2009-Sep/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2009

Scenes from the medical clinic in Leon, Nicaragua. Story on page 9.

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE The Ban on the Corporate Practice of Medicine

Charles H. McDonnell, III, MD

Take Your Medicine

Stephen A. McCurdy, MD, MPH

Airiel

David Gunn, MS III

The New POLST Form

Kathy Glasmire

Voices of Medicine

Del Meyer, MD

The Nicaragua Experience

Mike Lawson, MD

Allowing Natural Death vs. “Do Not Resuscitate”

Ham Radio — Enriching Public Health...and Life

Cecilia M. Hernandez, MD

Karen Tait, MD

Re-Revising Hippocrates

SPIRIT Matters

Kristine Wallach

John Loofbourow, MD

Charitable Giving and the Holiday Sharing Card

The Peer Review Crash

Jerilyn Marr and Marilyn Skinner

Gerald N. Rogan, MD

Two SSVMS Members are Running for Public Office

IN MEMORIAM Otto Neubuerger, MD

Bill Sandberg

New Applicants

Richard Pan, MD, (D) Assembly District 5

Steering Clear of Problems with Pain-Med Prescribing

Ami Bera, MD, (D) Congressional District 3

Mary-Lynn Ryan

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

SSV Medicine is online at www.ssvms.org/magazine.asp “Fall History,” the fifth cover this year by orthopedic surgeon Greg Joy of Placerville, is a product of his “digital darkroom.” His comments: “This is an example of how Photoshop, Illustrator and several photographs can create one piece of art. The photographs were taken in Hope Valley off Highway 88 in the fall of 2007. In this setting, people have used a single tree, over the years, to express their love for one another.

Volume 60/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

“Graffiti, on the one hand, is a horribly disfiguring and disrespectful art form. On the other hand, its significance and the interest it sparks, as an historical record, cannot be ignored. Consider cave paintings, for example. “Fall History” represents the conflict between these two truths.”

September/October 2009

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

Our Hours Are Changing, But Not Our Commitment. For over 28 years, the physicians at The Doctors Center have always been available to assist you throughout the year. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 14 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. Prior to November 1, The Doctors Center is open from 8 a.m. to 12 midnight. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for multiple HMO’s and PPO’s.

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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.

Sierra Sacramento Valley Medicine

President’s Message

The Ban on the Corporate Practice of Medicine By Charles H. McDonnell, III, MD Of the hundreds of bills introduced this year in California, three bills (the most in a single year on this topic) could erode the ban on the corporate practice of medicine in California. Their proponents have argued that allowing certain hospitals and hospital districts to hire doctors will increase access in underserved areas. The three are AB 646, AB 648 and SB 726. As I write this article, only SB 726 (Ashburn) remains in play, with amendments including major components of the two other bills. The CMA opposes this bill as amended, arguing there are more effective ways to increase access in underserved areas. The interests of patient protection, as well as physician integrity, served by the corporate bar are too important to be pushed aside.

The Bar on Corporate Practice California Business & Professions Code Sections 2052 and 2400 prohibit lay individuals, organizations, and corporations from practicing medicine. In simple terms, hospitals or other corporations cannot hire or employ physicians or other health care practitioners. There are important reasons for these laws. Shielding the physician-patient relationship from commercial interests has been supported repeatedly by California courts under case law since 1938. There has been long-standing legislative support for the public policy against permitting untrained or unlicensed people to practice medicine. For example, the corporate practice bar’s public policy concerns were expressly incorporated into the Moscone-Knox Act., commencing at Corporations Code Section 13400.

Furthermore, as the Attorney General’s office has repeatedly noted, the reasons underlying this proscription are two-fold: “[F]irst, that the presence of a corporate entity is incongruous in the workings of a professional regulatory licensing scheme which is based on personal qualification, responsibility and sanction, and second that the interposition of a lay commercial entity between the professional and his/her patients would give rise to divided loyalties on the part of professional and would destroy the professional relationship into which it was cast.”

Exceptions There are many exceptions to the corporate practice of medicine bar. Foremost, it does not apply to physician partnerships or professional medical corporations. The bar also does not apply to counties, given the broad “police powers” granted to them. Business & Professions Code Section 2401 allows a clinic operated primarily for medical education by a private or public university medical school to employ physicians. Case law has found the UC Regents are acting as a “state” and, because every patient is potentially a “teaching” patient, the Regents are excluded from the corporate practice of medicine bar. Hospitals are exempt for Medi-Cal psychiatric inpatient services. Under narrow circumstances, community clinics and primarily research clinics can employ physicians. In 2003, the Legislature created an exemption (under SB 376) for a rural hospital district pilot program. Specifically, a district hospital in a county with a population of less than 750,000 September/October 2009

that provides more than 50 percent of its care to Medicare, Medi-Cal and uninsured patients and that reported a net loss to the Office of Statewide Health Planning and Development in fiscal year 2000–2001, may employ up to two physicians. The medical foundation model is a less clear exception. It enables some alignment and integration of interests or incentives between hospitals and physicians. Under a complicated arrangement, a hospital may create, but not own, a 501(c)(3) medical foundation. The foundation can own and operate 1206(l) clinics if it meets rigorous requirements. The clinics arrange for physician services through professional services agreements with one or more medical groups. Physicians are employed by the medical groups, not by the clinic, foundation or hospital.

