads together to discuss the episode, they developed Episodic Tension Type Headache (339.11), and the doctor announced that he was about to succumb to his Coronary Atherosclerosis Due To Lipid-Rich Plaque (414.3). To his aid came his colleagues, Drs. Stevens and Johnson (695.13). They had recently joined forces in the Stevens-Johnson -Toxic Epidermal Necrolysis Overlap Syndrome (695.14). Soon all in the room were involved in a bargaining session as to whether Exfoliation Due To Erythematous Condition should involve 10–19 percent Of Body Surface (695.51) or 20–29 percent Of Body Surface (695.52) or 30–39 percent Of Body Surface (695.53) or

Health Notes By Glennah Trochet, MD

Rabies Vaccine

Influenza Survillance

A rabies vaccine shortage in the US is likely to persist for several months. The State Department of Public Health is requesting we only use vaccine for post exposure prophylaxis, and delay pre-exposure vaccination. To obtain vaccine for post exposure, the physician must call the local health department. On agreement that rabies vaccine is indicated, a password is used to order the vaccine from one of the two manufacturers. The Sacramento County Health Department telephone is (916) 875-5881.

Influenza season is upon us. We are seeking physicians and clinics willing to be sentinel practices, helping with influenza virus surveillance. If you are interested, please call Melissa Dahlke at (510) 620-3494 or e-mail the State Immunization branch at flu@cdph.ca.gov.

West Nile Virus So far this year, 17 West Nile Virus infections reported to the Sacramento County Public Health Division have been confirmed. Of this number, 3 are asymptomatic blood donors, 6 people had the diagnosis of West Nile Fever and 8 had Neuroinvasive West Nile, such as encephalitis or paralysis. Two additonal cases are pending confirmation. One person died of suspected West Nile, but it was not confirmed prior to death, so is not included in this count. Please remind all your patients to protect themselves from mosquito bites.

Flu Vaccinations for Healthcare Workers A law has gone into effect in California requires that all healthcare workers obtain the influenza vaccine or sign a waiver saying why they refuse it. Please remind your staff to get vaccinated in order to protect themselves, patients and family.

Disposal of Sharps Beginning in September it was no longer legal to dispose of used sharps in household waste, even in a closed rigid container. The Sacramento County Waste Management web site offers information on options: http://www. sacgreenteam.com. trochetg@saccounty.net

continued from page 12 even 40â&#x20AC;&#x201C;49 percent Of Body Surface (695.54). This discussion caused everyone to develop Pressure Ulcer, Unstageable (707.25), and Functional Urinary Incontinence (788.91). Functional quadriplegia (780.72) ensued, everyone had to sit down, and all went into a Postprocedural Fever (780.62). After an endless heated discussion, no Final Unequivocal Diagnosis (V911.411 â&#x20AC;&#x201D; see if you can find THAT code!!!!!!) was reached, and

finally both Doctor Eye C.D. Nyne, his patient Jacob Creutzfeldt (046.11), and their cronies, Gerstmann, Straeussler, Scheinker (046.71) and Drs. Stevens and Johnson (695.13) expired from Fatal Familial Insomnia (046.72). This is what discussion of codes DOES to you!! uvbhacker@pol.net

November/December 2008

Dr. Paul Kelly Honored for his Blood Salvage Work By Vicki Wolfe, BloodSource, Community Relations Manager

“The current version of Cell Saver is, of course, more sophisticated and part of big business today, but the germ of the idea started with Dr. Paul Kelly.”

Dr. Paul B. Kelly received the 2008 Dale A. Smith Memorial Award in October at the AABB annual meeting in Montreal, the very city where he received his medical degree from McGill Faculty of Medicine in 1961. AABB (formerly the American Association of Blood Banks) is an international blood banking association representing individuals and institutions involved in activities related to transfusion and cellular therapies, including transplantation medicine. Dr. Kelly shares this prestigious award with Keith Samolyk of Global Blood Resources, LLC, for innovation regarding blood salvage and autologous transfusions. Their contributions help conserve allogeneic blood products, benefiting patients and the community blood supply. Dr. Kelly is well known to the Sacramento Sierra Valley Medical Society (SSVMS), having received the 2006 Golden Stethoscope Award — the Society’s highest honor — for his many contributions to the Sacramento region over the years. In 1971 he joined the cardiovascular program at Sutter Memorial Hospital, where he and his colleagues brought the first heart transplant program to the capital area in 1989. Less well known is his work in 1974 to help create the Cell Saver, a device that revolutionized perioperative blood management. Dr. Forest Junod, a former colleague at the Sutter Heart Institute, recalls that in the late 1960s and early 1970s, a surgeon did not perform heart bypass surgery without at least 15 units of blood. Five were for the heart-lung bypass pump, five for the patient, and five in case post-operative transfusions were needed. A heart-lung machine oxygenated the blood while the patient’s heart and lungs were bypassed. It

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required a large volume of saline added to the bag that contained the patient’s blood, resulting in a total volume of approximately three liters. Following surgery, this bag contained two or more units of red cells. Dr. Kelly began to think about how to remove the saline so the red cells could be returned to the patient. He borrowed a cell washer from the Sacramento Blood Bank that was very efficient at concentrating red cells; but it was designed for use in a fixed location and was cumbersome to move. Nonetheless, it worked, so Dr. Kelly’s team used it routinely. In the fall of 1974, Gordon Kingsley from Haemonetics, developer of the cell washer, heard about the new process.. He promptly flew north to spend the next two days watching Dr. Kelly use the washer after heart sugeries. It was a “terrific idea,” but a more mobile device was needed. Kingsley sketched out an idea of what would eventually become the Cell Saver and came up with the trademark name; it described perfectly what was being accomplished — saving red cells. He built a model in his basement workshop, and, only three weeks later, a portable unit was delivered to Dr. Kelly. Kingsley comments, “The current version of Cell Saver is, of course, more sophisticated and part of big business today, but the germ of the idea started with Dr. Paul Kelly. No invention gets to the marketplace without that idea being born first.” A whole new perspective about blood transfusions exploded at the time the Cell Saver was coming into common usage. It was a difficult time for blood centers across the nation, as testing technologies were then unable to identify dangerous blood-borne viruses. Transfusion, once viewed as life-saving, was also viewed as

life-threatening. Dr. Kelly’s work minimized the need for allogeneic transfusions in the operating room and allayed fears of blood-borne viruses. Oncologist Dr. Vincent Caggiano says, “As a cardiac surgeon, Paul Kelly was always concerned about excessive blood transfusions during surgery, and the availability of blood needed in emergency situations. During my tenure at the Sacramento Blood Center we were faced with early testing for hepatitis B antigen (known as Australia Antigen initially) and later with the AIDS problem, involving blood centers nationwide. Paul always vigorously supported doing what was right for the patient, and as a result the quality of the blood remained high. This passion for a safe blood supply no doubt led Paul to develop ideas that led to the Cell Saver.” Dr. Gerald Simon who served with Dr. Kelly on the Sacramento Medical Foundation (now BloodSource) notes that “Dr. Kelly showed exceptional vision in stepping outside his role as a cardiac surgeon to learn and integrate medical pathology and medical technology to

help patients. His understanding for the need of highly specialized laboratory equipment and testing for cardiac transplant patients — as well as blood services — paved the way for heart transplantation to take place in Sacramento.” Dr. Kelly observes bemusedly, “I know that people today may view my handling regarding the business of the Cell Saver device as somewhat naïve, but at that time, crossing the line between medicine and financial rewards for the development of something like the Cell Saver was an ethical line that was not generally crossed by physicians. Today’s world is much different in that regard. Yet I have no regrets about that part of the process and though very grateful for this award, it is more important that patients were impacted for the good — and continue to be — through the use of the Cell Saver. It is gratifying to now see the Cell Saver as part of the routine for any time blood loss is involved, including emergency and trauma care.” Vicki.wolfe@bloodsource.org

November/December 2008

Voices of Medicine Why we attract foreign-trained MDs; handling physician stress; and becoming a patient.

