2009-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2009

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE Gossip, Anecdotes and Negotiations

2nd Place Student Essay

Aurora Mireille Singh

Voices of Medicine

Del Meyer, MD A Posit on the UN

Charles H. McDonnell, III, MD

GUEST EDITORIAL End the Carve-out

Ron Risley, MD

Do Not Go Gentle into That Good Night

The Golden Touch

William Peniston, MD

John McCarthy, MD

The 1914 Antarctica and 1996 Everest Expeditions

Caring for Those Who Care

Taryn Benson, MHA

John Loofbourow, MD

IN MEMORIAM Joseph Garland Stroup, MD

Physician Profiling AMA Private Sector Advocacy Staff

Board Briefs

IN MY OPINION The Tea Parties Revisited

New Applicants

David J. Gibson, MD, and Jennifer Shaw Gibson

Classified ads

1st Place Student Essay

Celynne Balatbat

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.

Inside back cover: Tickled Half to Death…

SSV Medicine is online at www.ssvms.org/magazine.asp This photo of Bryce Canyon, in Utah, was taken by retired orthopedic surgeon Greg Joy, MD, of Placerville. He used a digital SLR camera with a tripod and 400mm lens, shooting on a warm August afternoon in 2008. “Bryce Canyon is all about color, no matter the season or time of day,” he remarked. Some of Dr. Joy’s images can be seen at his website, www.alegriastudio.com.

May/June 2009

Volume 60/Number 3 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

Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2009 Officers & Board of Directors Charles McDonnell, III, MD President Stephen Melcher, MD President-Elect Margaret Parsons, MD, Immediate Past President District 1 Alicia Abels, MD District 2 Michael Flaningam, MD Michael Lucien, MD Glennah Trochet, MD District 3 Katherine Gillogley, MD District 4 Ulrich Hacker, MD 2009 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 Marcia Gollober, MD At-Large Alicia Abels, MD Michael Burman, MD Satya Chatterjee, MD Richard Jones, MD Norman Label, MD Stephen Melcher, MD John Ostrich, MD Charles McDonnell, MD Janet O’Brien, MD Kuldip Sandhu, MD Earl Washburn, MD

District 5 John Belko, MD David Herbert, MD Robert Madrigal, MD Elisabeth Mathew, MD Anthony Russell, MD District 6 J. Dale Smith, MD

Alternate-Delegates District 1 Robert Kahle, MD District 2 Margaret Parsons, MD District 3 vacant District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Karen Hopp, MD At-Large Richard Gray, MD Sanjay Jhawar, MD Robert Madrigal, MD Mubashar Mahmood, MD Connie Mitchell, MD Anthony Russell, MD Gerald Upcraft, MD

CMA Trustees 11th District Dean Hadley, MD Richard Pan, 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 William Peniston, MD Gordon Love, MD Gerald F. Rogan, MD John McCarthy, MD F. James Rybka, MD Del Meyer, MD Gilbert Wright, MD George Meyer, MD Lydia Wytrzes, MD John Ostrich, 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

Gossip, Anecdotes and Negotiations By Charles H. McDonnell, III, MD Most physicians today, whether in single practice, small group practices, or large group practices, are directly involved in negotiating and contracting. Even physicians in academic practices and in governmental organizations frequently find themselves negotiating for their financial well-being. Yet, we physicians often come into the negotiating process with little or no training to prepare us for such challenges. Medical school and pre-med curricula simply don’t afford us much opportunity to refine business education or acumen — and especially not for the nuances, pitfalls, and tactics of contract negotiations. I have limited experience with negotiating and claim no expertise. However, being involved in organized medicine has over the years exposed me to gossip about negotiations in our profession. With such gossip always comes some personal curiosity, especially given the impact of contract negotiations on one’s ability to practice. So I have something of an ad hoc education in the negotiations process.

Why Negotiate? I often hear physicians ask, “Is negotiating really necessary?” These days, the majority of reimbursement comes from government and a few large insurance companies and hospital systems, which can decide what they are going to pay. “Isn’t attempting to negotiate fruitless?” Simply stated, negotiating and contracting are necessities in today’s practice of medicine. Negotiating can make a difference. This is especially true in California’s competitive healthcare environment, where physicians are often presented with take-it-or-leave-it

options. Even in that environment, it is critical to remember that everything is negotiable, and “no” can perhaps be one’s most powerful tool. A case in point is governmental payers such as Medicare and Medi-Cal. Many patients enrolled in these programs are in managed care plans that directly negotiate with providers. In Sacramento, there are over 150,000 people in managed care Medi-Cal plans, compared to about 100,000 people with straight Medi-Cal. Some physicians are negatively impacted by the influence of managed care plans, but others are being reimbursed well above straight Medi-Cal rates for Medi-Cal managed care patients. Another example is Sacramento County’s Medically Indigent Services Program (CMISP), which outsources specialty care. For years it contracted with UC Davis for these services, but now contracts with Blue Cross, which in turn contracts with individual specialists and medical groups. This is perhaps a less than optimal example: CMISP claims are going unpaid due to cost overruns and the county’s fiscal crisis. A few anecdotes are also enlightening about private insurers. Years ago, the former Foundation Health reimbursed primary care doctors in the Stockton and Modesto area at much higher rates than doctors in Sacramento. When a former executive was asked why, he replied, “They just wouldn’t take any less.” Last year, a local surgeon had a family member receive medical care in the Bay Area. He was astounded to see that a major insurer in our region reimbursed more than double for a consult code than what is typically reimbursed for the same code in Sacramento.

May/June 2009

Simply stated, negotiating and contracting are necessities in today’s practice of medicine. Negotiating can make a difference.

Negotiation Targets. How does one arrive at appropriate targets for negotiations? It is critical to know one’s costs to deliver care to determine at what reimbursement you are better off without a contract. And one must have the discipline to walk away from substandard contracts or at the very least say “no” first. Frank Navarro, Associate Director of the CMA Center for Economic Services, calls it begging rather than negotiating when you don’t know the minimum rates you must come away with to be profitable before entering into negotiations. It is important to look at costs in one’s own practice — not only because that is the real litmus test at the end of the day, but because it is illegal for physicians to talk about fees with other physicians not in the same group. Doing so is considered to be collusion and anticompetitive. To avoid anti-trust problems in assessing the market for one’s services, the CMA has three rules: • Don’t agree with competing physicians on price, quantity or quality, including fee schedules or relative value scales. • Don’t agree with competing physicians on patients you are willing to serve, locations from which you are permitted to draw patients or where you will locate your offices. • Don’t agree with competing physicians to refuse to offer your services to a particular plan or set of patients. However, acquiring market information is important to prepare for the negotiating process, and it is possible to purchase claims data from different markets, such as from a company called Ingenix Inc. Ingenix? Isn’t Ingenix being sued by the AMA and the state of New York? Yes, there have been problems swirling around Ingenix, which certainly is cause for concern. However, these may now be behind them, leaving a potentially valuable tool for physicians to utilize, and the promise of a new independent database on the horizon. Ingenix Inc. is a subsidiary of United Health Group (UNH on NYSE), which owns United Healthcare, a major insurer in our region. There is, therefore, a glaring conflict of interest: it is

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in United’s interest to portray the market below reality. With such an obvious conflict, allegations of manipulation were sure to surface at some point. In New York, state Attorney General Andrew Cuomo’s healthcare industry task force investigated allegations of manipulating data underlying provider reimbursements and systematically understating physician fees to the insurance industry’s advantage. This led to an agreement this January in which United Health Group will contribute $50 million toward establishing a new independent database of provider’s fees, operated by a nonprofit organization. At least 5 other insurers have also agreed to contribute to the new nonprofit organization (WellPoint $10 million, Aetna $20 million, and Cigna $10 million). United Health Group also settled a class action lawsuit in March led by the AMA by agreeing to pay $350 million. In addition, a class action lawsuit against WellPoint, in which CMA is participating, is also centered around its use of the Ingenix database. One anecdotal source found the Ingenix database in our region to be fairly representative of our market. Nevertheless, it has been estimated that the database under represents markets by between 15 and 28 percent. Their 2009 Customized Fee Analyzer benchmarking product remains available and starts at around $300 for a single specialty. However, it still uses the same flawed database. The new nonprofit databases are at least 6 to 12 months away.

Skills and Strategies. What about basic negotiation skills and strategies? Of course, a quiver full of negotiating skills and strategies is clearly an asset. However, understanding your market power and using any potential leverage you may bring to the negotiating table can be even more valuable. It is vital to understand the market for your services well enough to assess the extent of your leverage and inherent market power. Most people I have spoken with believe that ultimately their contracting successes have had more to do with their leverage than with their negotiating prowess. Thus, one must always be

considering strategies to enhance leverage, such as through affiliations and the resources they often contribute to a practice.

Being Too Tough? Can one be too tough at negotiations? Playing tough to the point of canceling contracts and breaking off negotiations is common. Sometimes you simply have no choice but to say “no.” However, using “no” as a negotiating tactic can have mixed results. Recent negotiations between local hospitals and major payers got down to the final hours and even brief cancellations before the final handshake. However, Sutter Health’s negotiations with the California Public Employees’ Retirement System (CalPERS) a few years ago led to no deal in the final hours. Sutter lost significant revenue while CalPERS lost significant options and access to care. In our region there have been instances of physicians or groups of physicians losing contracts over more than just money. Resistance to providing desired services has been a major problem, such as with call coverage. Furthermore, if a physician or group is perceived as too problematic, entities have proved willing to spend more money to recruit replacement physicians or groups. Branding and control has also proven to be important to health systems. As an example, my own group has lost work due to internalization of services, despite substantial capital requirements and higher year-over-year costs associated with the internalization. What if physicians just do not want to negotiate? Some physicians don’t have the time or desire for negotiations and hire professional negotiators or use their office or management staff. One advantage is that if negotiations go poorly or even completely unravel, the physician can take over and blame the negotiator. This could be characterized as a version of the old “good cop-bad cop” routine. It can be effective if one doesn’t desire to be involved from the get go.