With rising pressures

Arguments in Support of the Bar

to control costs, any tool that can help assure the patient’s interests come first is worth fighting to preserve.

The driving force behind hospital employment of physicians is the alignment of incentives. This, however, may not lead to patientcentric care. While the concept of the physician as an independent patient advocate does not guarantee quality patient care, it is a potentially powerful safeguard. I am not just referring to malevolent intent or criminal behavior by corporations, which has been known to occur rarely. The influence on decisions can be subconscious. It is basic human nature to want your team (or employer) to succeed. An example from our own backyard is Redding. Even without direct employment, incentives between a couple of doctors and the hospital were aligned. This resulted in a climate of intimidation, which suppressed and delayed appropriate peer review. Direct employment of physicians by hospitals has the potential to squeeze out independent physicians, ultimately eliminating competition and diminishing patient choice. But what about access to care and physician staffing difficulties in complying with federal emergency transfer legislation? The pilot program referred to above, to improve access to care in underserved areas, has not shown direct employment of physicians to be a factor. A copy of the Medical Board of California’s report on this can be found at www.medbd.ca.gov. Sierra Sacramento Valley Medicine

The Medical Board also supports the corporate bar. Furthermore, the Office of Inspector General of Health and Human Services studied and reported on the subject.1 It concluded “these prohibitions do not appear to present a major overall problem for hospitals” and “the prohibition on hospital employment of physicians is a relatively unimportant factor in providing emergency coverage.” The bottom line is hospitals have many recruitment options (including the medical foundation model) other than corporate practice of medicine.

Arguments Against the Bar Certainly one of society’s great problems is the escalating cost of health care. There is growing belief and data indicating that, for many reasons, the models of care delivering the highest quality and most cost-efficient care are those that align hospital and doctor interests. There are other ways to assure the patient’s best interests are not overlooked, such as peer review, regulations and the threat of malpractice litigation. Despite the lack of proof in California, physician recruitment and retention could potentially be best addressed by hospitals via direct employment. Finally, hospitals in many states can employ physicians, further testimony against the need for the bar. My intent is to provide a brief, balanced review of the topic and our positions on pending legislation. The potential benefits of SB 726 for better access and recruiting are not certain, yet our willingness to fight for the integrity of patient care is still the primary function of SSVMS and the CMA. With rising pressures to control costs, any tool that can help assure the patient’s interests come first is worth fighting to preserve. We as Californians can be proud of our corporate practice of medicine bar. For those interested in more information, I encourage you to start with the CMA’s ON-CALL Document #0280 Corporate Practice of Medicine Bar, and the CMA’s Legislative Hot list at www.cmanet.org. mcdonnell@surewest.net 1 State Prohibitions on Hospital Employment of Physicians, November 1991 (federal publication # OEI-O1-91-0072).

Letter to the Editor

Controlling Trichinellosis How wonderful to see your article in Sierra Sacramento Valley Medicine, “Parasitic Diseases of Pork,” (July/August, 2009). Thank you for the good technical and historic perspectives. I love historical stuff like this! I wrote an article long, long ago for a dry “Proceedings” conference on Trichinellosis in Miami, Florida, in 1972. I was the EIS (Epidemic Intelligence Service) Officer of the US Public Health Service assigned to the California Department of Public Health in Berkeley at that time. The article summarizes the reported cases of trichinosis for the time 1930 through 1971. As I wandered through all the data, I learned a lot about the history of the condition. You may like (or, already know of) the story of how we finally got trichinellosis under control in this country. The Public Health advocates tried and tried to get the hog industry to cook the garbage they fed the hogs. As with every such engagement between Public Health and any industry, they refused to even discuss the matter (costs, no government mandates, lack of industry respect, etc.). In the back and forth over several decades, we Public Health folks got nowhere. THEN, along came an epizootic of vesicular erythema among the hogs. I have no idea what this infection is or what it does to the hogs, but with its discovery in one state, the state next door quarantined that state’s hogs. As

the infections spread nationally, we wound up with every state quarantining every other state and the industry was shut down (“frozen”). The remarkable SOLUTION they came up with was …drum roll!!… to mandate cooking the garbage they fed the hogs. And their justification for mandatory state laws to require it was, “Protection of the public’s health from trichinellosis.” Later, they shifted from garbage to grainfeeding which had the same effect. So, we sometimes do the right thing for the wrong reason. This is a case in point. — Don Lyman, MD, Chair, SSVMS Public & Environmental Health Committee

September/October 2009

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Take Your Medicine Our choice is not whether we take medication, but which we take.