By Del Meyer, MD

American Medicine’s Attraction Dr. Lytton W. Smith, editor for the Orange County Medical Association, wrote on “The Freedom of International Medical Graduates” in the July, 2007, issue of Southern California Physician. America’s allure has led many physicians trained overseas to the United States. The current debate on immigration reform has given me a chance to reflect on international medical graduates (IMGs). America’s allure of prosperity and political and economic freedom has led many physicians trained overseas to the United States, including me, a Canadian. After we arrived, the openness of American society allowed us to assume new roles, including as top leaders in organized medicine. This month, Satinder Swaroop, MD, becomes president of the Orange County Medical Association. Originally from India, Dr. Swaroop is the third IMG in the past seven OCMA presidents. Many IMGs assimilate into various forms of medical practice, and when established, they long to participate in determining the direction of the profession. We remember our background and culture, but have adjusted our perspectives to acquire acceptance and support from our fellow physicians. Daily, we use the confidence that inspired us to leave our “native land” — a phrase I borrow from the song “O’Canada” — to help advance healthcare in America. The root of American freedom is the Declaration of Independence, a document I recently reread. It is a true masterpiece expressing

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the aspirations of a group of determined men to free themselves of a distant tyrannical force. Yet to assure the rights of individuals, American people created a complex system of laws. In medicine, we also have a variety of pronouncements that we label principles, ethics or guidelines. These lack the enforcement component that laws have, but they give the practice of medicine some structure. In addition, hospitals have bylaws, which are enforced by physicians elected to uphold the rules for governing themselves within their institutions. IMGs collaborate with U.S.-educated colleagues in developing these bylaws. On behalf of IMGs this July — the month America celebrates its independence — I thank the physicians raised and trained in America for their acceptance and support. Their willingness to allow us to participate in the difficult debate about the future of this great profession confirms the strength of the American dream. Lead on Dr. Swaroop. Dr. Smith’s article can be found at www. socalphys.com/article/articles/494/1/

Physician Stress Dr. Stephen Jackson writes on “Physicians, Heal Thine Selves: Wellness Becomes a National Agenda,” in the Summer 2008 CSA Bulletin, of the California Society of Anesthesiologists) …Consider that our own lives can be characterized as a chain of reactions or responses to a continuum of destabilizing demands. These stresses can originate extrinsically from our family, friends, colleagues, patients, work and other environments; or intrinsically from self-derived pressures that we consciously or unconsciously place on ourselves. A situation becomes stressful when we feel unable to cope

with demands to which we feel compelled to respond. Stresses emerging from the demands of our professional practices, if not dissipated by effective coping strategies, or counterbalanced by equanimity derived from how we live and manage our personal lives, have the propensity to make us more vulnerable to maladaptive behaviors, including, in the extreme, emotional disequilibria, burnout, chemical dependence, and even suicide. Historically, CSA and ASA have focused on drug and alcohol abuse and their more morbid sequelae. Although affecting only a small number of our colleagues, there certainly is justification for attention to these afflicted individuals, a significant proportion of whom are less than a decade out of medical school. Indeed, it has been estimated that our specialty loses over 3,500 life years from the combined mortality attributable to drug abuse and suicide! From a manpower perspective, this represents a huge loss of practice years for our specialty, but from a purely human point of view, this is a tragedy of staggering proportions, eroding the very minds and hearts of family and friends… How do the ASA and CSA hope to accomplish their goals of achieving a satisfactory level of wellness for all of its members? A leading approach will be to develop a broad-based educational network to promote wellness and health enhancement (the basic elements of the Wellness Initiative)… Read the entire article on the CSA website, www.csahq.org/pdf/bulletin/ednotes_57_3.pdf

Impatient Patients Dr. Allan Bernstein reviews the book, When Doctors Become Patients, by Dr. Robert Klitzman (344 pages, Oxford University Press, $35) in the Summer 2008 issue of Sonoma Medicine. Do doctors make the worst patients? In his book, When Doctors Become Patients, Dr. Robert Klitzman begins by describing the depression he experienced after a traumatic death in his family. He was totally unable to recognize the classic symptoms. After all, he was a psychiatrist; he couldn’t have a mental illness. Klitzman goes on to interview, in depth, 70 physicians and medical students who had

illnesses that ranged from HIV/AIDS and metastatic cancer to myocardial infarctions, chronic infections, leukemias and lymphomas. His subjects describe the transition from their vision of themselves as God-like beings to the uncomfortable and often degrading experiences they endured in hospitals and emergency rooms, even in their own institutions. Two categories of illness appear early on: “medical student’s disease” and “post-residency disease.” The former is a syndrome of trainees, who fear they have the symptoms of the conditions they are studying. The latter is a denial of illness, no matter how glaring the signs and symptoms. Post-resident physicians seem to practice selective denial in regard to their own health. Their workaholic personalities and sense of invulnerability often preclude objective assessments of their own health. Magical thinking is rampant: “If I don’t have a biopsy, I don’t have cancer.” After Klitzman’s subjects acknowledged their illness, a common dilemma was whether to continue being the doctor, in control at all times, or to become a patient and cede that control. Many of the subjects ordered their own tests and imaging studies and prescribed their own medications. Others elected to let their physician run the show. For those who ceded control, certain topics were difficult to discuss with their physicians. The subjects could admit to poor eating habits, failure to exercise appropriately and inconsistent medication compliance — but depression, substance abuse and unsafe sex seemed off limits. Many subjects would prescribe their own antidepressants and fill them at pharmacies where they were unknown. They would not submit these bills to their medical insurance for fear of others finding out. They knew that confidentiality, even in this age of HIPAA, is rarely observed. After all, if you’re in the hospital, your chart is at the nurses’ station, and your colleagues are making rounds and writing notes at the same site… To read the entire book review, go to www. scma.org/magazine/scp/sm08/bernstein.html

The subjects could admit to poor eating habits, failure to exercise appropriately and inconsistent medication compliance — but depression, substance abuse and unsafe sex seemed off limits.

DelMeyer@MedicalTuesday.net November/December 2008

A Small Medical Clinic on the Burma-Thailand Border Humanitarian relief as well as medical care are desperately needed by a population caught up in a cycle of violence and militarization.