Resources for Information. What are good resources for information on

negotiating contracts? The CMA is the first place to turn for help. The CMA’s Center for Economic Services has recently developed a toolkit called Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations — A Focus on Payor Contracting. This is designed to guide physicians through the contract evaluation and negotiation and renegotiation process. This guide also provides physicians and their office staff with practical tips and tools to assist with the negotiation, implementation, and ongoing management of complex agreements. Included with this is an older CMA interactive CD called CMA’s Managed Care Contracting Toolkit. Within this is Managed Care Contracts Deciphered: The Physicians’ Guide to Their Rights and Obligations. This is CMA legal counsel’s guide to the actual language of managed care contracts. Other related toolkits available are: Back to Basics: A Step-by-Step Guide to Maximizing Cash Flow — A Focus on the Physician Office Billing and Collection Process and Getting Paid: Strategies to Maximize Reimbursement — A Focus on Revenue Collection. And don’t forget the “CMA On-Call,” a 24-hour information-on-demand Internet library service for CMA members. These “On-Call” documents are a repository of thousands of pages of medical, legal, regulatory, and reimbursement guidance. All documents are available free to CMA members. Document #1705 provides information about a contract review service set up by CMA, through which most types of contracts can be reviewed by an attorney for a $1,000 flat fee. Many non-CMA resources are also available. Fred Gaschen, the Executive Vice President of my group (Radiological Associates of Sacramento), has attended seminars on negotiating put on by the American College of Healthcare Executives (ACHE) and the Karis Group (a healthcare consulting firm) and has found them to be beneficial. In conclusion, it is important for physicians to do their homework prior to negotiating contracts. It does make a difference. mcdonnell@surewest.net May/June 2009

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Guest Editorial

End the Carve-out Why give mental health funds to a county government that doesn’t provide care?

By Ron Risley, MD Years ago, people with mental illness in Sacramento were cared for the same way we all were: a network of private providers would bill their patients, insurance, Medicare or Medi-Cal for their services. Inefficient and fraught with inequity though it was, it succeeded in providing care for most of the people who needed it. Then Sacramento County took over the job. Private providers were effectively taken out of the picture through a byzantine system of paperwork and applications — almost universally denied. The county got what is known in the trade as a “carve-out” — all the federal and state money destined to provide mental health care in the county got shifted to the county’s Department of Health and Human Services, which then doled out some of the money to a select group of non-profit agencies charged with delivering mental health care. The idea, I suppose, was to consolidate services and integrate systems to provide more efficient care. Now it’s 2009. The county’s newly-rebranded Department of Behavioral Health Services has a budget of $203 million and a population of fewer than 10,000 adults with mental illness. The Department is expecting about a 10 percent budget shortfall for next fiscal year, so its response — kept secret until mid-April — is to eliminate services to over two-thirds of our friends, neighbors, and family members with mental illness. With effectively no warning, a lifeline is being cut that thousands of Sacramentans rely on to remain active members of mainstream society. The bureaucrats cynically claim to have “found” other sources of care for these patients:

They are referring thousands to tiny mental health programs staffed for a few hundred patients. Thousands more are being told to ask for help from their primary care doctors — who haven’t the time, clinic resources, training, or experience to comply. More new patients are being denied entry into the system, with little regard for the severity of their illness. Others are being told that they simply are not sick enough to deserve care. The real tragedy, though, is that nobody involved in these decisions believes that they will save any money. Those abandoned by DBHS will seek care in already overcrowded emergency rooms or the Sacramento County Mental Health Treatment Center, venues which provide county-funded care at costs far higher than outpatient clinics. Those less fortunate will end up getting their care from their neighborhood drug dealers, from jails and prisons, and ultimately from the county coroner. Those increased costs will be borne by taxpayers, but the DBHS budget will balance. The county intercepted federal and state mental health money with a promise to do a better job of providing care. Whether it ever succeeded or not is the subject of some debate, but now it won’t be providing care at all to the majority of those who need it and qualify for it. If you won’t provide the care, you shouldn’t take the money. Let’s end the mental health carve-out now. ron@risley.net Dr. Risley is a family doctor and psychiatrist who has been working in the public mental health system in Sacramento since 1997.

May/June 2009

Do Not Go Gentle into That Good Night By John McCarthy, MD Dr. Risley’s comments come from someone who works in our mental health system and so he knows its deficiencies from personal experience. I work with very much the same population of mentally ill patients, except that I do so in the drug treatment system. I know how intractable problems in the mental health system are by virtue of trying to get access to care for our patients with ”co-occurring disorders.” I have participated on a county-organized Co-Occurring Disorder Committee over the past 2-plus years, where everyone agrees that the current system of county managed care does not meet our patients’ need. There has been some glacial progress in cross training staff in both systems to recognize and refer co-occurring disorders, but the most measurable outcome has been extreme frustration at the barriers to system change and inability to adapt and meet obvious needs. Sacramento County’s mental health system is a failed system in spite of the best intentions of all involved, and it was failing long before the budget crisis. It has an enormous administrative overhead that uses treatment dollars to shuffle paper, which requires paying unnecessary administrative salaries. It has a no show rate of 60 percent that has been chronically accepted as ”the way things are.” We run a psych clinic in our narcotic treatment program, and we have a missed appointment rate of 20 percent. We treat the patients where they are and where they want to come (to the limited extent we can do this with zero mental health money).

Sacramento County’s mental health system is a failed system in spite of the best intentions of all involved, and it was failing long before the budget crisis.

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And we have a model that is truly cost effective because it treats two problems with minimal psychiatric administrative overhead and uses one cross trained counselor and one physician — not two of each in parallel systems. There is broad agreement that our model is more efficient and gets people the care they need, but there is no ability to change anything. So we have paralysis as the governing paradigm and the current collapse as its logical outcome. We are now watching the county mental health system go into a prevent defense (preventing patients from accessing care as the primary administrative goal). A patient we referred to the county ”Access Team” (gatekeepers of the mental health system) brought us a form letter denying him care for his recurrent major depression. There were four boxes on the form detailing reasons for excluding people: you were not sick enough to be eligible; you don’t have the right diagnosis; you are hopeless and our services won’t help you; or your mental health needs can be provided by a physical healthcare provider. Handwritten at the top of the form was a doctor’s name and number. I called him and he knew nothing about being on a county referral list and was not taking new mental health patients. The patient had no “physical healthcare provider,” so this ”referral” was bogus. Of course the idea of dumping the mental healthcare needs on the collapsing primary care system is also bogus. Since community psychiatrists were taken out of the treatment system, access to the mental health treatment has been burdened with barri-

ers and hoops not negotiable by those most in need — especially excessive delays of months in getting to see a doctor, in a system with a 60 percent no show rate! Now, with our budget crisis, the barriers are becoming absolute. We need to get the county out of the managed care mental health system and allow doctors in the community to experiment with new models of care. We can develop private models of care, as we have done at Bi-Valley, which can deliver services instead of denials and bogus referrals. I am not criticizing the efforts of county mental health staff who genuinely have tried to work within the system to create access to care, to try to make it work. I have long time friends

and colleagues in that system, including Dr. Risley, who would love to be part of an effective model of care. But I am criticizing the system of mismanaged care by paralyzed and inefficient County and State beaurocracy. If $203 million is being spent on a system of denial of care, then maybe we need to go to patient advocate attorneys and take the case to court. If the system is both rejecting those in need and barring psychiatrists from meeting that need, then that system, to reverse Dylan Thomas’s admonition, needs to “go gentle into that good night”. jmccarthy@bivalley.com

May/June 2009

Independent But Not Alone. Randy Winslow, D.O. Hill Physicians provider since 2004. Uses Ascender preventive care reminders, RelayHealth online communication tools and Hill’s EHR for a comprehensive solution to patient care, practice management and ePrescribing.

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Sierra Sac B/W Dr. Winslow.indd 1

3/16/09 4:55:18 PM

The 1914 Antarctica and 1996 Everest Expeditions Two books: A spectrum of behavior and character at the extremes of the 20th Century.

By John Loofbourow, MD In August, 1914, 28 men, including two physicians, left England intent on making the first overland crossing of Antarctica. Almost two years later they returned home, having failed in their quest but overcoming continuous physical and psychological conditions beyond all ordinary imagination. All survived. The expedition is beautifully documented in Alfred Lansing’s 1959 book, Endurance. In preparation for writing his book, Lansing spoke with 10 of the expedition’s surviving members and was granted access to the journals and personal diaries of 8 others. In early May of 1996, more than 166 men and women participated in 5 large-group, 12 small-group, and 2 single-climber Mount Everest expeditions. Of these, only a small and uncertain minority could be found at one time or another above 24,000 feet, and only a few had any intent or chance to ”summit” at 29,028 feet. Among those who did ”summit,” 12 people died in the throat of an average summer storm that struck on May 10. In 1977 journalist Jon Krakauer, who made the ascent himself, published Into Thin Air. It is and exhaustively documented, researched, and meticulously put together account of events of those few days and weeks, well worth reading. There are similarities in the two expeditions and in the two books. Both authors are journalists, who have written expositively, with some moving and descriptive eloquence, in a timeforward order of events, without much speculation. In both expeditions, many participants at either end of the 20th century were clearly

motivated by some sort of personal gain, notoriety, profit, publication, lecture circuit income or commercial interest. The Antarctic explorers, very conscious of the fame and renown that could accrue to them, often had high expectations of notoriety and profit; many kept careful diaries, often preserving them through almost two long, fiercely harsh hopeless years on ice and across the world’s most hostile seas. The early BritishAmerican-Norwegian competition at the earth’s poles is well known, and national competitiveness at Everest and elsewhere is always with us. Yet what struck me most were the contrasts between very early and late 20th century ventures. Where profit and nationalism are concerned, there was a marked difference of degree; both were the overriding features of the Everest expeditions, clearly contributing to a tragic outcome. These motivators were present but far less significant in Antarctic 1914. Late century groups were in fierce commercial competition for what could be called market share. Fischer and Hall, organizer-leader-guides of the largest groups, competed for patronage; to demonstrate that anyone who had enough money could ”summit” safely despite marginal experience or physical condition; each guide needed to show that he was the better leader. These considerations led both highly regarded guides to accept climbers who were neither experienced nor capable; to make decisions near the summit that were clearly unwise; and, as a result, to die on the mountain. May/June 2009

Where profit and nationalism are concerned, there was a marked difference of degree...

As one reads the Everest account, this toxic accumulation of so many people in such dire circumstances is where the ultimate outcome first announces itself.