By Stephen A. McCurdy, MD, MPH The last several years had not been kind to Adam Sawyer.1 In his early 40s, he had come to see me because of a job-related knee injury that stubbornly refused to resolve. Despite the usual medications and physical therapy, his knee was still “not right.” A review of his recent medical history showed that his knee was not our only concern. He had recently been diagnosed with diabetes and high cholesterol, for which he was taking three expensive medications. Although his blood pressure was not in the range requiring medication, it was above the ideal, and it was likely simply a matter of time before he would be taking medication for this as well. Finally, he had gained approximately 50 pounds in the past several years. In an effort to reverse his weight gain, he had purchased a home exercise bicycle and was using it two to three times per week. The common thread for all of Mr. Sawyer’s medical conditions was his weight gain. Successful treatment for this — with a mix of increased exercise and dietary change sufficient to bring his weight down — held the potential not only to improve his medical problems, but to cure them. That’s right: cure. Exercise is a medicine with a “triple whammy”: with an appropriate diet, it can prevent, improve, and cure conditions of increasing importance in our society, such as high blood pressure, heart disease, diabetes, high cholesterol, and others. I shared with Mr. Sawyer this perspective of exercise as a medicine. Virtually everyone in our society who lives long enough will eventually have to take medications. Usually this is for high blood pressure, but diabetes, high

cholesterol, and heart disease are also important causes. The need to take medications eventually is essentially universal, so we have little choice in whether we take medications. Our choice, then, lies in which medications we take. In choosing, we must consider side effects and cost. “Mr. Sawyer, you are at the point where you must take medications, but you still have a lot of choice in which ones you take. Here is my question to you: Would you rather continue the medications you are now taking, which improve but will not cure you, cost money at the pharmacy, and have a range of side effects including dizziness, stomach upset, sexual difficulties, and others? “Or would you rather take a medication that will definitely improve and has a good chance of curing, can be obtained for free, and has side effects that are desirable, including more energy, improved mood and sense of well being, and better sleep? The only bad side effect of this medication is that, for approximately 40 minutes when taking it, you sweat and breathe hard. But that is over quickly, and after a shower you will feel great.” A thoughtful look came over Mr. Sawyer as he realized the medication I was talking about was daily exercise: five to six days a week of 40 minutes or so. Were these side effects so intolerable when stacked up against the side effects he had accepted from the medications he bought at the pharmacy? “If I were to write the next chapter in your life, Mr. Sawyer, I would want you to make that exer-cycle your best friend. I would want you to get up a little earlier in the morning to start your day on it, five to six days per week. And when

September/October 2009

Exercise is a medicine with a “triple whammy”…

your enthusiasm flags with the sweating and the hard breathing, and you ask yourself why you are doing this, I would want you to answer yourself that you are doing it because it is your daily medicine, and you have chosen this side effect instead of those the come with the medicines for sale in the pharmacy. “If you do this and, in combination with your diet, get your weight down into the normal range, there is a good chance that your diabetes will go away, your high cholesterol will normalize, and your blood pressure will remain low. At the very least these conditions will improve, and you may reduce or no longer need your pharmacy medications. It may well be that the only medication you will need is exercise. “And did I mention? It will likely help your knee as well.” While we all have heard and know that we need to exercise more and eat less, most of us don’t view this from the perspective I offered Mr. Sawyer, i.e., that exercise and diet are medi-

cines that must be taken in the proper dose. The plain truth is, we all will eventually require medications as we move through life. Our choice, then, is not whether we take medication, but which we take. Will we choose the kind that helps but doesn’t cure, costs us our hard-earned money in the pharmacy, and may have numerous undesirable side effects? Or will we choose the kind that prevents and cures, with side effects are all positive but for the sweating? (In fact, many people enjoy this side effect.) Like it or not, we must choose. samccurdy@phs.ucdavis.edu In addition to office hours at UCD Medical Center, the author can be found six mornings a week at Sacramento’s Bertha Henschel Park, taking his medicine. — J.L. 1 Names and some details altered.

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

Sierra Sacramento Valley Medicine

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.