By Terrence Smith, MD, MPH One day young Ma Myint Win went out to collect bamboo shoots in the forest behind her village in Burma, and her life changed forever. She stepped on a landmine buried by the Burmese military. It blew off both of her legs. Villagers brought her across the Moei River from Burma into Thailand, arriving near midnight. At the hospital, doctors amputated both legs above the knee and sent her to Mae Tao Clinic where she was fitted for prosthetic limbs and learned to walk again. That was over seven years ago. Now Ma Myint Win works at the clinic, helping out in the trauma department, rolling bandages and raising the spirits of patients. She will never return to her home in Burma, but she is not looking back. She feels strong now and wants to help. She was luckier than many of her countrymen. She got help that is not available inside Burma, a county in turmoil. Continuous fighting with large-scale social and economic disruption has been a way of life in Burma for decades. After a brief stint of parliamentary government, military generals have ruled since 1962, solidifying their hold on power after the brutal repression of the democracy movement in 1988. Since then, political solutions have been frozen and the condition of people caught up in this cycle of violence and militarization has steadily deteriorated. Human rights

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abuses abound: the Burmese military uses the anti-ethnic policy of four cuts (against recruits, supplies, information and food) that has been regularly accompanied by summary executions, rape, torture, human trafficking, forced relocation, compulsory labor, burned villages, scorched crops and the use of landmines to restrict movement.1 Burma was once described as the breadbasket of Asia, but it is now the basket case of Southeast Asia. Misrule and armed conflict have gutted the once self-sufficient country. Instability and poverty have resulted in some of the worst health indicators anywhere. The World Health Organization in 2000 listed Burma as the second worst health care system in the world. Only war-torn Sierra Leone was worse. In ethnic regions of eastern Burma, the situation is even more dire. Between 15 and 30 percent of children suffer from malnutrition. Twelve percent of the population is infected with Plasmodium falciparum, the most dangerous form of malaria; the maternal mortality rate is estimated at 10 percent.2 Thousands of children die every year in infancy from malaria, malnutrition, diarrheal disease and other treatable conditions. Burma has one of the fastest growing HIV/AIDS epidemics in Southeast Asia. Malaria and tuberculosis are endemic.3 The rate of drug resistant tuberculosis is double that of Burmaâ&#x20AC;&#x2122;s neighbors and the 2,500 malaria-related deaths per year are more than in India, which has a population 20 times as large.

Just inside Thailand, on the border with eastern Burma lies the Mae Tao Clinic. It was founded by Dr. Cynthia Maung, herself a political exile after the 1988 democracy protests. Physically the clinic is not much more than a ramshackle collection of buildings on rented land, but it provides essential health care to migrants and to people uprooted by the sustained conflict and oppression. This is where I’ve worked over the last six years to assist Dr. Cynthia and her staff in addressing the most basic needs for health. Today the clinic maintains 120 inpatient beds, an operating room, and pediatric and maternity wards. It has ambulatory programs for reproductive health, medical, surgical, child health, mental health, eye care/surgery, a blood bank, and a workshop for building prosthetic limbs. It operates programs for TB, malaria, dental care, and HIV/AIDS outreach, support and treatment program. An average of 270 patients are seen each day. Last year they included over 81,000 cases, including 5,000 cases of malaria, 1,300 blood transfusions, and 2,117 baby deliveries. Increasingly, the Mae Tao Clinic has taken on the responsibility of training Burmese health care workers in skills they can take back to their villages in Burma. They come to Mae Tao clinic to learn how to recognize and treat disease or malnutrition, use a microscope or deliver a baby. They then return to their village with these skills to serve the members of their community who could never travel to the clinic. Far from being a depressing scene, the clinic is a village. It’s a vital hub for medical care, training and advocacy. On any given day there are births, deaths, weddings, funerals, celebrations of sadness or joy, Buddhist ceremonies, human rights training, youth movements, environmental campaigns and so on. This is a community striving to hold together and strengthen the disparate elements of a refugee population. The response to Cyclone Nargis in May of this year is an example of the clinic’s role in the community. While foreign governments and non-governmental organizations were shut out of the affected areas by the military government,

the clinic with other organizations like the Backpack Health Workers Team reached out to find underground networks to get food, water, shelter and medicine to those most in need. At the height of the response there were 18 teams working through monasteries, churches, health worker networks, families and other avenues. Despite the severe restrictions by the regime, and the appalling scale of the damage caused by Cyclone Nargis, the people continue to fight to provide their own humanitarian assistance. The relief effort continues today to rebuild — providing pumps to clear the salt water out of rice fields, providing seed for replanting and building boats to navigate the waterways that are the main transportation arteries.

November/December 2008

These photos were taken outside the clinic.

It is exciting and challenging to be part of the clinic. As clinician and adviser for the HIV/ AIDS program and the obstetric program, I see the commitment of so many people, young and old, stepping forward to help. They do so even at the risk of being targeted for arrest or worse. As a friend to many at the clinic and to some who have moved away, I am inspired by their resilience and undaunted good spirits in the face of adversity. I don’t see my work as particularly charitable and certainly not as missionary. I do it first and foremost because I enjoy the challenges and opportunities to work alongside like-minded people on something that seems Above, outside a clinic building; left, the author with two young patients.

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important to all of us. Paul Farmer once described his attraction to healthcare for the poor as “the unarguable immediacy of need and the vitality of practice of those seeking to meet those needs.”4 I have found medicine offers a uniquely personal way to reach out across cultural and language differences to meet those needs. Secondly, I see it as an investment with benefits for everyone. Health care is a basic value and the health of a population is fundamental to the other dimensions of society: family, education, economic productivity. Helping to improve health is a step toward building a healthier, safer world. tsmith@calana.org From 1982–90, Dr. Smith was an SSVMS member practicing in South Yolo and Sacramento counties with Dr. Henry Go. Since acquiring an MPH, he has been fully involved in a broad array of local, national, and world health efforts; 2002 found him on the Myanmar (Burma) Thailand border. He is still there, periodically returning to update his skills, CME, and his personal finances, as he has no source of income in Thailand. For more information about the Mae Tao Clinic visit the website: www. maetaoclinic.org. Dr. Smith notes that due to demands of culture and language, a volunteer is only helpful when a commitment of six months or more is possible. — JL 1 Public Health and Human Rights: evidence-based approaches. The Johns Hopkins University Press, Chris Beyrer ed 2007. p 393 2 Chronic Emergency: Health and Human Rights in Eastern Burma, Back Pack Health Worker Team, August 2006 3 Martin Smith. State of Strife: the dynamics of ethnic conflict in Burma. East West Center Washington. 2007 4 Paul Farmer: Infections and Inequalities. University of California Press 2001 p. 24