By comparison, Shackleton’s Antarctic Expedition was only marginally commercial, with no need or effort to ”lead” adventurers for pay. Nationalistic competitions in the Antarctic were also more remote, old fashioned, or aristocratically sterile. (If sometimes foolishly so; in the 1911-12 South Pole race Robert Scott’s British expedition, which ended tragically, dragged linen and tea sets over the ice, and was at first prone to spend evenings in soiree-like discussions; Norwegian Roald Amundson’s successful trek to the pole had been, like Shackleton’s, lean and practical, meticulously planned and constituted.) On Everest, in addition to the usual New Zealand, Australia and USA teams, there were groups from India, Nepal, Sweden and Japan. There were also particularly uncooperative and difficult groups from Taiwan and South Africa whose aggressiveness and intransigence promoted a lethal outcome; they refused to cooperate with competitors, or to agree on an order of ascent that could have avoided the deadly delays and traffic jams of May 10. Some climbers had to wait for hours for a turn to ascend; and worse, to wait for descent from the summit, where every minute delay raises the risk of death, and lack of oxygenation dulls decision-making. There were, of course, great technologic differences between the early and late 20th century in terms of equipment, communication, medical care. At Everest, people might speak to family or friends from the summit; use satellite guidance, and modern cold weather gear; be treated by the team physician or by one of the many climber physicians; or by a base camp medical team with advanced equipment after being carried down the mountain by Sherpas who had earlier carried up virtually all needed for the ascent. In Antarctica, two years could pass before any outside communication whatsoever. Geographic fixes often were impossible for many days when neither sun nor stars could be seen. Two physicians provided very basic medical care; a man sustained what appeared to be a myocardial

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infarct. Ironically he was treated according to a modern British protocol for minor MI: rest at ”home.” He survived. The 166 people on the skirts of ”Sacred Mother” Everest was also was in sharp contrast to the 28 men on the Endurance, trapped in both the ice and the mind numbing isolation and desolation of the Antarctic; or in three small life boats that they had dragged with them over the ice, and in which they faced the torrential winds, rain, and moving mountains of Arctic waters. Often the large numbers so impacted the Everest environment that a health hazard resulted. Krakauer’s vivid description of conditions at the jumping off point toward Everest base camp include unhealthy sleeping conditions with choking smoke, water and food contamination by sewage, severe shortage of good food, and the resulting gastrointestinal and pulmonary consequences. Why? Because of the concentration of expeditionary teams, Sherpas, media crews, communication teams, camp followers, and pack animals in a very confined area, as they awaited more auspicious weather conditions, and jockeyed for advantage. Every preventable tragedy, it is said, results from a series of related errors, any one of which if avoided would have prevented the outcome. As one reads the Everest account, this toxic accumulation of so many people in such dire circumstances is where the ultimate outcome first announces itself. On the other hand, reading of Shackleton, the sense is that at every step there is cohesion between the expedition’s members and Shackleton, who take intelligent, thoughtful consistent steps to protect the relationships among expeditionary members. He takes care to assign likely troublemakers to his own tent; carefully physically and psychologically selects the crews for each lifeboat when they begin an impossible open sea crossing. There is a military feel to the process; though some might have resented or openly disagreed with Shackleton’s decisions, they follow his instructions without fail. The sled dogs, for

example, were beloved of their team drivers. Yet when the dogâ&#x20AC;&#x2122;s food ran out, they are ordered to kill them; they do so with great affection and with sadness but without resentment. By contrast late 20th century group behavior was not cohesive. In many instances, a leaderâ&#x20AC;&#x2122;s orders were simply refused; one of Hallâ&#x20AC;&#x2122;s highly paid and very strong Russian guides simply refused to use oxygen at the summit; therefore became cold, due to the delays, and refused to wait for the climbers in his charge. Hall died trying to rescue the abandoned climbers. The various expeditions were encrusted with people who were an end to themselves: A New York socialite journalist with entourage, with special food, clothing, communication equipment, CD players, and TV; cinema actors and directors and crews; and the many wealthy individualistic egos who collect summit accents like stamps, for show. The mere presence of these self-satisfied, self-directed luminaries, and a world class media that follow them, charge the atmosphere as they did the O. J. Simpson trial; the outcome and the behavior of people

so affected, is not one of cooperation, tolerance or even intelligent thoughtfulness. Krakauer himself, having reached the summit, having written his hugely successful book, but also having lost four of his five summiting teammates, gives an edge of pain and remorse to his documentary. He fears he contributed to the result. That somber note seems justified in spades. Quite different is the very uplifting and impossible accomplishment of Shackleton and crew, who all survived their Antarctic frozen hell for almost two years. These two books are great reads. They provide some vague insight into the contrasting character and behavior of people who lived at the beginning and the end of the last century. I do not claim that one age is better or worse; but I do claim that one age is irretrievably different from the other, probably in ways neither could even understand. We are basically captives, mental, physical, and psychological, of our own times. john@loofbourow.com

Physician Wellness CME Mandate Proposed by MBC

May/June 2009

Physician Profiling What you don’t know can hurt you.

By the AMA Private Sector Advocacy Staff Big news related to physician profiling came out of New York last year, when Attorney General Cuomo announced his landmark settlements with insurers operating in his state. The insurers are now required to submit the rating criteria they use to place physicians in tiered networks, in which members pay lower co-pays or otherwise receive discounts for seeing favored physicians. In addition, these insurers must abide by a set of standards for their physician profiling programs and hire an independent Ratings Examiner to report to the Attorney General every six months or incur penalties. Shortly after the insurers signed agreements with Mr. Cuomo, members of the ConsumerPurchaser Disclosure Project adopted The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs. Under this voluntary agreement, health insurers will follow a set of standards, hire an independent entity to audit their programs to ensure they use valid measures to rate physicians, and work toward pooling their data. Although neither the New York settlements nor the Patient Charter is a panacea for the problems associated with physician profiling, they represent important steps forward. However, the AMA contends that all physician-profiling programs must follow standards that require the use of valid methodologies, promote transparency at all levels, and assure accurate results. In order to encourage legislation on physician profiling programs, the AMA developed a model bill, which mandates profiling programs adhere to a set of standards, use valid quality standards, properly adjust for risk, use sufficient sample sizes, and correctly attribute episodes of care. Additionally, insurers must fully disclose the

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methodology used to profile physicians and disclose the limitations of the methodology, profile physicians at the group level, establish a reconsideration or appeal process, and hire an independent third party to oversee the program. Recently, Colorado Gov. Bill Ritter signed legislation regulating the physician rating systems used by many of the state’s health insurers. The Colorado law requires health insurers to make their processes for profiling, rating or characterizing physicians more transparent, and ensure greater accuracy in the results. The law also provides for an appeal mechanism so physicians can challenge the validity of their rankings prior to their release or use by health insurers. Regulations like those adopted in New York and now Colorado, and documents such as the Patient Charter, are essential to help ensure that the physician performance information that health insurers provide patients is both reliable and meaningful. They establish processes that temper some of the inherent risks that can result from physician profiling. The AMA neither supports nor opposes physician profiling per se, but patients and physicians have the right to understand how profiles are developed and to expect that results accurately reflect the realities of the physician practice. Some health insurers have unfairly evaluated physicians’ individual work. Not only can incorrect and misleading information tarnish a physician’s reputation, it is unfair to patients who may consider it when choosing a physician. Erroneous information can erode patient confidence, trust in physicians, and disrupt patients’ longstanding relationships with doctors who know them and have cared for them for years.

In an effort to assist physicians engaged in programs that use physician data, the AMA Private Sector Advocacy (PSA) unit created an entire series of informational pieces designed to help physician practices understand and effectively deal with such programs: • Physician Pay for Performance Initiatives is a white paper detailing all facets of the pay for performance movement. • How physician incentives are used to impact medical practice describes the various incentive models in use and provides examples of these models in practice. • Tiered and narrow physician networks explains how these networks are constructed and gives numerous examples of programs. • Pay for performance: A physician’s guide to evaluating incentive plans provides physicians with a roadmap to evaluating pay for performance programs. • Optimizing outcomes and pay for performance: Can patient registries help? describes how patient registries may be used to enhance pay

for performance opportunities. • Economic profiling of physicians: What is it? How is it done? What are the issues? is a white paper that explains how cost of care measurement is performed and what its abilities and limitations are in providing accurate results. • How to Challenge Your “Profile” or Placement in a Tiered or Narrow Network is a one-page document that gives physicians a systematic process to follow for challenging their profile ratings. • Physician Profiling: How to prepare your practice provides physician practices with steps to take to be well prepared for profiling programs. • TO OUR PATIENTS is a poster designed for physicians’ offices to educate their patients on the problems with physician rating systems. • A Comparison of 4 Physician Profiling Programs is a chart comparing key components of The AMA model bill, the Colorado law, the Patient Charter and Mr. Cuomo’s settlement with CIGNA. susan.close@ama.assn.org

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

not-for-profit since 1948

For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.

May/June 2009

In My Opinion

The Tea Parties Revisited By David J. Gibson, MD, and Jenifer Shaw Gibson An old saying describes individuals this way: There are people who make things happen, there are people who watch things happen, and there are people who wonder what happened. On April 15th, over 300,0001 American citizens gathered in more than 800 cities to voice opposition toâ&#x20AC;Śwhat? Increasing tax rates? Increasing levels of government spending from local to federal levels? Creeping bureaucratic encroachment of personal decision making and self-determination? What? Conservative pundits opined that these protests represented a return to an era of fiscal conservatism and limited government. Liberal pundits painted the protestors as unsophisticated hicks unworthy of participation in public debate. Both were wrong.

Making Things Happen. Most decisions about future government size, spending and involvement in the private lives of its citizens were made in the 1930s by the New Deal; the paradigm was sealed in the 1960s by the Great Society era. Those designing and developing Social Security, Medicare and Medicaid were people who make things happen. The programs enacted during these eras, mostly elderly, middle class entitlement and wealth transfer programs, were a quantum increase in government involvement in the private sector. They were also a massive funding vehicle for financing activist government. Social Security and Medicare were designed with â&#x20AC;&#x153;trust fundsâ&#x20AC;? that were never funded. All of the involuntary contributions by workers into these funds were immediately used to buy government bonds that funded new government programs. It was a great deal; Ponzi schemes always are.

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Unfortunately, the consequences of the unfunded entitlement programs are now coming due. Moving money from one section of government to another does not generate wealth. We are about to begin experiencing a massive cash flow problem in this country. The pay-as-you-go systems that finance these entitlement programs, including government retiree medical programs, require taxpayer subsidies of shortfalls between trust fund contributions and obligation payments. There are no trust funds to draw upon. The trend in the liability is breathtaking. By 2012, we will need 1 in 10 income tax dollars for entitlement obligation payments. By 2020, 1 in 4 dollars will be required. By 2030, 1 in 2 tax dollars will be required.