The Nicaragua Experience By Mike Lawson, MD In June, I accompanied eight medical students on a UC Davis field trip to Leon in Nicaragua. Leon has a population of 200,000 with per capita income $2,200 per year. A global health system has been the vision of Dr. Michael S. Wilkes, Vice Dean of Medical Education. Some visited families to confirm vaccination status of children in the household, while others headed for the mountains to visit a health co-op attached to a coffee plantation. I and two students attended urgent care type clinics, while other students observed surgeries or followed other specialists We would arrive at 7:30 a.m. at the clinic with 60 to 70 people lined up and waiting. They were orderly and patient. Our clinic director was friendly and obliging, and we were given the break room for history taking and physical exam. We were provided a formulary of drugs that we could prescribe at no charge and basic labs were free but any imaging studies would incur cost and would often require specialist referral. There was a preponderance of somatic complaints mostly in women, and we spent much of our time explaining the brain gut connection. We also prescribed a lot of nortriptyline. Similar to Western society, patients with functional complaints were often misdiagnosed and inadequately treated. Nicaraguans have been caught in intense civil wars between 1975 and 1985; including the Sandinista Revolution (1975–1979) and the Contra War (1981–1985); many inhabitants of Leon have been exposed to war trauma. In addition, domestic violence is prevalent, occurring in 15 percent of families. Therefore, it was no surprise that functional abdominal complaints and somatic syndromes were common. Studies from Leon University’s Department of Epidemiology and Health show a prevalence of IBS of 12.8 percent and non

ulcer dyspepsia of 10.8 percent, with a slight female preponderance. Teenage pregnancy is very common with several generations of women supporting each other on small stipends. In the evening, the UCD preceptors gave lectures at the medical school mostly in English or via interpreters to a mixed medical student audience. The level of comprehension varied but they all seemed to value the information. I sent my last Sleisinger Gastroenterology textbook to a student who was dedicated to studying gastroenterology. He had started to look at the prevalence of Hepatitis B induced cirrhosis in the Leon population and could not afford a reference book. Before leaving, we helped our favorite Leon student chaperone celebrate his birthday by baking a Pavlova desert cake and partying at a local night club as part of the cultural exchange. Finally, we were shown the ruins of the capital, Managua, which resulted from the internal conflicts. We were amazed how the people of Nicaragua survived that turmoil plus the natural disasters of earthquakes and tsunamis. This is how one student, Andrea Griem, reacted to the trip: “This was an amazing opportunity to learn about practicing primary care medicine in an international setting. It opened my eyes to the challenges unique to practicing global medicine, where typical barriers like limited resources, lack of access to health care, language, and cultural differences are amplified a thousand-fold. MEDICOS Nicaragua has made my first year a richer one with unique clinical experiences that will make me a more well-rounded physician in the future.” Nicaragua is a country of resilient, forgiving, friendly people deserving of any help that we can provide.

...many inhabitants of Leon have been exposed to war trauma.

Michael.J.Lawson@kp.org September/October 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.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Your health. It’s our mission.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

Sierra Sac B/W Dr. Winslow.indd 1

3/16/09 4:55:18 PM

Ham Radio – Enriching Public Health...and Life By Karen Tait, MD, Lake County Health Officer, KI6SAH (aka “Safe and Healthy”) Slightly more than a year has passed since I left Sacramento County and became Health Officer in Lake County — a rural county with roughly 65,000 residents. Sacramento County Public Health provided me with invaluable training and experience, which enabled me to hit the ground running. What followed was the discovery of an amazing community that will forever enrich my life. Lake County is geographically beautiful but resource poor when it comes to government and business. It contains the largest natural lake that is wholly in California and the lake is surrounded by a variety of tiny communities. Like many Lake County residents, I live in a remote rural area and part of my commute is on a bumpy dirt road. Power and telephone outages are not uncommon and cellular telephone service is spotty at best.

Venturing into Ham Radio I quickly concluded that getting a ham radio license was a good idea — both for personal safety and as part of our emergency public health response. Little did I know what a wonderful decision that was — on many levels. Within a few months, I successfully obtained my Technician Class entry level amateur radio license. I learned to communicate with ham operators at local hospitals with whom we conduct quarterly drills. A few hundred dollars later, I had a professional quality mobile radio with government and ham channels complete with a three-foot antenna proudly displayed from the roof of my car. I also became acquainted with other local ham radio operators. Ham radio operators are the most diverse

people you will ever meet — all joined by the common bond of their love of amateur radio. Our local group consists of musicians, mechanics, machinists, information technology personnel, nurses — you name it. They are generally energetic, industrious, and communicate with each other constantly. If you need anything, they will be there. When I announced that I wanted to install a base station (a radio in a fixed location at my home with a permanently mounted antenna), local hams immediately went to work. They came to my house, advised me on where to locate my antenna, welded the necessary mount and conducted a veritable equivalent of a “barn raising” event. After a few hours of frantic activity, I had the best amateur radio station operating out of the tiny town of Upper Lake. Later, when I decided I wanted to add a high frequency antenna for access to global radio transmissions, I authorized the local vendor of radio equipment to provide materials to designated local hams at my expense; they built and installed a 120-foot wire antenna suspended among the trees on my property.