California’s Ambulance Services During the 1960s By Irma West, MD A trip in a California ambulance in the 1960s costed about $45 in metropolitan and $60 in rural areas. Half the ambulances did not have enough head room to provide emergency care. Less than 10 percent had direct radio communication with a hospital. Required of the driver (or attendant, if there was one) was an Advanced Red Cross First-Aid Certificate. Most drivers and attendants worked part time and 25 percent were volunteers. In the rural areas, 64 percent were volunteers. About 40 percent of drivers were not required to have an ambulance driver’s license. Fewer commercial ambulance operators showed a profit than showed a loss or broke even. Most had support from other businesses. These were a few of the findings in California’s Ambulance Survey-Final Report1 conducted 1968–1970 in response to the National Highway Safety Act of 1966. It required that “Every state in cooperation with its local political subdivisions shall have a program to insure that persons involved in highway accidents receive prompt emergency medical care under the range of conditions encountered.” Compliance was a condition for receiving federal highway construction funds. California was unable to meet this standard because it had no data. Services had developed independently at the local level. With unusual speed, federal money was transferred from the state Business and Transportation Agency to the Department of Public Health for a survey and recommendations to meet the federal standard. The project was headed by a physician (me) and included a nurse, a paramedic, an epidemiologist, a statistician, two secretaries,

and a part-time aircraft pilot. An advisory committee was assembled representing government and private organizations. Thirty technical consultants were appointed. The effort took two years and produced an inch-thick comprehensive detailed report and many recommendations. Each county received an individual report and was ranked in accordance to its needs. Obtaining a complete inventory of ambulance operations serving the public was tedious, and even more difficult when it came to special groups, such as industry, the military, state and federal institutions, and those serving racetracks and other sporting events. The first unexpected finding was how many there were. The highest estimate had been 450. The study documented 612 ground, 88 air and 1 boat ambulance service. An 18 page questionnaire was mailed to each operator and an abbreviated version to the military. To improve chances of receiving replies, $5 (more than $50 in today’s money) was offered for each completed questionnaire. And 95 percent responded! Because the military had documented superior emergency care and transportation of wounded, a part of the survey was directed toward comparing California’s capabilities. Additional questionnaires were sent to emergency care physicians, California Highway Patrol commanders, Red Cross chapters and the county Emergency Medical Committees established in 1968. The pilot tracked the air ambulances and visited each one.

November/December 2008

Two Sacramento policemen stand next to a victim on a stretcher, circa 1945. The photograph is from the Noel LaDue Collection at the Sacramento Archives and Museum Collection Center, and used with their permission.

About two-thirds of the ambulance operations served the public. Of these, 64 percent were commercial, 20 percent were tax supported, usually from fire or police departments, and the others were voluntary or non profit. About 11 percent of the commercial operations came from Funeral Homes. The ratio of services to population was 1 to 60,000. California, with 10 percent of the nationâ&#x20AC;&#x2122;s population, had 6 percent, or 1557, of the nationâ&#x20AC;&#x2122;s ambulances. Operators serving the public reported 743,182 trips in 1968; almost half were emergencies. Traffic accidents accounted for 15 percent of all trips and 35 percent of emergency trips. For voluntary ambulances, most often from rural areas, traffic accidents accounted for half of their trips. One in 1,500 emergency trips was made by helicopter. Ambulance operators lauded the Highway Patrol for the services rendered to traffic acci-

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dent victims, and saved their harshest criticism for poor emergency services at some hospitals; at times the ambulance was turned away. One-fourth of the geographic area of the state was notably deficient in ambulance services. Not included in this assessment were uninhabited areas without traffic. In rural areas, the nearest service might take over 30 minutes to arrive at the scene, and the hospital could be 100 miles away. These delays in themselves were judged inadequate emergency care and transportation, no matter how skilled and well equipped the ambulance service was when it arrived. More persons per 1,000 population were injured in rural highway accidents, their survival rate was worse, they died of less severe injuries, and they died sooner after their injuries. In rural areas, most of the ambulance personnel were part-time volunteers and an attendant was

less likely to be on the ambulance. Thirty-two percent of emergency trips in rural areas were for non-residents, while only 5 percent were for outsiders in metropolitan areas. Response time in metropolitan areas was 10 minutes or less. Only Los Angeles County had a communications center. Call boxes along highways were experimental. The 911 system was on the drawing board. Most ambulances had twoway radios but half the operators reported that they were ineffective in part of the area served. Three-quarters of the ambulance services were not listed among the emergency numbers in the telephone directory and 13 percent were not listed anywhere. Station wagon and van ambulances without headroom were a national problem. In 1969, the National Academy of Sciences, National Research Council convened an advisory group (including me) to set standards for ambulance construction and equipment. Ambulances began their conversion to roomy trucks.

It was clear that emergency medical transportation, particularly in the rural areas, was on a financial starvation diet. Compliance with the most basic recommendations of the survey would require substantial new financial resources and improved governmental administrative and regulatory responsibility. For example, all parties to the survey agreed that medically directed paramedical training at educational institutions must be provided and required for ambulance personnel, and they recommended that a state law require an attendant as well as the driver present whenever a patient was in an ambulance. Neither could be required without first finding the resources to make it possible. We often lament passage of the “good old days.” But today’s ambulance services are far superior to those of a half century ago. imariewest@aol.com 1 Available at the SSVMS Museum of Medical History.

This amublance was built by James C. Cunningham and Sons, Rochester, NY, and used in Bar Harbor, Maine, until the 1950s; it was also used as a hearse. Its body is made of handformed aluminum. The photo was taken by Dr. Robert LaPerriere and used with permission of Peter Cunningham, the vehicle’s owner and the great grandson of James C. Cunningham, the builder of the Towe Auto Museum in Sacramento. The Towe Auto Museum is having a special exhibit from January 10 to April 4 on “Red Lights & Sirens Vintage Emergency Vehicles.”

November/December 2008

Become a Volunteer Doc By Kristine Wallach, Program Manager, Community Service, Education and Research Fund (CSERF)

The health care needs of the uninsured and underinsured have not gone away. In fact, there is a greater demand than ever for volunteer primary and specialty care physicians.

When a physician ponders the myriad of projects for his or her “free” time, the list is long and the options varied. As we head into the holiday season and take stock of this year’s accomplishments and next year’s goals, I would like to tell you what some of your colleagues have been up to. Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) is in its 16th year of helping underinsured residents access free medical services they would otherwise go without. Volunteer physicians — 47 at present — make an annual commitment to volunteer for a 4-hour shift once a month. More than 26,000 patients have benefited from the SPIRIT Project, receiving care for ailments like allergies, dermatological issues, ear nose and throat illness, orthopedics and retinopathy screening. The SPIRIT Project began in response to a county budget crisis of the early 1990s, when many county primary care physicians were laid off and fewer patients had access to medical care. The health care needs of the uninsured and underinsured have not gone away. In fact, there is a greater demand than ever for volunteer primary and specialty care physicians. In addition to Sacramento County clinics, SPIRIT recently began placing volunteers at The Effort, which has provided medical care in downtown Sacramento for over 35 years. The Effort Community Health Center provides primary medical care to over 5,000 patients each year, serving the uninsured and underinsured. It is experiencing tremendous growth in its medical services and is expanding the clinic to provide more comprehensive services and extended hours. UC Davis medical students and physicians make significant contributions to the health of underserved populations through their volunteer efforts at several community clinics. The Sierra Sacramento Valley Medicine