Watching What is Happening. This brings us to the Tea Parties. These protesters were everyday folks who rarely think about government other than on April 15 each year. They disgruntlingly pay their taxes and go on with their private lives, leaving the rest of the year to the professional and largely permanent political class. In the past, they have tolerated politicians enacting programs provided they were paid for using wealth redistribution and borrowed funds. These taxpaying protesters fall into the second group of people. They have observed that something very bad is happening. What the Tea Party protesters do not appreciate is that it matters not what party is in power. The consequences of decisions made five to eight decades ago are dictating current events. We are about to experience a perfect fiscal storm that has been foreseen since the inception of the activist government era. Exploding government spending beyond entitlements; the looming inability of the government to service its existing and increasing debt; the collapsing

ability of state and local governments to support their unfunded retirement liabilities; are all conspiring to crush the economy of the United States. This economy has been the greatest wealth producing system in the history of mankind. It is now technically bankrupt when assessed by accepted public accounting standards. The Democrats who now control policy making in Washington are entering sui generis territory. Their current and planned spending initiatives are unprecedented. The Administration and Congress are generating spending bills for bank bailouts, union-centric Detroit rescues, comprehensive health care overhauls to cover all the uninsured, education reform programs, climate-change cap-and-trade regulation and various stimulus plans increasingly recognized as “political pork.” During the first six months of this fiscal year, the federal deficit is running at $956.8 billion, or nearly one seventh of gross domestic product — levels not seen since World War II, Federal debt alone, backed by public liability, as projected by the Congressional Budget Office, will rise from 41 percent of gross domestic product in 2008 to 51 percent in 2009 and to a peak of around 54 percent in 2011. Unless the economy rebounds sharply later this year, these projected deficits will be far greater. For all of 2009, the administration will need to borrow approximately $2 trillion. The Congressionally mandated debt ceiling of $12.1 trillion will most likely be breached in the second half of this year. Government borrowing to pay for debt servicing will displace the capital needed by the private sector to invest for competition in the evolving world economy. This lack of investment capital will destroy the engine that drives our economy. The Congressional Budget Office expects interest payments to more than quadruple in the next decade as Washington borrows and spends ($806 billion by 2019 from $172 billion next year). The ability to service this debt through borrowing is showing signs of distress. America is facing increasing competition in global financial markets for its bond-based borrowing

needs. A consortium of investor nations ranging from China and Russia to most of OPEC have announced intentions to extricate themselves from dollar dependency as fast as they can. Zhou Xiaochuan, the Chinese central bank governor, earlier this year called for a world currency modeled on the “Bancor.” The Bancor was first proposed by John Maynard Keynes at Bretton Woods in 1944; his proposal called for anchoring international finance to 30 commodities. International investors have announced that they are seeking a basket of units, similar to the Bancor that will be based upon the euro, the sterling, the dollar and the yen as well as a collection of industrial metals. China has already begun to implement this investment strategy. China now holds the world’s largest foreign reserves, believed to be mostly in dollars, along with around 800 billion dollars in US Treasury bonds. Treasury Department data show that investors in China have sharply curtailed purchases of bonds in January and February of this year. China’s State Reserves Bureau (SRB) has instead been buying copper2,3 and other industrial metals over recent months on a scale that appears to go beyond rebuilding of stocks for commercial reasons. Beijing appears to have made a strategic decision to stockpile metal as an alternative to U.S. Bonds. From China’s perspective, buying raw materials is a solid self-interest move. China will enjoy a rate of return for their $1.9 trillion of reserves that exceeds by a factor of 10 what it reaps from U.S. Bonds. Of even greater significance, China can implement its stated plans to dominate industrial development for the next half-century. As an example, the next industrial revolution is going to be led by hybrid cars, and those cars need copper. These unfolding and irreversible developments mean our ability to finance increasing debt through bond sales to foreign investors is about to end. So the Tea Party protesters have every reason to express their concern.

May/June 2009

This economy has been the greatest wealth producing system in the history of mankind. It is now technically bankrupt when assessed by accepted public accounting standards.

What happened?

to cover

This brings us to those who wonder “what happened”? “Joe six-pack” is about to become engaged in the political process. When this segment of the population, which as a rule does not vote, finally engages things happen. Remember the car tax and the dumping of Governor Davis? This group can best be categorized as former Louisiana Senator Russell Long, political party agnostic, populists. “Don’t tax me, don’t tax thee, tax that feller behind the tree!” Other than taxing the rich, the populist public will not tolerate higher taxes that are levied upon them — witness the recent defeat of all initiatives here in California to increase taxes despite the looming state deficit. Unfortunately populism is a ruse to manipulate Joe. Taxing the rich is an artifice well understood by policy makers throughout government. The utterly disingenuous rhetoric coming from Washington presents a policy of ending tax breaks for the wealthiest 2 percent of Americans, and promising that households earning less than $250,000 won’t see their taxes increased. At best, this is utter nonsense. Increasing taxes on the salaries, dividends and capital gains of all those making more than $250,000 will not raise the revenue needed to fund the programs in the pipe-line and service existing debt.

individuals

What’s Ahead for Health Care?

Should economic reality prevail, a likely Democratic back-up plan will be to expand Medicare

down to age 55.

Many physicians fall into the “what happened” group. They will be shocked at what is about to happen to their practices. We make the following 10 predictions using economic trends and data rather than ideology. We predicted the demise of health care reform here in California a year before its implosion;4 and we predict the same for comprehensive national health care reform. The unfolding catastrophe in Massachusetts should be instructive. The state is trying to manage the huge costs of a subsidized middle-class insurance program that is gradually swallowing the state budget. Over the next year, America will come to recognize that health care is not free. It costs far more than a $5 co-payment. It cannot be paid for by

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the rich. The public will discover that federal credit card, used to pay for much of health care, is maxed out. The only wild card in this prediction is that Washington has the ability to escape economic reality. The federal government can print money, as opposed to California and Massachusetts. Furthermore, the Democrats have the political power to pass any form of comprehensive health care reform they choose. With the defection of Senator Specter and the likely seating of Al Franken they will have a filibuster-proof Senate. They also have the backup option of passing a health plan through the “budget reconciliation” process. There is no obstacle short of economic reality to restrict their passing a comprehensive health reform measure. Elections have consequences and to the winners go the spoils. Should economic reality prevail, a likely Democratic back-up plan will be to expand Medicare to cover individuals down to age 55. With the expansion of the State Children’s Health Insurance Program (SHIP) eligibility up to 35 years earlier this year, this would leave only a 20 year gap in full coverage under singlepayer. With either comprehensive reform or expansion of SHIP, the government will far exceed its current 50 percent level of funding for health care in the United States. Controlling health care spending will become a priority for government at all levels. Spending is driven by two variables: the cost per unit of services delivered and the number of units delivered. Americans receive more medical services than do other peoples, and they pay more for them. Controlling the cost per unit of service will require substantial reductions in the cost of labor in health care. Labor costs now consume more than 70 percent of every unit of health care delivered across the U.S. The U.S. labor costs are double those seen in our most comparable system, Canada. By leveraging its monopolistic payer position the government will dictate rather than negotiate unit pricing. With the demise of private health plans, reimbursement for services will initially decline to Medicare allowable rates. Ultimately, as was the plan under the rejected

Clinton plan over a decade ago, reimbursement levels will drop to Medicaid levels for doctors and hospitals. No current health care unit’s business model will withstand this level of funding reduction. No American hospital, no staff model health plan and no medical group will have a viable business model. We will likely see the return of the old county hospital system with attached medical groups. The only difference from the past will be that now everyone will get their care from these facilities, not just the indigent. If you like the DMV, you are going to love this delivery system. Reducing the number of units of service will also be necessary. Every single-payer system around the world limits access to high-tech diagnostic and therapeutic modalities by limiting supply. Waiting time will grow to those commonly seen in Canada or the European continent. In addition to limiting supply, we are likely to see age-based overt rationing of goods and services in health care over the next few years. Many are now speculating that the patient data collected by the Administration’s national electronic health record (EMR) initiative will be mined to assess the cost effectiveness of different treatments. This analysis could then be used to determine return-on-investment and cost-benefit-ratios. Thereafter, guidelines will be set using these calculations. These guidelines will be used to dictate which drugs and devices doctors can provide to their patients while the EMR monitors conformance to those standards. As the above restrictions take hold, the elderly, the terminally ill, the infirm and the disabled will see significant reductions in their ability to access health care services. One of the announced goals for health care reform under the current administration was articulated by Tom Daschle in his book, “Critical: What We Can Do About the Health-Care Crisis.” Daschle called for a Federal Health Board (FHB) for the health care industry that would resemble our current Federal Reserve Board for the banking industry. One of the primary assignments of the FHB would be to set cost effectiveness and

return on investment values for each medical procedure. It should not be a surprise if hip replacements or coronary stints and bypass procedures for elderly patients would not pass muster with this cost-benefit methodology. Innovation in the development of new pharmaceuticals, diagnostic and therapeutic technology will be driven offshore. With the FHB having a stranglehold on access to these new products and modalities, no company will be able to justify the R & D costs associated with development. Furthermore, no hospital receiving Medicaid levels of reimbursement will have the ability to purchase new technology. As access to health care is limited by technology supply and cost considerations, those with the ability to pay for their own care will migrate to the international markets for needed procedures and cutting edge technology. The inevitable result – America will no longer be the leader in effective health care delivery. So, the Tea Party protesters are right. Something bad is happening to them and their families. Unfortunately, almost all of the government activist and redistribution programs are now in place. There is little a typical political protest will do to change the inevitable. Only a real rebellion by Joe Six-pack will fundamentally change the definition and direction of government.

Ultimately, as was the plan under the rejected Clinton plan over a decade ago, reimbursement levels will drop to Medicaid levels for

DJGibson@winfirst.com Jennifer Gibson traded energy commodities on the Chicago Mercantile Exchange. She is also an economist who trained at the London School of Economics and now specializes in evolving health care markets. David Gibson is the C.E.O. of Reflective Medical Information Systems, a software development, data mining and consulting firm.

doctors and hospitals.

1 http://www.fivethirtyeight.com/2009/04/tea-party-nonpartisanattendance.html 2 This explains why copper prices have surged 49-percent this year to $4,925 a ton despite estimates that world demand will fall 15 to 20-percent this year as construction demand declines. 3 Chinese imports reached a record 329,000 tons in February, and a further 375,000 tons in March of this year. 4 http://www.sacbee.com/static/weblogs/crossroads/healthcare/ archives/005138.html#more

May/June 2009

1st Place Student Essay “Should Middle School Students be Subjected to Drug Screening by the State of California?”