Join by Coming to Breakfast That was just the beginning. The real treasure was the extended family that I had just acquired. Although there is an official Lake County Amateur Radio Club (“LCARS”), there is also an unofficial radio club. This group has designated “officers,” but thrives on a deliberate lack of structure. If you show up for breakfast, you are a member. This group meets faithfully and enthusiastically every Saturday morning at 7 a.m. at a local diner, where the waitress knows

September/October 2009

Ham radio operators are the most diverse people you will ever meet…

The author at her base station.

Ham radio takes care of its vulnerable members.

us all by name and remembers what we like to eat. Attendees look forward to breakfast as the highlight of the week. There is good humor and fellowship every time. It is our “eyeball” time with those we talk to on the radio. Until our group’s Google account memory filled up, each weekly breakfast resulted in the posting of more than 30 photos of attendees. Despite its lack of structure, this group productively helps new hams get on the air and gives them a big dose of encouragement. The group has holiday gatherings and barbecues, and hosts an annual “fox hunt,” which is a very fun treasure hunt event in which we seek out and find a concealed interfering transmitter signal by using directional radio antennas. Ham radio is inherently positive. The local hams call each other up every morning, starting as early as 5:30 a.m. They celebrate the sun coming up and the fact that they wake up each morning. If someone doesn’t call in as expected, concern about their wellbeing arises. That generally prompts a telephone call or a stop by their house. The more senior members of the group who live alone feel greatly reassured by this. If a ham operator does not appear at the

Sierra Sacramento Valley Medicine

Saturday breakfast as expected, the group becomes concerned. In Public Health emergency preparedness, we talk about “vulnerable populations.” Ham radio takes care of its vulnerable members. As the local Health Officer, I glean a great deal of information from ham radio. When a tractor-trailer went into a local lake in the wee hours of the morning, I heard about it first from my morning ham radio group chatting over coffee. By the time I got to work, I knew I had a hazardous materials incident in progress. The group shares information about traffic delays and weather. We, who reside on the top of various hills and mountain peaks throughout the county, share information immediately about the first snow fall, the rain and anything else of interest. We talk about everything and nothing. Ham radio operators keep each other company by chatting as they commute to and from work and assure their safe arrival. Children check throughout the day on elderly parents who are also ham operators. When I conduct my quarterly radio drills with local healthcare facilities, hams from my breakfast group call in as guests, showing their support and availability for emergencies. As the result of the morning “chatter,” I have contacts all around the Lake. I know who they are, where they are, their capabilities, and the radio frequencies needed to reach them. I know who I can rely upon to relay messages and how to go about it. So, our daily greetings substantially strengthen our emergency response. The local ham community also conducts regular evening “nets,” which are organized roll calls of hams who support local emergency response. These nets occur every Monday and Wednesday.

Helping Gunter Move I can’t describe our local ham community without mentioning “Gunter,” a local ham

operator that I first heard as a very weak radio signal coming from Lake Pillsbury, a remote part of Lake County accessible via a good two or three-hour drive, much of it on unpaved road sometimes passable only with 4-wheel drive. Gunter turns out to be an elderly man who lived in a recreational vehicle lacking telephone service. His sole support came from the ham community. At one point, he fell and sustained an injury that needed care in a local skilled nursing facility (SNF). There, he continued to communicate via a portable radio. When we decided to include SNFs in our emergency communication drills, I suggested the facility use Gunter as its representative. What a delight — Gunter represented the facility perfectly! Perhaps SNFs should more often consider the valuable resources available in their own residents. Eventually, Gunter recovered from his injuries and arranged an apartment in Senior Housing. Over the air, I heard that he had signed papers for his apartment, and I inquired about when he planned to move there. The answer was immediately, despite the fact that he didn’t have a single piece of furniture — not a chair to sit in or a bed to sleep in. Many of our ham “family” members had already anticipated the need to set Gunter up with a household, and we quickly moved into emergency mode. Over the air and within a few hours, we coordinated to get a mattress and various household items to Gunter’s apartment and set him up with basic necessities. As a true “ham,” he was preoccupied with how he could install an adequate antenna outside his window! As an aside, I believe that ham radio is an excellent tool to prevent dementia. To be an amateur radio operator, it is necessary to memorize both names and call signs of contacts. For those who subscribe to the concept that one must “use or lose” mental faculties, ham is an ideal form of mental exercise.