UC Davis Student Run Clinics train students in delivering primary care services while improving access in underserved communities. The programs have been recognized nationally as an exemplary partnership between an academic medical center and the community. Medical students, typically in their first or second year, and undergraduates who staff the clinics receive course credit. At least two volunteer licensed physicians supervise the students. There is always a need for physician preceptors. A few hours on a Saturday could make the difference in the lives of local patients as well as future doctors. Many volunteers enjoy getting back into the community to provide medical care. Andrew Hudnut, MD, a family practice physician at Sutter Health Elk Grove Family Medicine, has volunteered for SPIRIT for the past 10 years and handles primary care for patients, including infections, diabetes care, and lipid disorders. “I recommend this type of volunteer activity to all my physician colleagues,” Dr. Hudnut said. “It reinvigorates the community aspect of your medical skills and applies them to populations who value and need your interventions.” If you have a few hours on a Saturday, during the day or in the evening, SPIRIT can match you with a clinic that needs your help! We work only with clinics that provide SPIRIT volunteers with support staff to navigate the system of referrals and prescriptions, so you can focus on doing what you do best — providing outstanding medical care. In addition, the clinics we work with provide liability coverage, whether you are in active practice or retired. To learn more about SPIRIT or to volunteer, visit us on the SSVMS website at www.ssvms.org, or contact Kris Wallach at 916.453.0254. KWallach@ssvms.org

A Posit on Universal Electronic Medical Records “The single most effective step that (only) government could take to improve medical care would be to impose and finance a universal electronic medical record which, excepting in emergencies, is password controlled by the patient.”

Among 126 replies, 30 agreed, 85 disagreed and 11 had no opinion. A posit is an intentionally strident and simplistic statement about a complex problem, intended only to promote discussion among members. It is not a poll, nor does it reflect the views of the SSMVS Board of Directors or the editors of Sierra Sacramento Valley Medicine. Complete comments can be viewed at www. ssvms.org. Edited comments follow. “I STRONGLY AGREE and have advocated for this for years. It would have an immediate positive impact on several aspects of medicine. Beyond the obvious clinical benefits, it would also facilitate medical research using shared datasets. It could also quickly trickle down and impact insurance forms, payment submissions, review and approvals. The next step would be to impose a universal insurance payment submission form using selected fields directly from the universal medical record.” — Edward Panacek, MD “The government would have a hard time pulling this off. Nothing the government does is simple. Haven’t we figured that out by now?” — Byron Demorest, MD “It would allow doctors to see who else is treating the patient and if lab, x-rays and prescriptions were included, it might reduce medication conflicts and abuse.” — James Farley, MD “Likely to make care more cumbersome: no reasonable universal EMR exists.” — Joel Pearlman, MD, PhD

“The most effective step the government can take is to extend COBRA options until one becomes Medicare eligible.” — Gerald Rogan, MD “HIPPA has allowed the insurance industry to invade the private lives of our patients.... This would only work if the Insurance companies have NO ACCESS to those records and could not demand them. They are a risk-taking industry; that is their job to earn their money! We have been duped long enough to believe that the doctor is the one who has to take the risk when a patient walks in the door. These companies can start paying their billion dollar profits back to their customers instead of dictating medical care to them.” — Franklin Long, MD “Since relocating to Menlo Park, CA, after retirement from my ophthalmology practice in Sacramento, my medical history has been electronically available to myself online or to any physician at the Palo Alto Medical Foundation.... It is a great convenience to all concerned in the delivery of care — your past surgeries, medication, ready access to information to the many specialists one is referred to, and ability to quickly give medical information when away from home to a new physician. This would definitely reduce the cost of medical care and be helpful in the care of the patient…” — Gilbert Reese, MD “An EMR is not a panacea for the nation’s health care problems. While it creates efficiencies in data collection, transmission and prescribing, it also creates inefficiencies in patient narratives

November/December 2008

“This would definitely reduce the cost of medical care and be helpful in the care of the patient…”

“The downside: imagine the legal nightmare and the hacking capabilities. Will there be private anything any more after that?”

and documentation by creating templates that turn individual encounters into cookie cutter documents. AN EMR does nothing to help fund care for the millions without it, nor does it help recover the millions of dollars siphoned out of the system by for-profit health insurers. AN EMR does not insure that care is proper or even done.” — Joanne Berkowitz, MD “[I] disagree unless you mean ’personal health record.’” — Jack Lewin MD “I do agree that a standardized electronic medical record which, excepting in emergencies, is [password-]controlled by the patient or patient’s designee could improve medical care. However, government mandates and subsidies have proven to be a costly violation of liberty and free markets. A voluntary consensus standard would be superior to any mandate. A free market has historically produced the best outcomes.” — Lee O. Welter, MD “The singlemost intervention Government can do is to disallow health insurance companies to be traded in stock market.” — Rugmini S. Shah, MD “I think it is a fantastic idea for both ambulatory as well as the emergency pt. It is great to have the pt have the ability to carry their medical records with them as it becomes easy for continuity of care particularly for those who move around a lot from doctor to doctor, place to place, insurance to insurance or whatever to whatever; but I feel the information should be in summary form only and the details to be accessed only by the professionals or the caregiver with special access codes. The downside: imagine the legal nightmare and the hacking capabilities. Will there be private anything any more after that? Ever since Hilary Clinton publicly started the affair 16 years ago, there has been this gradual metamorphosis to universal health care (UHC) and reimbursements are almost on par with Medicare payments or close to it for the most part. We are working ourselves incrementally towards UHC.” — Elisabeth Mathew, MD “A universal EMR would be great. The single most important step, no. I would say Medicare for all ages would be my first step. How to

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pay for it is another matter, and it won’t be by cutting taxes and increasing military spending.” — Thomas Curran, MD “Government should help with universal access. CMA should work on the best EMR, using it partially as a member-benefit.” — Richard Gray, MD “A bargain; this would only cost millions!” — Tom Wilkes, MD “[I] prefer the Google and Cleveland Clinic approach wherein the EMR is localized to the patient’s doctor and his associates and colleagues, his hospital and the medical staff and support facilities utilized by them or the patient. The Cleveland Clinic patient’s records can be accessed by any physician or medical facility from any computer with the patient’s permission and his clinic card. There is no reason for the government to have access.” — Del Meyer, MD “The government should not control health care.” — Terry Zimmerman, MD “I think an electronic record is wonderful, but very difficult to keep ’healthy.’ Do you really want the people who gave us Medicare, Medicaid and Medi-Cal to be in charge of such a sensitive system?” — Jeffery Rabinovitz, MD “’Informatics’ is indeed an important part of health care reform. This posit is much too simplistic. The ’fixes’ to our currently inadequate system will indeed be plural — many of them. That is, there will surely not be a singular universal medical record.” — Donald Lyman, MD “Of course will be a major step toward ’socialized’ medicine but that doesn’t bother me.” — William Peniston, MD “I would approximate that 90 percent of patients would lack the required competency for being in strict charge of their overall health care management.” — Colin P. Spears, MD “Prohibitively expensive and impractical.” —Samuel V. Bartholomew, MD “Government controlled medical records are bad. [But] yes they should be patient controlled.” — Virgil Williams, MD “I disagree vehemently.” — Wayne C. Matthews, MD