By Celynne Balatbat EDITOR’S NOTE: The author’s name may be familiar: she also won first place in last year’s contest. Both the Early Diagnosis and Preventive Treatment of Psychotic Illness (EDAPT) Clinic at the University of California, Davis and Xavier Amador in his book: I Am Not Sick I Don’t Need Help? (2000) found that there may be a direct correlation between mental illness and the use of illegal drugs in individuals twelve years of age up to forty years old. The EDAPT Clinic at the University of California, Davis determined the eligibility age for referrals to start from age twelve up to forty years old. Early diagnosis and Preventive Treatment of Psychotic Illness begin with individuals who need intensive multidisciplinary treatment. Xavier Amador, the Director of Psychology at the New York State Psychiatric Institute is a professor of Psychology in the Department of Psychology at Columbia University College of Physicians and Surgeons. Dr. Amador believes that individuals with mental illness at times refuse treatment because they don’t believe they are ill. He offers guidelines and strategies to conquer denial and makes recommendations how family members can assist their loved one to seek professional help for schizophrenia and manic-depression. Anna-Lisa Johansson assisted Dr. Amador in writing the book. Ms. Johansson works part time for the Treatment Advocacy Center in Arlington, Virginia. She suffered with schizophrenia and schizoaffective disorder. In my opinion, early diagnosis of mental illness can make individuals more susceptible to treatment. They can live their lives as productive citizens rather than deny their situations. Dr. Amador points out that 50% of individuals

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with mental illness deny their condition. He gives successful cases where his step by step guide assisted families in encouraging their loved ones into accepting their situations, seek treatment and take their prescribed medicines. Educational leaders often failed to realize that teens need education in the areas of drug prevention, sexually transmitted diseases, mental health problems, teen pregnancy and bullying in schools. Parents also are hesitant to allow their children participation in these programs if they are offered in the schools. As a result, comprehensive health programs have always had a battle to find its rightful place into the school curriculum. In his book: Promoting Teen Health: Linking Schools, Health Organizations, and Community, Alan C. Henderson hints on the serious problems that young people are facing in the schools, and he recommends ways to address these problems through health promotion, information and education. Each chapter addresses a specific problem with demographic representation and facts concerning the problem and the approaches that have proven to solve them. The most valuable part of the book is the list of resources included and the factors and interventions by health promotion programs and their funding sources. These successes of these programs are evaluated in the book with perspectives from the participants. If in fact direct correlation exists between the use of drugs under the age of fifteen and mental illness such as schizophrenia then early detection can decrease the progression of mental disease. Both educational leaders and health professionals should work together to assist in early diagnosis to slow down its development. Educational and health professionals can help

young people in getting life long treatment for other problems as well such as obesity, teen pregnancy, hypertension or diabetes. Even if drug testing is proven to be negative the results can be use to assist middle school students to be a more responsible young adult and to make better choices. In conclusion, I believe that drug screening should be included into the school programs just like checking hair for lice and eyes for better vision. These practices are all preventive; so should be drug screening. However, for drug screening to be a successful part of the program Parents, Community Leaders, Health Science Professionals and educational Leaders must collaborate to provide pertinent information to parents and caregivers about the advantages of drug screening. Middle school students also will need knowledge about drug screening, the resources and counseling they need to make better decisions about their mental health. Young people need help to cope with problems and to succeed. Thus, working together as a team, educators and health professionals can offer a better solution to promote and subject middle school students to the drug screening process for better mental health. The study conducted by Gottfredson et al (2000) found that at least 9 percent of secondary schools conduct some sort of drug testing programs. Most of these programs focused mainly on athletes as a condition for participation in extracurricular activities. In addition, the Supreme Court (515 U.S. 646, 1999) mandates drug testing for athletes. Many students and parents still opposed drug testing programs. Every effort should be made by school officials and health officials to get parent involvement in drug screening programs and to keep them informed on illegal uses of drugs and their harmful effects on individuals and school age students. Subjecting middle school students on drug screening programs is a preven-

tive measure in assisting them to overcome peer pressure. If knowledge is power, then by providing parents with the goals and reason for drug screening, they can support the drug screening programs in the schools from middle to high schools. However, I agree with the studies that based on their findings that drug screening in middle schools through high schools is necessary to monitor illegal use of drugs in youth and as preventive measures of promoting healthy mental health.

References

Amador X., Johanson A.L. (2000). I Am Not Sick, I Donâ&#x20AC;&#x2122;t Need Help! New York: Vida Press, 137-200 Henderson, A. C., Champlin S., & Evashwick, W. (1998). Promoting Teen Health: Linking Schools, Health Organi-zations, and Community. California: Sage Torrey, E.F. (2006). Surviving Schizophrenia: A Manual for Families, Patients, and Providers. Colorado: Harper Collins Press Imaging Research Center: http://www.ucdmc.ucdavis.edu/ucdirc Carter Lab UC Davis: http://carterlab.ucdavis.edu

May/June 2009

2nd Place Student Essay “The Costs of Drug Screening”

By Aurora Mireille Singh Drug abuse exacts an immense cost on American society, both medically and economically. Each year, thousands of Americans die due to drug induced causes and many more battle the devastating effects of drug addiction. In addition, millions of Americans must shoulder the burden of lost revenue and pay for increased health care costs. As an attempt to combat drug abuse, drug testing of the American public has steadily expanded over the last 20 years to include areas such as the workplace, professional sports, and schools. With statistics from the United States Department of Justice showing that roughly 42.3% of high school seniors have used marijuana, it is unsurprising that government officials want to prevent any illegal drug use. In 2002, the Supreme Court ruled that drug testing is constitutional in middle school and high school students, and since then millions of dollars have gone toward funding drug testing in schools. Schools can legally require students to take drug tests, but many have not embraced such testing for various reasons. White House officials have supported expanding such programs, with the belief that it lowers the rate of drug use among students. However, drug testing can be unreliable and very limited. At roughly 20 to 50 dollars per drug test, its cost means that other government programs must be cut. Drug screening is not a cost effective way to deter students from using drugs. In order to achieve the goal of reducing illicit drug use, the state should not require drug screening in schools, but rather focus on education and outreach programs that directly communicate with the affected individuals. Despite the growing presence of drug

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screening in schools, it is unclear whether such efforts actually reduce drug use. In 2003, Ryoko Yamaguchi, Lloyd Johnston, and Patrick O’Malley of the University of Michigan, which also produces Monitoring the Future, the university’s highly regarded annual survey of student drug use that is funded by the National Institute on Drug Abuse, conducted a study on rates of drug use in schools and concluded that drug testing is not associated with a change in the number of students who use drugs. In that same study, there was one exception where randomly tested twelfth graders were more likely to smoke marijuana. Furthermore, there are many limitations to drug testing. Preliminary research by Dr. Sharon Levy, director of the Adolescent Substance Abuse Program at Children’s Hospital Boston, and colleagues indicates that drug testing is very susceptible to both tampering and misinterpretation, even in the hands of reputable medical officials. A market already exists for products, such as chemical additives to urine samples, that allow individuals to pass urine drug tests, the most common and inexpensive form of drug screening. At schools, officials may escort students to give a urine sample, but may not monitor the student as they give the sample. As a result, the student may tamper with the sample by adding other fluids or even substitute a clean sample from other individuals. Additionally, prescription drugs can interfere with drug tests, causing certain illegal drugs to falsely come out positive. The problem of drug abuse cannot be solved overnight or through one comprehensive, government mandated program. Common reasons for using drugs include boredom and

peer pressure. Adults and officials must present educational programs, peer support, and alternative activities to combat illicit drug use. Self reported surveys have shown that students who participate in extracurricular activities are less likely to use drugs than those who do not. An environment where drug use is not common may also discourage students from experimenting with drugs. Expanding programs that involve students in various activities may be one aspect of the solution to reducing drug abuse, combined with other approaches such as simply facilitating discussion between parents and children so that individuals using illegal drugs can receive appropriate treatment. Understanding the harmful effects of drug use may also deter students from abusing drugs. Drug abuse does not just affect particular individuals and their families or friends, but permeates all of society. Our country cannot afford to ignore this pressing issue, but must

also not waste its resources on ineffective programs. California should not require drug screening in middle school students, but instead should address the underlying circumstances that prompt drug abuse.

Upcoming Museum Lectures Following are the remaining lectures this year sponsored by the Sierra Sacramento Valley Museum of Medical History. Contact SSVMS to reserve a seat. June 24, 7 p.m. The Aging Brain, Alzheimerâ&#x20AC;&#x2122;s Disease and Strategies to Maintain, Robert F. Halliwell, MD August 27, 7 p.m. A Brief History of Transfusion Medicine, Christopher Gresens, MD November 4, 7 p.m. Magical Medical History Tour, Faith Fitzgerald, MD

May/June 2009

Voices of Medicine Death of the medical autopsy; ODs in primary care; stress and the President’s brain?

By Del Meyer, MD

Remember the Autopsy? Dr. Scott Sattler discusses “Medical Autopsy: The Forgotten Teacher” in the March 2009 issue of the Humboldt-Del Norte County Medical Society Bulletin. Remember when we used to do autopsies on other than just coroner’s cases? When I trained at Valley Medical Center in San Jose in the 1960s and 70s, essentially every hospital death went to autopsy unless the family requested otherwise and the resident couldn’t persuade them differently. The involved medical staff would usually attend the procedure. Weekly morbidity and mortality conferences (M & M’s) would discuss the case and correlate the pathologic findings with the premortem diagnoses. It was often a humbling experience. In the mid-1980’s, data showed that such autopsies revealed a major misdiagnosis of the primary cause of death in 20 to 40% of cases. In 10 to 15% of all cases, the missed diagnoses would likely have affected patient outcome. Did I mention that autopsies are a humbling experience? When I first came to Humboldt County (to the Hoopa Indian Reservation to be exact) in 1974, the tradition of medical (as opposed to forensic) autopsy was still going strong. I well remember the woman with advanced diabetes whose chemistries and comfort just couldn’t be controlled and, despite intensive care and multiple specialty consultations, whose deterioration was unstoppable. I remember her, in great part, because of her autopsy. The vision of her large undiagnosed pituitary tumor and the dent it had made on her optic chiasm is burned onto my permanent intracranial hard drive. Before that day pituitary tumors were a theoreti-

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cal construct I’d learned about in med school. That day they became real. When I moved my practice to Eureka in 1982 we were still doing medical autopsies, but over the years they became fewer and fewer. Out of curiosity I went over to the Coastal Pathology office the other day and talked with them about it. They showed me the book where they record all the autopsies done by their group (and by the Humboldt Central Pathology group which preceded them). It contains records going back to 1983, when 40 medical autopsies were performed. By 1986 it had dropped to 30, and by 1989 to 16. There were only 9 done in 1991. By 1999, only 4. In 2005 there were just 2 and there have been none done in the area served by Coastal Path (Humboldt and Del Norte counties) since June of 2007, almost two years ago. We have lost a helpful friend and an inspiring teacher. On this part of the North Coast, medical autopsy is no more… Read the entire article at www.humboldt1. com/~medsoc/images/bulletins/2009-03%20 MARCH%20BULLETIN_for%20web.pdf

Osteopaths in primary care Dr. Stephen Kamelgarn discusses why osteopaths are half of all new primary care physicians in the March 2009 issue of the Humboldt-Del Norte County Medical Society Bulletin. At least twice in the last several months I’ve gone to meetings about health care where the statement (or variations, thereof) was made: “Only 7 percent of medical school grads go into Family Medicine as a specialty.” Although that number seemed somewhat low, I felt that it could conceivably be real. We all know that primary care receives abysmal reimbursement from the insurers…