Public Health Surveillance Ham radio is also an unexpected Public Health surveillance tool. During recent H1N1

events, I learned via radio chatter of cases of pneumonia and other influenza-like illness. I followed up on those cases to rule out H1N1 and chuckled at the idea of conducting public health surveillance via amateur radio! In Lake County, the chemistry of our local ham operators is delightful. Radio etiquette requires a focus on the positive. Nobody likes to hear negative conversation on the airwaves. That positivity translates into actions off the air. The group encourages its members and celebrates their successes. At a professional piano concert involving the performance of a local ham operator, a sizeable section of the audience was filled by local hams, who cheered for the performer and chattered between vehicles while traveling to and from the event. On Valentine’s Day, the same hams and family members filled a local restaurant and made sure that the tip jar for that same performing pianist was filled; the pianist used a portion of the tips to fund a local ham radio project. Hams support each other through good and bad times. They support members when elderly parents and spouses move through the process of dying. When those hams transition to “silent keys,” the entire ham community expresses its sympathy and pays its respects over the air. The arrival of numerous vehicles equipped with visible antennas at funerals has a profound and positive impact for the grieving family. The local ham group has supported its members through divorces, unemployment, premature births and other difficult times. It is a true community in the most ideal sense, valuing the company of others over all else. As Health Officer for Lake County, I have quickly developed a huge affection for the people who live here and I attribute this to ham radio. Never before have I found an opportunity to enjoy so many and varied community members as “family.” The benefits to emergency preparedness are tangible, but the benefits to human existence and community spirit are immeasurable.

For those who subscribe to the concept that one must “use or lose” mental faculties, ham is an ideal form of mental exercise.

ktaitmd@hotmail.com

September/October 2009

Re-Revising Hippocrates By John Loofbourow, MD “No one in this world, so far as I know… has ever lost money by underestimating the intelligence of the great masses of the plain people.” — H. L. Mencken The Hippocratic Oath commands that the physician consider his teacher’s family as his own; do no harm in treating patients; defer to specialists where surgery is concerned; abstain from sexual seduction of/by patients; and never divulge the secrets of the medical profession to the public. Since 1948 it has been repeatedly revised by the World Medical Association, adding more modern commandments, including: • Service to Humanity; • Respect for ”secrets” confided by patients; • Non-discrimination by age, disease, disability, creed, ethnicity, gender, nationality, political affiliation, race, sexual orientation, or social standing; • A carefully but vaguely defined ”respect” for human life; and • Not using medical knowledge to violate human rights or civil liberties, (whatever those terms may mean.) In the U.S., other ethical maxims are often declared sacrosanct, such as: • Medical care is a human right, properly guaranteed by the state. • Any human life is priceless, so cost is irrelevant. The problem is then obvious, because no one, and no state, can provide unlimited medical care to everyone. The inevitable necessity to limit medical care is what fuels our national debate today, and brings idealistic populist ethical standards into question. Despite much noxious misinformation from conflicting powerful self-interested parties, the U.S. medical care debate will, I feel, ulti-

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mately be constructive, positive and, in a word, healthy. We are undergoing a transformative process forced upon us by technologic progress. (Yet when has it been otherwise? That is the nature of life.) Our debate, fortunately, is made more honest, open, and productive by yet another technologic development: the uncontrolled exchange of ideas and information on the internet. Bypassing the hereditary bias of old media, over time the public is perfectly able to sort truth from half truth or lies, emotion from reason, and collectively reach the best conclusion.1 This is why the free exchange of ideas is feared by power, and by government everywhere, even here. That is why so many totalitarian governments restrict, or control the internet, as for example, but not limited to, China, Russia, Iran, Venezuela, and Cuba. Our national dilemma is that technology offers limitless possibility, while human limitations are inadequate to fulfill all our needs or expectations.2 Nonetheless, we are, I believe, in an incomparably privileged position to transform our national medical care, even though there is no way to provide everything for everyone. Unfortunately we cannot successfully adopt or adapt a ready made import for health care. Why? The U.S. is not comparable to any other country; that is why the many comparisons often made are simply vacuous. They are all true lies. For example, it is iterated ad nauseum that the U.S. pays more per capita for health care than any other nation but lags behind most industrialized nations on any accepted standard of health care. The UN, to the contrary, rates the U.S. as first among 190 nations in responsiveness to the needs and choices of individual patients. Is it any wonder we are undecided continued on page 16

The Peer Review Crash The lesson from the Redding heart surgeries is that the hospital licensing agency needs the ability to impose intermediate sanctions.