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 BRAUN, Ryan E., Anesthesiology, The Chicago Medical School 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 CAHN, Jennifer M., Family Medicine, Georgetown University 2005, Sutter Medical Group, 2210 Del Paso Rd #A, Sacramento 95834 (916) 285-8100 CHAI, Lisa, DO, Internal Medicine, Touro University 2005, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 CHOU, Steve H., Pediatrics, Loma Linda University 1998, The Permanente Medical Group, 1840 Sierra Gardens Dr., Roseville 95661 (916) 787-6433

HOE, Francis M., Pediatric Endocrinology, UC Davis 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4906 HONG, Yuhwan, Orthopedic Surgery, New York Medical College 1996, Sutter Medical Group, 1201 Alhambra Blvd., #400, Sacramento 95816 (916) 731-7800 HUANG, Candice C., Family Medicine, Medical College of Virginia 2002, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 746-6724 JAN, Altaf, Gastroenterology, Khyber Medical College, Pakistan 1984, Sutter Medical Group, 2801 K St #502, Sacramento 95816 (916) 733-8730

DEL ROSARIO, Bernadette V., Family Medicine, De La Salle University, Philippines 1998, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6539

KOPF, Christiana T., OB-GYN, University of Illinois 1996, Sutter Medical Group, 8170 Laguna Blvd., #113, Elk Grove 95758 (916) 691-5996

FERRIS, Sarah, Internal Medicine, Mt. Sinai 2004, The Permanente Medical Group, 2345 Fair Oaks Blvd, Sacramento 95825 (916) 973-5000

LEE, John S., Surgical Oncology, New York University 1995, Sutter Medical Group, 1020 – 29th St #580, Sacramento 95816 (916) 453-5951

GILL, Karanbir S., Pediatrics, Wayne State University 2004, Sutter Medical Group, 9281 Office Park Cir #120, Elk Grove 95758 (916) 691-5999

MANJUCK, Janice E., Critical Care Medicine, University of Florida 1990, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 325-1040

MITTAL, Sandeep K., Cardiology, University College of Medical Sciences, India 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5282 PARULEKAR, Sangetta S., DO, Internal Medicine, Nova SE University College of Osteopathic 1997, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 STEINER, Julie L., Internal Medicine, Washington University 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 TAMIRISA, Srinath, Internal Medicine, Kasturba Medical College, India 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 TRUMMER, Jason G., DO, Family Medicine, WUHS College of Osteopathic 2004, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 746-4467 WANG, Yan, Pediatrics, Beijing Medical University, China 1991, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4802

GUIRGUIS, Lisa M., Surgical Oncology, University of Vermont 1992, Sutter Medical Group, 1020 – 29th St #580, Sacramento 95816 (916) 453-5951

continued from page 26 “I strongly disagree with the government controlling any information about health care. There would have to be a central server to store the information and who would control that?” — Robert S. Treat, MD “I disagree completely; however, if it ever comes about, the description of ’emergencies’ would be very critical.” — Kamer Tezcan, MD “I would vote yes if it were not password controlled by the patient at all times!” — Reginald D. Rice, MD “Government needs to get out of micromanaging medicine. They should make medical malpractice no-fault, and all the extra unneces-

sary cover-your-behind costs will go away.” — Richard Wakamiya, MD “The greatest strides in community health and longevity have been through government intervention with sanitation and immunizations. In comparison, treatment of cholesterol, diabetes, cancer, and heart disease or the implementation of an EMR bring baby step improvements to community health.” — Craighton Chin, MD “These posits are universally inane and worthless because they inevitably reduce complex problems to a yes or no answer. Best to discontinue them.” — Gerald Upcraft, MD

November/December 2008

ANNOUNCING THE 2009 ESSAY COMPETITION First Place Award $400 Second Place Award $100 Any High School Junior or Senior in the counties of Sacramento, El Dorado, and Yolo is eligible to enter the SSVMS Essay Competition. Results will be available in time for inclusion in college application packets.



Contestants Must Address the Following Essay Topic 

“Should California Require Drug Screening in Middle School Students?” Background: There is a significant correlation between use of marijuana under age 15 and subsequent psychosis, notably schizophrenia, a progressive disease most successfully controlled through early diagnosis and lifetime treatment like diabetes or hypertension. If undetected, it usually becomes less controllable and more devastating; (see www.earlypsychosis.ucdavis.edu). Authors are encouraged to do their own online or library searches, or to emphasize personal knowledge and experience to support or to challenge these assertions.

 Entries must be received by 5:00 p.m. April 2, 2009  The winning essays will be announced on April 30, 2009  The winning essays will be published in SSV Medicine  The First Place winning author will be awarded $400  The Second Place winner author will be awarded $100

Complete guidelines for the 2009 SSVMS Essay Competition are detailed in the November/December 2008 online version of SSVMedicine at: http://www.ssvms.org/essaycontest/student.pdf

In My Opinion

The Next Mideast War Has Already Begun Terrorists could stay home, yet launch a devastating attack on an unprepared and vulnerable healthcare system.

By David J. Gibson, MD, and Jenifer Shaw Gibson A caveat: this article is based on observation and supposition. We have no inside information contacts to support any of the following. However, the implications for healthcare are profound. Problems in the Middle East are not going away. Iranian-Israeli conflict is serious and escalating. Israel, home to half the world’s Jews, has been threatened almost daily with destruction by Iran’s President, Mahmoud Ahmadinejad (the sixth and current President of the Islamic Republic of Iran) as well as other senior Iranian officials. Israel takes these threats seriously. The Israelis have announced their intention to bomb Iran’s nuclear facilities to prevent Iran from obtaining nuclear weapons — which would, in their view, precipitate a larger, immeasurably more destructive war to annihilate Israel. Even so, our reading of current history leads us to believe such an overt armed attack on Iran is unlikely. The Iraq War has left the United States and most of Europe disinclined to engage in another armed conflict. However, both presidential candidates in the recent campaign confirmed that America will enter any conflict to protect Israel. Unfortunately, years of concerted diplomatic initiatives have thus far resulted in stalemate. After more than four years of painstaking talks with the Vienna-based International Atomic Energy Agency, Iran continues to enrich uranium at its underground facility at Natanz.

If diplomacy is ineffective and armed aggression unlikely, what will prevent the Iranian Mullahs from obtaining nuclear weapons? We are increasingly convinced that either Israel or the United States will bring this confrontation to a suitable end without overt and public acts of aggression. The option involves covert and electronic warfare.