In 2008, there were 2,654 available Family Practice residency slots available, and 2,404 were filled (90.6%). Now, if only 1,200 MD’s elected to go into Family Medicine and 2,400 slots were filled, who made up the other 1,200? Well, it turns out that the remaining 1,200 slots were filled by graduate DO’s. (This isn’t exactly rocket science math, since only MD’s and DO’s are considered doctors and can go into any residency program.) According to AOA statistics, approximately 40% of DO grads choose Family Practice as their primary specialty. There has been an approximately 50% increase in the number of DO grads between 1995 and 2007 with 3,024 graduating last year. This represents about 15.8% of the total number of newly graduated physicians. But it does represent another 1,200 (or about 50%) of the number of new graduate physicians electing to go into Family Practice. Osteopathic physicians represent one of the fastest growing segments of health care professionals in the US. AOA estimates that by the year 2020, there will be at least 100,000 practicing DO’s, and they will represent an ever increasing proportion of the physician pool. The other noticeable trend is that osteopaths tend to be somewhat younger than their allopathic colleagues. In 2008, almost 50% of DO’s were younger than 45 while only 39% of MD’s were. Conversely, only 10% of DO’s were older than 65 while 19% of MD’s were. This implies that as we age, our likelihood of having a DO as a physician (especially as a primary care physician) will be fairly high… To read the entire editorial, please go to www.humboldt1.com/~medsoc/images/bulletins/2009-03%20MARCH%20BULLETIN_ for%20web.pdf

Presidential Stress Lyle B. Stillwater, MD, discusses “The President and His Hippocampus,” in Vital Signs, the journal of The Fresno-Madera And Kern Counties Medical Societies. Way back in 1979, I had the misfortune to be the only ENT resident at Stanford for thirteen days and thirteen nights including that many nights were on-call in a row (as a result I still

hold the Bill Fee Iron-Man award in that department). At age 28, I could just tolerate the stress but I did lose 25 pounds in weight over a three week period centered around that time on-call, surviving on canned Ensure, Sudafed, and caffeine. I was interested to read recently on the anatomical correlates involved in the effects of chronic stress on a normal brain, i.e. the hippocampus over time may decrease significantly in size. With the recent change in U.S. presidents after eight years of essentially being on-call as the president, available day and night constantly, I started to wonder what effects that constant stress would have on any president’s brain… The president’s unique stressors would include the constant need to personally be available every minute of the day constantly for eight solid years, even when on supposed vacations… Robert Sapolsky at Stanford has shown that a prolonged flood of stress hormones can actually cause shrinking in certain brain areas particularly in the hippocampus. A major role of the hippocampus is in memory. It is not unusual for persons with prolonged stress to report forgetfulness and difficulty learning (certain portions of the hippocampus can recover and the stress response is reversed)… The ultimate brain effects would manifest themselves in depression, anxiety and most importantly dysfunction in decision-making. A Novel History Ph.D. Thesis Project would be for a Masters student to review all two term presidents to see if in the last year or two of their second term, consistent poor presidential decision making existed, no matter who the president was, compared to earlier in their stint as president. It would also be interesting for all future presidents to get a baseline brain MRI scan, and then repeat the study eight years later to see if the hippocampus has decreased in size, more than expected from reviewing an age-matched control group… The entire article is at www.fmms.org/pdf/ Feb09_VS.FINAL.pdf

It is not unusual for persons with prolonged stress to report forgetfulness and difficulty learning...

DelMeyer@MedicalTuesday.net May/June 2009

A Posit on the UN “The H1N1 flu and the Somalia pirates were only the two latest events that begged for UN leadership. As usual, there has been no UN response beyond rhetoric. The world will not continue to support such a costly, corrupt, failed political experiment.”

Among 65 responses, 33 agreed, 29 disagreed, 3 undecided but with comment. The UN commonly does not take handson action but it is a forum for discussion and debate of issues of international importance, which might in itself lessen the chance of armed conflict.

A few commentators expressed annoyance at the appearance in their magazine of a posit statement they didn’t agree with. Therefore, the editors recognize that we have not adequately conveyed the central idea of posits, even though it is attached to each posit assertion. We want to do better, and hope a discussion triggered by this particular posit will promote that end. A posit is simply the expression of an opinion; it is necessarily brief and terse. However, posits do not necessarily reflect the opinion of the editors or the Board of Directors. Any member is welcome to propose a posit. Participation is voluntary. The purpose is to encourage an exchange of opinion among members. Why opinion? Opinions are very important in a democracy, where they are the prime mover of action; logic or careful considerations are latecomers, secondary determinants of action. Therefore, exchange of ideas and opinion is critical to a healthy democratic process, particularly between those who disagree. Please remember that any member’s expressed opinion is not per se a personal attack. To the contrary, those who take on the risk of expressing an opinion trust and honor those who they know will disagree. How? To reveal an opinion is to tacitly or innocently trust that those who disagree are able to hear and perhaps respond without offence or offending; it is an assumption that both sides of a disagreement are capable of civil discourse, which elevates and honors the adversaries. To believe our colleagues incapable would be to belittle or insult them. There must be somewhere, a Sierra Sacramento Valley Medicine

Golden Rule like this: “Hear and respect a dissenting opinion as you would have your own opinion heard and respected.” In doing so, we can learn something important about Ourselves and about the Other, this is the basis of a civil society. Two responders objected that this posit is not strictly about medicine. That is so; but our magazine has never been strictly about medicine. It has always been about the lives of physicians. Even the practice of medicine today is not about medicine only, but about politics, economics, and culture, including ethical decisions by non physicians. We live and operate in a community, often in a family or families, in states, in nations, on continents, in a world, in a galaxy. Our magazine is subject to change of course, and change is in the air we breathe today; so an article about changing the magazine might be very interesting. That, or making recommendations to the editorial committee, where any member is welcome. Edited commentary on this posit appears below. — John Loofbourow, MD, Editor The UN commonly does not take handson action but it is a forum for discussion and debate of issues of international importance, which might in itself lessen the chance of armed conflict. We all can and should express our disgust with all governmental and paragovernmental organizations in their failure to stop the genocide and civil war in Somalia and the horn of Africa. UNICEF, World Food Program, World Health Organization, and many other members of the UNDG (United Nations Development Group) perform or coordinate important functions throughout the underdeveloped world and deserve the support of the developed nations. — Joe T. Hartzog, MD

The United Nations is an impotent, costly and corrupt organization. When it comes to providing safety or relief for any group of people in the world, it is usually one of the major powers, chief among them being the United States, to get the job done. This is in addition to the excessive yearly dues that the USA provides and this without any public accountability or scrutiny...case in point the Oil for Food Program/Scandal. The only department in the whole UN structure I could commend would be the World Health Organization. — William W. Johnson, MD The United Nations is only as effective as the nations supposedly united under its umbrella are allowing it to be. After eight years of total obstruction by the Bush Administration, one should not be surprised that the UN appears less than effective. The “world” (meaning nearly every country OTHER than the US!) has seen responses that went well beyond rhetoric, and should continue to support the UN, despite the US calling it a failure. Not every organization that disagrees on certain issues with the American government is a “failure”! — Ulrich Hacker, MD I visited the UN with a church group when I was a junior in high school (1963). It was impressive and had high ideals and hopes. It seemed very important during the 60’s and 70’s. I regret having to agree with the statement. It is a very quiet voice in a loud crowd. — Ronald A. Rogers, MD What the hell is this posit doing on SSVMS? It’s this spurious geopolitical meddling that fuels my antipathy towards organized medicine. If my group didn’t require membership, I’d resign. — Wendy W. Forrest, MD The UN is such a mockery! Not only does it not do any good, it delays definitive and timely action while we hold our breath in the hopes that once, just this once, they will ACT on one of their many, MANY resolutions that are routinely ignored by rogue nations and by the world at large. Have they EVER done anything to justify their existence? — Kelly A. Sharrar, MD What does this have to do with medicine in Sacramento? — Gary McLaughlin, MD

Why SSV would ask opinions on international politics over which it has no say is beyond any good sense.... Get back to your local concerns…. Wonder why there are so few members? — Michael H. Burman, MD This one is long overdue. — Deane Hillsman, MD What on Earth does this have to do with medicine? — Mark Tong, MD Actually, it is the U.S. which is the main U.N. financial support. The majority of its members hate us and are corrupt. Move the whole thing to Belgium or Switzerland. — James Farley, MD The WHO, which is associated with the UN, is very active in addressing the H1N1 issue. Actually the changes that the UN and the WHO pushed for improving collaboration between countries early in pandemics improved our outbreak response and our ability to analyze the infection more quickly. I have no opinion about the pirates. — Anthony Russell, MD Lack of efficacy rarely results in the demise of political institutions. The more spectacular the failure the larger it grows. — Mark Zlotlow, MD Such a stupid, idiotic posit I almost didn’t respond. — Daniel A. Egerter, MD While I agree with your statement, I question whether SSVMS should be commenting on Somali pirates. — Robert C. Midgley, MD I can only say that the UN works at snail pace if at all, much slower than even a democracy. — Joseph Lash, MD I admit they have trouble taking definitive action, but I feel the world is steadily moving to charge leaders with crimes against humanity (Darfur etc.). The world can no longer tolerate such events. Without a strong military force, the action has to be really effective sanctions and legal measures. Without the UN we have no world wide political forum where the problems can be hashed out. Eventually all nations should get the message. — R.J. Frink, MD I don’t see that as the role of the UN. Rather the WHO and CDC should address these things. — Thomas Curran, MD This is inappropriate. I am sick of…right wing ignorant unrealistic editorials and will not

May/June 2009

I can only say that the UN works at snail pace if at all, much slower than even a democracy.

What exactly is this political position doing in the medical society magazine?

participate and think it is an inappropriate use of Med Soc resources. — Robert P. Diamond, MD The UN I’m sure could do a better job, but the UN has to continue. The ideal of the UN has to continue. It is very expensive to run, I’m sure; but, as inefficient as it appears to be, it is money well spent. Hopefully, everyone remembers the League of Nations that President Wilson was involved with, and the fact that the US refused to join with the resultant result, WWII. The world, I fear, would not recover from a WWIII. The UN’s strong suit is that it keeps people talking. Talking is good. The UN has done a lot of good things as well. — Maynard Johnston, MD What exactly is this political position doing in the medical society magazine? “Costly, corrupt, political experiment”!!? This is a totally inappropriate way to discuss the UN and its response to H1N1 flu. Is this a political journal? — Jane O’Green Koenig, MD The UN folks talk good but have too weak a “police force” to do what was once expected of them. Very sad. — Byron Demorest, MD We need to strengthen, support, and improve the United Nations so that it can deal effectively with global problems such as these. This will require that all nations, including the U.S., give up some degree if individual sovereignty, just as when primitive tribes joined city-states, which joined larger states, which joined nations. — Robert Meagher, MD Move the UN to Somalia. — Michael D. Maddox, MD Although I agree that it is costly and relatively worthless, there needs to be some sort of global arena for discussions of global issues and the UN fulfills that purpose at the moment. — David R. Jeffcoach, MD Sorry; I think the topic is a bit fatuous. The UN is not in charge of pandemic influenza. The WHO monitors such things and may make recommendations but, once again, the US came through with the CDC. The Somali pirate situation is more complicated, because the situation in Somalia is so bleak that this is a lifestyle for these young men. The solution is not something that can be resolved diplomatically by asking the Somali government to please stop its citi-