By Gerald N. Rogan, MD “A jetliner carrying 700 passengers crashed into Mount Shasta killing 69 and injuring most of the remainder. Pilot error caused the crash. The FAA ignored the incident.” If this story were true, we would be outraged and demand a full government inquiry of the FAA’s negligent failure to investigate. The “passengers” were patients at Redding Medical Center in Redding, California between 1993 and 2002. The two “pilots” were Drs. Fidel Realyvasquez, Jr., a cardiac surgeon, and Chae Hyun Moon, a cardiologist. In late 2002, the FBI broke up this scheme of negligence. Dr. Moon has lost his license to practice in California. The hospital administrators who helped hide details from public scrutiny reportedly have relocated to foreign countries to find work. But ending unnecessary heart procedures and surgery on healthy patients did not solve the problem. Two doctors from RMC and I set out to discover how this gross medical negligence could possibly be tolerated for 10 years at this well respected, accredited, and licensed hospital. Based on our investigation and report, gleaned from public documents and private testimony (available at www.roganconsulting. com), our government officials failed to enforce our laws: laws necessary to assure hospitals are safe for the public. Both state and federal health care officials knew as early as 1999 that RMC and its medical staff could not assure patient safety for cardiac services. These officials knew the hospital and medical staff provided no oversight or review of the quality of care provided by the two physi-

cians. Effectively, both of these physicians were in charge of their own reviews. Moreover, our main hospital accreditation organization, the Joint Commission on the Accreditation of Healthcare Organizations, also knew in 1999 of the danger Doctors Moon and Realyvasquez posed to patients because their patient care services were hidden from review by their peers. JCAHO accredited RMC anyway. The first peer review provided for the two physicians was performed by outside medical experts hired by the FBI in 2002. Why would our enforcement agency, the Department of Public Health’s Licensing and Certification Program (L&C), not use its power to enforce our laws? L&C can impose fines of $50,000 to $100,000 against hospitals for allowing imminent danger to patients but have not used this power to enforce peer review. L&C has not explained when and under what circumstances it will enforce our peer review requirements. Patients at many California hospitals are vulnerable to medical negligence that can only be prevented by physicians using peer review to hold accountable those who endanger or harm patients. In hospitals where peer review is absent or ineffective, there is no mechanism to cull out negligent physicians until after many patients are damaged. The Legislature ordered a report on peer review and hired Lumetra, a private company to write it. Lumetra published its report in 2008, finding that peer review in California is unacceptable, inadequate, and ineffective. RMC is the “poster child” for what too often goes wrong. Now, seven years after the Department

September/October 2009

of Justice and CMS kicked RMC out of the Medicare Program, our peer review laws remain unenforced throughout California. In the 2009 legislative session, the California Legislature has taken up the peer review issue (SB 58, SB 700, AB 120, AB 245, and AB 834). But current proposals will not instruct L&C to enforce our laws by explaining to stakeholders what penalties it will impose for failure to perform peer review on repeat audit. L&C needs to promulgate its penalties to help reluctant stakeholders comply. For example, L&C may impose intermediate sanctions that remove the license of a hospital for certain elective services only in those clinical departments (e.g., cardiac services) where peer review is not provided or is ineffective on repeat audit. Should L&C chose to use its power, a negligent hospital and medical staff would face huge financial losses and, therefore, would provide the missing peer review immediately. Without imposing intermediate sanctions, hospitals and

medical staffs can continue to flaunt our laws knowing the state has no power to enforce them. In other words, current peer review is selfadministered and unaudited; when it is not done, L&C imposes no penalty. Self-administered peer review in hospitals works as well as self-administered regulation compliance did on Wall Street in 2008. Doctors who need help are not identified, and future patients continue to suffer the consequences. In 2009, patient safety will remain a goal, not a reality; except, perhaps, in a few centers of quality. To push for change of this unacceptable situation, write to your California legislator and demand that L&C enforce the peer review laws in California. Until then, good luck next time you are admitted to a hospital in California. You will need it. It is likely much safer to fly to India. jerryroganmd@sbcglobal.net

Hippocrates, continued from page 14 about abandoning the system? The U.S. is, well, our own unique people and country. No nation with so many resources, and so large and diverse a people as ours could address the complex issue of 21st century medical care in such a productive, universal, and public manner. We are still a relatively wealthy, open, civil society. While many of us are not great readers, nor great intellects, we are not all stupid. Given open access to information of all sorts, and free debate, any people’s collective wisdom in making decisions outperforms that of the educated, the wise, the powerful, privileged, and the best informed. Provided we can protect our democracy, despite its defects, and if the public debate over medical care is allowed to continue to a reasoned conclusion, our resulting decisions will effectively provide the best health care possible, considering our strengths, and limita-