The “soft war.” Consider the following, published in 1998 concerning the capacity of counter insurgency and electronic warfare a decade ago.1 “In the less emotional environment of day-to-day tactical antiterrorist warfare, the U.S. response is likely to revolve around highly aggressive covert actions against the military, economic, social and political infrastructures of nations that are known, from intelligence gathering efforts, to be supporting, either directly or indirectly, anti-American terrorism. “These will include such things as crippling attacks of sabotage on critical infrastructures, such as water supply; electrical grids; communication networks, including telephone, radio and television services; all manner and sorts of computer networks; industrial production facilities, particularly oil and gas drilling operations; and critically needed imports, particularly November/December 2008

... the immediate need for hardened healthcare data repositories and information links will become even more of an imperative.

those related to oil and gas operations, and agricultural production. “The severity of damage could range from a total breakdown of electrical power to the incapacitation of a nation’s commercial airline by a computer ’failure’ that destroyed all reservations. Various other types of economic warfare will also be employed, including counterfeiting; constant transactional disruptions, which make routine international trade difficult or impossible; and the spreading of rumors that cause massive swings in the value of a nation’s currency. “In addition, actions aimed at discrediting the influence of political leaders will be employed, such as the counterfeiting of ’confidential’ documents linking them to salacious or illegal acts, and support for insurgency operations both at home and abroad.”2 A credible case can be made that this “soft-war” has already started. Seymour Hersh, national security reporter for The New Yorker, recently wrote,4 “Late last year, Congress agreed to a request from President Bush to fund a major escalation of covert operations against Iran, according to current and former military, intelligence, and congressional sources. These operations, for which the President sought up to four hundred million dollars, were described in a Presidential Finding signed by Bush, and are designed to destabilize the country’s religious leadership.” As has been noted in multiple published analyses, for a low-intensity conflict of sabotage and subterfuge to succeed, it requires the full participation of both the U.S. Special Forces and the intelligence community. Until recently, both entities were preoccupied in Iraq. The forces necessary to wage a low-intensity war against Iran were engaged elsewhere. Today, by contrast, the Special Forces role in Iraq is essentially over. The ability to deploy these assets against Iran has been available for several months now.

The Relevance to Health Care According to Newton’s third law of motion, for every action there is an equal and opposite

Sierra Sacramento Valley Medicine

reaction. Forces always come in pairs — known as “action-reaction force pairs.” If a soft war has already started, it will produce retaliation from the Middle East. In fact, the assets required to respond may already be in-place. The Department of Homeland Security has quietly declared a Period of Heightened Alert, a time-frame when terrorists may have more incentive to attack. This results from a growing concern that al Qaeda or similar organizations might try to capitalize on high-profile events in the coming months. Published reports indicate that the time-frame for the alert runs roughly through July 2009. We have pointed out previously that the most effective way to attack the United States is to attack our health care system.5 The ability to insert counterfeit pharmaceutical products into the deployed inventory has been well documented. Inserting toxic substances into these counterfeit products will make the 1982 Tylenol incident6 in Chicago look like a walk in the park. There is a growing effort to convert healthcare’s antiquated information system from an analog to a digital platform. Congress this year overrode the President’s veto of The Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331). The bill contains significant incentives to move to electronic medical records, electronic prescribing and telemedicine. The move to digital information systems will bring healthcare into conformity with all other industries within our economy and is long overdue. However, the immediate need for hardened healthcare data repositories and information links will become even more of an imperative. While shortcomings attributable to our current paper-based record system have been widely discussed, the vulnerability of electronic records to attack has not. The smart move by terrorists will not be to attack America with high jacked airplanes or atomic dirty bombs. These will have but a limited local impact. The smart move will be to stay at home; export counterfeit toxins laced pharmaceutical products; and electronically attack the softest of data

In Memoriam

Arnold R. Haugen, MD 1929–2008

Arnold R. Haugen, MD, pathologist for many years with the Permanente Medical Group in Sacramento, died on July 31, 2008. Arnold was born in Tacoma, Washington, on September 16, 1929. He graduated from Puyallup High School, where he was a track star, and pursued pre-med studies at the University of Washington. He graduated from the University of Chicago Medical School in 1954. After completing a pathology residency with the United States Public Health Service, he practiced pathology in Southern California for nine years. In 1971 he joined the Pathology Department at the Kaiser Medical Center on Morse Avenue. Dr. Haugen’s opinion as a consultant in difficult cases was widely sought and highly valued. He retired from Kaiser after 23 years of service. Arnold’s personal life was dominated by his devotion to his wife and family. Arnie and

Shirley were high school sweethearts and were married for 56 years. They had six children, three daughters and three sons, 21 grandchildren and 10 great-grandchildren. All of them attended a memorial service held in Puyallup, Washington. Arnie encouraged all his children to participate in hiking and camping, bicycling, tennis and board games. There was no television in the house except for a rental set for watching bowl games around the holidays. Dr. and Mrs. Haugen financed more than 70 years worth of higher education for their offspring. The cause of death was pneumonia following several years of complications from heart valve surgery. Arnold R. Haugen, MD — Carter Mosher, MD

continued from page 30 systems in America — the healthcare system. These attacks will bring America to her knees. djgibson@winfirst.com David Gibson is the president of Reflective Medical, a health care software development company. Jennifer Gibson is an economist specializing in evolving health care markets as well as a futures commodity trader specializing in oil and gas.

1 Melcher and Soukup, “Some Thoughts On Terrorism,” Prudential Securities Strategy Weekly; August 19, 1998. Note that the date of publication is three years before September 11, 2001. It also precedes the investment by western governments in information technology to combat terrorist activities over the ensuing eight years. From a technology perspective, the above represents a primitive discussion as to current capabilities. 2 This quote was brought to our attention by Mark L. Melcher and Stephen R. Soukup in the July 28 edition of “Politics et Cetera”; published by the Political Forum, LLC. 3 http://www.telegraph.co.uk/opinion/main.jhtml?view=DETAILS&g rid=A1YourView&xml=/opinion/2008/07/25/do2503.xml 4 http://www.newyorker.com/reporting/2007/03/05/070305fa_fact_ hersh 5 Terrorism’s Next Target; David J. Gibson, MD; Sierra Sacramento Valley Medicine; September / October Volume 55 / Number 5; http://www.ssvms.org/articles/0409gibson.asp 6 http://en.wikipedia.org/wiki/1982_Chicago_Tylenol_murders

November/December 2008

The Morning Walk By William Peniston, MD While I was in the Air Force in the 1960s, Lt. Gen. Richard Bohannon, USAF Surgeon General, instituted an Air Force-wide exercise program based on the research of Dr. Kenneth Cooper. Many of us at the time resisted, often with somewhat derogatory comments. Our hospital commander, of course, strongly supported the program which only added to our derision as we thought him inept clinically. This, despite the fact that he started one of the first coronary care units in the Air Force. I cite the above for two reasons: to show how far our profession has advanced regarding exercise during the last 40 odd years, and to show how immature we younger physicians could be on occasion. As I look back, it seems to me that our opposition to Dr. Bohannonâ&#x20AC;&#x2122;s edict was mostly to the regimentation and authoritarianism, and to the military in general. As the years passed, I became aware of the importance of exercise, particularly after my father had an infarct in 1955. So, in time I started jogging in the early morning and continued until the 1980s when my ankles, knees, and hips began to complain too often. So about 25 years ago, I switched to walking. In more recent years, when my walks were in residential areas, I found it interesting to note the changes, particularly those occurring on a day to day basis. Many of course were structural in nature, such as remodeling, new driveways, and reroofing and these were always of interest to me. But more interesting were activities that involved landscaping. Replacing unwanted plants, making raised flower beds, disrupting one side of a yard to construct a pool in back,