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zens from doing this; it will require a show of force that makes any such attempt not worthwhile, [like] dropping fragmentation grenades on these guys when they approach each ship, and the UN isn’t going to suggest any such thing. —Richard Gray, MD The UN needs reform, but I do not think abolishing it is a good solution. — Katherine M. Gillogley, MD But for a few health related activities, the UN is a worthless exercise in throwing good money after bad. It is an orchestrated anti-America forum unworthy of any dollars extracted from hard-pressed “hated” American taxpayers. Un-funding the U.N. is long overdue. Let the “Hate America” crowd foot the bills. We’ve paid for UN principles with excessive dollars and American blood. I was in San Francisco in 1945 when the U.N promised to succeed where the League of Nations had failed. What a bust! — Cleve B. Baker, MD The League of Nations only survived 27 years…. The United Nations organization has successfully survived to date which is 64 years…. We owe this success to the concerted, collaborative effort of the member nations of this organization, which numbers 150 to date, of which Somalia is a member. Somalian piracy has existed for several decades. In 2008 a multinational coalition task force formed the Maritime security patrol area (MSPA) to safeguard the coast of Aden where most of the international oceanic trading occurs, and so this activity happens, and they take the pirates to task, and the United Nations was a major part of that creation, and America…did exactly what had to be done, although deadly… The World Health Organization (one of the five bodies of the UNO responsible for the international health and wellbeing) stepped up the grade of threat of the swine flu pandemic to 5. With that global alert, all the necessary emergency needs are poised for action. Then we are responsible to act. Peace and wellbeing are expensive when there are rogues, people or bugs. — Elisabeth Mathew, MD And they want One World government?? — Hal Renollet, MD

Book Review

The Golden Touch By William Peniston, MD I was my wife’s caregiver for about four years as she declined with dementia. My daughters and I believe she probably had some very early signs during the year before our 50th wedding anniversary, but it wasn’t until about five years later that a brain scan showed evidence of a silent stroke. We were told this was the beginning of multivascular dementia. Her course would probably be familiar to most readers, although every person with dementia is unique in how they manifest their disease. Equally critical in this situation is the reaction of the demented patient’s caregiver. It took me a good many months to learn that I was not as patient as I had thought; that the repeated questions and nagging were causing a gradually rising level of annoyance and increasingly frequent episodes of anger. Those emotions led to deeper and more frequent feelings of guilt and self-dislike. So much so that, as time progressed, I began to realize that I was not the strong, silent type I had thought but desperately needed help. As I wondered where to turn I thought of our neurologist, one of the few really “amiable” physicians I know. And what a lucky thought that was! He recommended Del Oro Caregiver’s Resource Center which quickly resulted in a one hour interview and a very pleasant and understanding young lady (young enough to be my granddaughter) who advised me to attend a monthly Del Oro meeting of men with similar problems. She was the facilitator for the group, and I quickly learned that I was far from unique in my response to my wife’s illness. I also learned that Del Oro hosted, frequently in association with the Alzheimer’s Association and similar groups, public presentations regarding the evaluation,

course, treatment, and care of persons with dementia. Additionally, Del Oro was able to provide me with brief episodes of respite care for my wife as well as help in finding someone I could hire for help with my wife’s care. Yet there still remained a low grade but persistent and depressing anger toward my wife and myself. After several months at the group’s meetings, our facilitator apparently sensed this and suggested I might wish to accept Del Oro’s offer of six psychotherapy sessions at no cost. Having undergone four years of psychoanalysis as a young man because of panic attacks, diagnosed as “anxiety neurosis” in those days, I readily accepted the offer — and my life changed. After completing the six sessions, I realized I needed much more. Luckily, I bonded well with the therapist, and we soon learned that although the psychoanalysis superficially resolved the panic attacks it never really addressed the root causes. One fundamental thing that “talk” therapy helped me recognize was that I never was the strong, silent, patient type like my father was. I had spent my life trying to imitate him. (I suspect that’s why I chose surgery over family practice.) I also learned I had problems of a more basic and long term nature that were important in my responses to my wife’s illness. So I settled down to some basic “talk” therapy that I may continue indefinitely. During that therapy I learned about the childhood experiences that had led to my confusion about love and self worth, and how that confusion was affecting my current feelings about myself and my wife. As a result, I gradually stopped disliking myself and began to love my wife again. As her illness progressed I was able to recognize when it became necessary to place continued on page 31

May/June 2009

One fundamental thing that “talk” therapy helped me recognize was that I never was the strong, silent, patient type like my father was.

Caring for Those Who Care By Taryn Benson, MHA, Education Coordinator, Del Oro Caregiver Resource Center

What Is Del Oro Caregiver Resource Center? The Del Oro Caregiver Resource Center is part of a system of California Resource Centers founded over 22 years ago. Caregiver Resource Centers throughout California were established state-wide under special legislation and signed into law in 1984. Del Oro Caregiver Resource Center is an independent, private, non-profit program funded through a contract with the California State Department of Mental Health, grants from the Area 4 Agency on Aging and private donations. Del Oro provides a coordinated resource system to meet the needs of caregivers caring for a loved one with brain impairment or for someone who is frail.

How Can Del Oro Help Caregivers? We are a local provider of support for caregivers. Our comprehensive package of services includes information and referral, family consultation, family counseling, respite care, legal and financial consultation with an attorney, education and training and support groups. Our office is located in Carmichael and we cover a wide territory, serving 13 Counties: Alpine, Amador, Calaveras, Colusa, El Dorado, Nevada, Placer, Sacramento, San Joaquin, Sierra, Sutter, Yolo and Yuba. Del Oro Caregiver Resource Centerâ&#x20AC;&#x2122;s mission is to improve the overall wellbeing of family caregivers throughout the caregiving journey. We are all about encouragement, empowerment, empathy, and support for the caregiver.

Eligibility Family Caregivers are eligible for services through our contracts with the State Department of Mental Health, Area 4 Agency on Aging (A4AA) and Area 11 Agency on Aging (A11AA). Del Oro clients are those caring full-time for a

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loved one who is 60 years or older with physical and/or cognitive limitations who resides in our 13-county service area. If there is a diagnosis of Alzheimerâ&#x20AC;&#x2122;s or Dementia, the care receiver may be under 59. As the demand for some of our services exceeds current funding, Del Oro has an established priority list of eligible caregivers. Depending on the service requested and the severity of the situation at the time of intake, the caregiver will be placed on the waiting list, placed on the waiting list as a high priority, or served immediately if dealing with a crisis or terminal care situation. As Del Oro delivers a comprehensive package of caregiver services, most caregivers on the waiting list are simultaneously using other services such as education/ training, counseling, legal consultation, and support groups. Caregivers in need will also be referred to appropriate community resources.

How does one become a Del Oro client? Upon making that important phone call, callers will go through a brief over-the-phone assessment to first determine eligibility. Our services are available to those providing care for a person whose brain impairment occurred during adulthood (age 18 and older) and who is not eligible for assistance from other publicly supported programs or similar benefits. Once eligibility has been established, caregivers will receive a phone call from a Del Oro Family Consultant within 3â&#x20AC;&#x201C;5 business days to conduct an in-depth over-the-phone or an in-person interview to assess his/her individual situation as well as the condition of the person(s) for whom he/she is caring. From there, the Family Consultant develops an individualized care plan and partners side-by-side with the caregiver/client to provide relevant and beneficial services directly through Del Oro and refer

clients to outside agencies that provide additional assistance.

How Can Del Oro Help Doctors? According to the AARP Public Policy Institute, 4 million Californians are caring for a family member over the age of 18. Chances are you are providing care to a patient who is also a caregiver. Many caregivers take great pride in what they do, and compromise their own health by trying to be a caregiver super-hero. They may be desperate for assistance and appreciate physicians who understand the complexity of their situation. Older adults in particular often need

a nudge from their trusted family physician to reach out to a program for formal support. We offer a comprehensive package of services, with one-on-one emotional support from our Family Consultant to promote a more relaxed, healthfocused, medication compliant, educated, lessstressed patient whose doctor appointments are more beneficial and productive. Further information is available on our website, www.deloro.org, or by calling us at 916-971-0893 or 1-800-635-0220 tbenson@deloro.org

continued from page 29 her in a care facility. Although I liked to think this was primarily for the physical aspects of her care, there is no question that my psyche also benefited. Following the change, my emotional healing continued in an erratic and progressive manner. Despite the sadness of the gradual slipping away of my life’s partner’s persona, I was somehow able to tolerate it. I knew the ending would be close to intolerable, and it was. But because of Del Oro I was able to deal with it in a manner

acceptable to myself. I’m thankful for all they did for me. As I look back on life I recognize that the worst thing that ever happened to me was my wife’s developing dementia. Even so, this was followed by one of the best things, my finding Del Oro and the psychotherapy that has changed me for the better. peniston@mcn.org

Added: A Museum Lecture on Alzheimer’s Disease A new presentation has added to this year’s lecture series of the Sierra Sacramento Valley Museum of Medical History: June 24, 7:00 p.m. The Aging Brain, Alzheimer’s Disease and Strategies to Maintain Memory, presented by Robert F. Halliwell, MD Learning and memory can take many different forms, from acquiring the skill to ride a bicycle to learning the capitals of all 50 states in the USA. Perhaps consistent with this, neuroscience has revealed that these different forms of learning and memory involve very different brain systems. As humans age, the ability to acquire new skills and knowledge however becomes more challenging; damage to the nervous system and

disease (such as that associated with Alzheimer’s) can also impair brain function. This lecture will review the brain systems involved in human memory, the impact of aging on cognitive function and some of the current strategies to minimize the impact of aging and Alzheimer’s disease on the brain. Dr. Halliwell is Professor of Neuropharmacology at the School of Pharmacy, University of the Pacific, California. His laboratory investigates the effects of drugs on nerve cells; his new book on the history of the drug receptor will be published this Fall. Admission is free and open to the public. Call SSVMS for reservations; seating is limited.