Sierra Sacramento Valley Medicine

and complete relandscaping of an entire front yard intrigued me. When such activities last a year or longer, it is always interesting to speculate: are they my type of weekend projects or are they done by owners due to budget limitations? Although manâ&#x20AC;&#x2122;s work is interesting, Mother Natureâ&#x20AC;&#x2122;s is often more beautiful. Occasionally there are unsightly dying plants, of brown leaves of fall, but these are forgotten with the burst of glorious spring blossoms. Daffodils, tulips, irises, azaleas, hibiscus, rhododendrons and countless other cultured and wild blooms can be spellbinding. Unfortunately, the wonderful fragrances of some plants such as daphne, gardenia, and viburnum are usually too elusive for the average walker to come close enough to detect. Most interesting of all during those morning walks, though, were my interactions with fellow walkers. While aiming for aerobic exercise, I always greeted my fellow walkers in some manner, usually verbal, but when earphones were obvious, a wave sufficed and commonly that was initiated by one of us when we were on opposite sides of the street. But with teenagers the situation was usually very different. The most unforgettable incident was with a boy riding a bicycle. As usual my little border collie-mix was with me and, when the boy spied her, he jumped off his bike and ran over to her, proclaiming her beauty. He was around 15 years-old and I found his enthusiasm and spontaneity remarkable. Another teenager provided a series of encounters more interesting and gratifying. On first meeting, he appeared somewhat slovenly, slouching along with a less than cheerful expression. He gave no response to my initial greeting (did he hear me?) nor until our third or fourth

meeting, at which time I thought I detected a grunt. He was obviously going to school and I usually walked around the same time but tried to change my route frequently. We kept meeting irregularly and eventually his “grunts” became more coherent and he actually did say “Hi.” Of even more interest, his appearance and demeanor improved with time. I am quite certain the change was due to events elsewhere in his life, at home or school or both, and doubt that I had much to do with it. But it is interesting to speculate, and perhaps a little gratifying, that I may have made a small contribution. We never really are fully aware of the effects of our interactions with others, are we? willpen@mcn.org

November/December 2008

Board Briefs September 8, 2008 The Board: Authorized establishing a new Fund Management Account (FMA) with Smith Barney for the purpose of holding operating funds in a higher interest earning account than the existing commercial bank checking account. Accepted the Second Quarter SSVMS Financial Statements and the Second Quarter Investment Reports from Smith Barney. Renominated Paul Phinney, MD, and Lee Snook, MD, to another term, 2009–2010, on the CALPAC Board of Directors. Approved 2008 grants of $3,000 from the William E. Dochterman Medical Student Scholarship Fund to: Tracy Burns, MSII, UC Davis School of Medicine; Carly Grovhoug, MSI, Boston University School of Medicine; Lindsey Sheffler, MSIII, UC Davis School of Medicine. Adopted a resolution and amendments to the employee pension plan as required by the Internal Revenue Service and authorized the SSVMS President and Executive Director to sign the resolution. Ratified the tally of the ballots approving amendments to the Bylaws of the Sierra Sacramento Valley Medical Society. Enorsed the following 2008 resolutions to the CMA House of Delegates: Qualifications of Delegates and Alternates; Influenza Vaccine Distribution; In MemoriamHarvey L. Rose, MD. Approved the appointment of Karen Hopp, MD. as an Alternate-Delegate representing District 6, (Yolo County). Approved the Membership Report: For Active Membership — Bijan Bijan, MD; Yuhwan Hong, MD; Altaf Jan, MD; Janice E. Manjuck, MD; Karen L. Murrell, MD; Mimi E. Reiss, MD; Jennifer Scoble, MD; Kuldeep S. Tagore, MD. For Reinstatement to Active Membership — Leon J. Owens, MD For Reinstatement to Retired Membership — Dennis J. Sullivan, MD For Acceptance of Resignation — Christopher M. Haas, MD (moved to Texas) Serving as the Administrative Board to BloodSource,

the Board approved the appointment of Harry “Skip” Lawrence, DDS, as a member-at-large on the BloodSource Executive Committee.

October 13, 2008 The Board: Received a report from William Sandberg, Executive Director, regarding the Sacramento Health Improvement Project and Yolo County’s Future of the Safety Net. Both programs are a coalition of health care providers and other community stakeholders who have come together to explore ways to improve health care for low-income residents in each county. Approved the Third Quarter Financial Statements. Reviewed the Report from the Nominating Committee of nominations to vacancies on the Board of Directors and CMA Delegation. In accordance with Society Bylaws, the report is mailed to all active members, who can nominate additional members to any vacancy on the Board or Delegation. Approved the Membership Report For Active Membership — Jesse D. Babbitz, MD; Ryan E. Braun, MD; Jennifer M. Cahn, MD; Lisa Chai, DO; Steve H. Chou, MD; Sarah N. Ferris, MD; Karanbir S. Gill, MD; Francis M. Hoe, MD; Candice C. Huang, MD; Christiana S. Kopf, MD; Sandeep K. Mittal, MD; Srinath K. Tamirisa, MD; Jason G. Trummer, DO; Yan Wang, MD. For Reinstatement to Active Membership — Kent B. Hart, MD For Annual Renewal of Postgraduate Leave of Absence — John T. Cornelius, MD For Annual Renewal of Illness Leave of Absence — Douglas R. Schuch, MD Acceptance of Resignation — Sheryl A. Haggerty, MD; Robert C. Jacoby, MD (moved to Washington); Jack E. Sebben, MD (moved to Washington); Byron F. Vandenberg, MD (moved to Iowa). Serving as the Administrative Board to BloodSource, the Board approved the following appointments to the BloodSource Board of Trustees and Executive Committee. Elected to serve a first 3-year term (2009–2011) on the BloodSource Board of Trustees: Brenda Crum; Angelo continued on page 36 November/December 2008

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

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

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

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Medical Society (916) 452-2671

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

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

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

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continued from page 35 M. De Mattos, MD; Donald M. Delach; Diana S. Dooly; Robert J. Forster, MD; Sherri M. Kirk, Esq.; Gerald Simon, MD. Re-nominated to serve a second 3-year term (2009–2011): Harry H. Lawrence, DDS; Anthony J. Nasr, MD; Richard J.D. Pan, MD. Elected to the 2009 Executive Committee: George Chiu, MD, President; Frank Apgar, MD, Immediate Past President; Keith W. McBride, Esq., Vice President; and Paul J. Rosenberg, MD, Secretary/Treasurer; and as Members at Large, Harry H. Lawrence, DDS; Anthony Nasr, MD; Margaret E. Parsons, MD; Michael Ueltzen, CPA.

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