May/June 2009

First Trimester and Integrated Screening Now Available for Women in California California Prenatal Screening Program For more information, please visit our website: www.cdph.ca.gov/programs/pns

The benefits of the new program include: • Improved accuracy and detection rates for certain birth defects • Earlier follow-up and diagnosis • One fee for all screening services across both trimesters • NT Ultrasound covered by Medi-Cal Clinician start-up packets have been mailed as of April 10, 2009. If you do not receive a start-up packet by that date, please contact: California Prenatal Screening Program - Supplies Phone: (877) 984-8450 Fax: (877) 984-8650 Email: PNSsupplies@SBF-inc.com

Sierra Sacramento Valley Medicine

In Memoriam

Joseph Garland Stroup, MD 1929–2008

Spring seems to be a fitting time to remember Dr. Joseph Garland Stroup, who passed away on September 12, 2008 at the age of 78. He had seen and treated many allergy patients over his 45-year career beginning back in 1962 and spring had always been his busiest time of the year. I had known and worked for him for the past 14 years. He offered me my first job after the military when I came back to Sacramento to practice medicine as a civilian. We both shared a military background. He had been a West Point Academy physician early in his career and would share stories of his Army life while stationed there. Although he tended to be a free thinker and independent person, he admired the structure and discipline of the military life. He was the Academy’s staff pediatrician and took care of the families of soldiers stationed there. He was trained at UC San Francisco at one of the few certified allergy training programs at that time, under Dr. Albert Rowe. Like most of the Allergy textbooks at the time, Garland was skilled at observational medicine. Most research now is largely dependent on evidence-based medicine but observational medicine often gives us the impetus and postulates for doing the research in the first place and is sometimes underappreciated. He correlated what he saw and heard from the patient, with what he knew about the practice of medicine. He was a great listener of patients and took detailed notes from his observations much like a medical detective. He especially took interest in what people did for a living or their personal interests because it often impacted what he said to motivate or improve compliance from the patient. He taught me to always listen to patients and listen to them well for the details of their

disease because sometimes the history is the most telling part of their diagnosis. He was very astute at identifying most pollinating trees and paid particularly close attention to identifying hidden food allergens. He enjoyed seeing and following patients over time and often took care of several generations from the same family. He took great interest in all aspects of their lives, from their home lives to their academic accomplishments. He even made house calls when needed. Many Hispanic patients particularly liked him because he had a great command of the Spanish language. It was the language he learned as a child, when his father was stationed in Joseph Garland Stroup, MD Puerto Rico. Many times he offered free or low cost medical care to those who could not afford it, and tried not to turn away any patients that were truly in need. He was an especially generous man in that way. He was a strong believer that a satisfied patient was his greatest accomplishment and ally. Even though he was a soft spoken and modest man, he was a great innovator and often ahead of his time in many areas. He had a great entrepreneurial spirit and “can’t” he took as a great personal challenge. He loved travel, history, food, wine and music (especially opera) and generously shared these things with those around him. I, as well as many others, will miss him and think of him often when confronted by difficult situations. His words of advice and calming voice will often come back to me during those times. — Allan R. Au, MD

May/June 2009

Board Briefs May 11, 2009 The Board: Approved the 2009 First Quarter Financial Statements, Smith Barney Investment Reports and Recommendations. Approved the appointment of Robert Forster, MD, to the SSVMS/CMA Delegation as an At-Large Alternate-Delegate. Approved the following nominations to the 2010 CMA Councils and Committees: Barbara Arnold, MD, Committee on Medical Services and the Council on Legislation representing the 11th District Delegation; Satya Chatterjee, MD, Council on Judicial Affairs and Professional Liability Committee; Richard Gray, MD, Council on Ethical Affairs; Ruth Haskins, MD, Council on Legislation; Tom Ormiston, MD, Council on Legislation representing the Medium/Large Group Forum; Lee Snook, MD, as a consultant to the Committee on Quality Care; Mary Jess Wilson, MD, Council on Legislation representing the Government Employed Mode of Practice Forum. Approved the following appointments to the 2009 Nominating Committee, which is responsible for nominating members to vacancies on the Board of Directors and Delegation to the California Medical Association. Margaret Parsons, MD, Immediate Past President, Chair; Ruth Haskins, MD, District 1; Pat Samuelson, MD, District 2; Barbara Arnold, MD, District 3; Earl Washburn, MD, District 4; Paul Phinney, MD, District 5; Marcia Gollober, MD, District 6; Richard Jones, MD, At-Large; Richard Pan, MD, At-Large. Approved the April Membership Report For Active Membership — John H. Greenfield, III, MD; Darryl C. Hunter, MD; Julia S. Logan, MD; Julie K.N. Motosue-Brennan, MD; Kanwaldeep S. Randhawa, MD; Gregory Rogalski, MD; Patricia B. Sierra, MD; John N. Winn, MD; Wendy J. J. Yang, MD

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For Resident Membership — Kapil R. Dhingra, MD For a Change in Membership Status from Active to Active 65/20 — Franklin L. Banker, MD For Retired Membership — Frank J. Boutin, Sr., MD; Grey M. Leo, MD; Philip Messah, MD For Resignation — Manor Agarwal, MD (moved to Texas); William G. Cushard, MD; Heidi L. Gassner, MD; Sherellen B. Gerhart, MD; Mark C. Gorrie, DO (moving to Indianapolis); Michael K. Haseman, MD (moved to Arizona); Jennifer L. Hefner, MD; John E. Hendry, MD; Elliot E. Mazer, MD; Catherine Moizeau, MD; Amanda Tagle, MD; Leonid Treyger, MD; Mary Tu, MD; Steven Uzelac, MD; John P. Walter, MD; Daniel C. West, MD; Stephen G. Weyers, MD; A. Alan White, MD; Jill L. Young, MD. Approved the May Membership Report For Active Membership — Yekaterina V. Axelrod, MD; Dheepa Balakrishnan, MD; Maria V. Banez, MD; Virginia T. Corpuz, MD; Matthew J. Gargulinski, DO; Satyendra Giri, MD; Mark A. Hofer, MD; Geumjoo Hwang, MD; Raymond L. Jones, DO; Darrell W. Randle, MD; Peyman Salimi-Tari, MD; John J. Skratt, MD; Paul B. Sobelman, MD; Bernard J. Sopky, MD; Greg S. Takemoto, MD; David P. Teicheira, MD For Multiple Membership — Abdullah A. Ahram, MD; Shaila Garg, MD; Pamela E. Mercado, DO For A Change in Membership Status from Active to Multiple — Nicholas B. Lee, MD For Reinstatement to Retired Membership — Marcela Lau, MD For Retired Membership — Ralph E. Cox, MD For Resignation — Amer H. Khan, MD; Robert S. Miller, MD (moving to Baltimore). Termination of Membership for Nonpayment of 2009 dues — Laura J. Anderson, MD; Donald L. Ansel, MD; Anthony F. Bellomo, MD; Leslie Bernstein, MD; Rohit Bhaskar, MD; Bijan Bijan,

Meet the Applicants The following applications have been referred to the Membership Committee for review. Information pertinent to consideration of any applicant for membership should be communicated to the committee. â&#x20AC;&#x201D; Glennah Trochet, MD, Secretary Ahmad, Shirin M., Rheumatology, Ross University 2000, Sutter Gould Medical Foundation, 600 Coffee Rd, Modesto 95355 (209) 550-4730 Ahram, Abdullah, Pediatrics, UC Davis 2005, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 474-7620 (Multiple Member) Balakrishnan, Dheepa, OB-GYN, Northeastern Ohio University 2001, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4441 Caparas, Maria J., Psychiatry, University of St. Tomas, Philippines 1984, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 (Multiple Member) Chang, Margaret A., Ophthalmology, Columbia University 2002, Retinal Consultants, 3939 J St #106, Sacramento 95819 (916) 454-4861

Hunter, Darryl C., Radiation Oncology, Uniformed Services University 1988, The Permanente Medical Group, 504 Gibson Dr, Roseville 95678 (916) 771-2871 Jones, Raymond L., Family Medicine, WUHS/ College of Osteopathic Medicine 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040 Logan, Julia S., Family Medicine, Drexel University 2005, Sutter Medical Group, 2210 Del Paso Rd #A, Sacramento 95834 (916) 285-8100 Mercado, Pamela E., Internal Medicine, Kansas City Medical College of Osteopathic 2005, The Permanente Medical Group, 1900 Dresden Dr, Lincoln 95648 (916) 543-5471 (Multiple Member) Randle, Darrell W., Anesthesiology, Mayo Medical School 1984, Sacramento Anesthesia Medical Group, 3939 J St #310, Sacramento 95819 (916) 733-6990

Garg, Shaila, Cardiology, Govt Medical College, India 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4406 (Multiple Member)

Rogalski, Gregory, Radiology/Body Imaging, UC Davis 2001, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Hartnell, Joan M., Internal Medicine/Geriatrics, Loyola Stritch 1979, Sacramento VA Medical Center, 10535 Hospital Wy, Mather 95655 (916) 843-7000

Sierra, Patricia B., Ophthalmology, University of Honduras 1996, 1515 River Park Dr #100, Sacramento 95815 (916) 649-1515

Skratt, John J., Emergency Medicine, Albany Medical College 1993, Mercy General Hospital, 4001 J St, Sacramento 95819 (916) 453-4428 Sobelman, Paul B., Family Medicine, Jefferson Medical College 1976, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5345 Sopky, Bernard J., Family Medicine, Temple University 1997, The Permanente Medical Group, 1001 Riverside Ave, Roseville 95678 (916) 784-4050 Takemoto, Greg S., Internal Medicine, University of Hawaii/John A. Burns 1992, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-5493 Taylan, Michael A., Anesthesiology, U of the East, Ramon Magsaysay, Philippines 1993, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000 Teicheira, David P., Anesthesiology/Pain Management, University of Southern California 1985, 83 Scripps Dr #310, Sacramento 95825 (916) 923-0900

Board Briefs, continued from previous page MD; Frank J. Boutin, Jr., MD; Gregory M. Bricca, MD; Andrew T. Brooks, MD; Michael L. Chang, MD; John L. Chen, MD; Richard P. Clark, MD; Karl R. Clayson, MD; Jeffrey R. Cragun, MD; Herman V. Devera, MD; Prakashchandra V. Dobaria, MD; Eliot R. Drell, MD; Neil M. Flynn, MD; Louis J. Gallia, MD, DDS; Dale J. Gorski, DO; Jagdev S. Heir, MD; Artur Z. Henke, MD; Mark B. Horton, MD; Carl C. Hsu, MD; Andrew H. Huang, MD; Kendra Hutchinson, MD; Javid Javidan-Nejan, MD; Ira T. Joyner, MD; Aaryan N. Koura, MD; Munish Kumar, MD; Edmond Lee, MD; James E. Lett, II, MD;

Eric M. Liederman, MD; Donald P. Lombardi, MD; Robert A. Lufburrow, MD; Elizabeth T. Madarang, MD; Michael D. Matson, MD; Henry E. McNeely, II, MD; Linda R. Miles, MD; Jon Moness, MD; Gregory P. Moore, MD; Stephen Ramondino, MD; David E. Root, MD; Howard K. Sakima, MD; Sarita S. Salzberg, MD; Manpreet S. Sanghari, MD; John A. Scavone, MD; Steven J. Schorer, MD; Anissa L. Slifer, MD; Ali T. Tajlil, MD; Patricia A. Takeda, MD; Jannie Tang, MD; Karin K. Wertz, MD; Vivian E. Worn, MD; Dawei David Zheng, MD.

May/June 2009

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Positions Available PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any of Special Consultant. Physicians will be paid on an hourly basis for their time and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if you may be interested.

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