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tions. I think we should be thankful that the debate has been resuscitated. But we must not be stampeded for the benefit of someone’s name, fame, or legacy.3 Let’s continue the discussion, speak up, and listen, and together decide on the future of medicine in this fortunate land. Hippocrates, roll over. Again. Get used to it, man. john@loofbourow.com 1 See James Surowiecki, The Wisdom of Crowds, 0-385-72170-6 2 See the Unabomber. His manifesto is on line: voluminous, ranting, but interesting. He feared Big Tech would ruin our world, our lives, shut us off from our real selves. To the contrary it has amplified our lives, our potential, and our world; but we ourselves are hard put to use it wisely or even understand its potential. 3 For a taste of the eloquence and the urgency of the argument, google Ezekiel Emmanuel. For the past 10 or more years he is read everywhere that matters, a powerful, gifted writer, and a man in a hurry. Impressive. But hey, Zeke. Easy. Your separate and equal colleagues and citizens want to participate. Even if we ain’t on your Big Stage we may be able to contribute; and if we feel we are heard will more willing to accept the Change.

Two SSVMS Members are Running for Public Office By Bill Sandberg We would like to introduce you to two of our members who have announced their candidacy for public office. As far as we know, this is an unprecedented event to have two of our members running for public office at the state and federal level. While SSVMS does not have a political action committee, and we do not make political contributions to candidates, we are involved in the political process and believe it is vital to have physicians in the Legislature and in Congress. We have asked the candidates to answer some basic questions, and we hope you will support them in their campaigns. Amerish Bera, MD, is running in the 2010 primary against Congressman Dan Lungren of the 3rd Congressional District. The district covers most of Sacramento County and part of Solano County, as well as all of Alpine, Amador and Calaveras Counties. Dr. Bera graduated from UC Irvine School of Medicine and received his training in Internal Medicine from the California Pacific Medical Center in San Francisco. He is a clinical professor of medicine at the UC Davis School of Medicine. Dr. Bera has served as the chair of the Medical Societyâ&#x20AC;&#x2122;s SPIRIT Project. He is married to Janine Bera, MD, an internist with Kaiser Permanente in Elk Grove, and they have a daughter. The family resides in Elk Grove. Richard Pan, MD, a pediatrician, is running in the 2010 primary for Californiaâ&#x20AC;&#x2122;s 5th Assembly District, a spot currently held by Roger Niello, who is termed out. The district is in

the Northern portion of Sacramento County encompassing Folsom, Carmichael, Citrus Heights, Orangevale, Fair Oaks, portions of North Highlands, most of Arden Arcade, the Natomas area and a small portion of Placer County. Dr. Pan graduated from the University of Pittsburgh School of Medicine, completed his training at the Massachusetts General Hospital in Boston and received an MPH at the Harvard School of Public Health. He is Associate Professor of Pediatrics and Pediatric Residency Director at UC Davis Medical Center. Dr. Pan served as President of SSVMS in 2004 and is a current member of the CMA Board of Trustees. He is married to Wen-Li Wang, DDS and they have a son. The family resides in the Natomas area. bsandberg@ssvms.org

Amerish Bera, MD

Richard Pan, MD

September/October 2009

Richard Pan, MD, (D) Assembly District 5 Dr. Pan and Dr. Bera were given a similar set of questions. Following are Dr. Panâ&#x20AC;&#x2122;s responses.

demonstration of effectiveness of every impact program United Way funds.

Why Are You Running for Office?

Your Thoughts on Health Reform?

California needs more leaders with real world experience in public office. As Chair of the CMA Council on Legislation, I witnessed how much effort CMA had to spend educating legislators about health care. As a legislator, I will bring my experiences as a practicing physician, a SSVMS President, and CMA Trustee to shaping policies that impact medicine and the state. I also am dismayed by the dysfunction in state government and its negative impacts on both the local and California economy. I am committed to working on solutions to our stateâ&#x20AC;&#x2122;s problems and not partisan posturing. I want to build a California that I want my child and all of our children and grandchildren to live and prosper in.

Successful health system reform needs to address access, cost, and quality, and the foundation of all three must be the patient-physician relationship. Access to a strong patient-physician relationship where the physician can provide continuous, coordinated care will reduce unnecessary spending and improve patient adherence and quality. Health system reform also needs to change incentives focused on treating acute episodes to providing incentives for chronic condition management and prevention.

Can You Make a Difference? I can make a difference with the support and help of my friends and colleagues. I will bring experience and knowledge about health care, education, and business from my experience and accomplishments as a practicing physician; a leader in SSVMS, CMA, and AMA; a residency director and leader in higher education; a community leader; and a co-founder of a small business. I will advocate for accountability in state government. I have a Masters in Public Health with a focus on program evaluation and clinical effectiveness. As a Sacramento First 5 Commissioner, I chaired the Commission Evaluation Committee, and now as Chair of the Impact Council Chairs for the United Way California Capital Region, I have required

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Experience? I am Associate Professor of Pediatrics and Pediatric Residency Director at UC Davis where I founded and direct Communities and Physicians Together, which partners resident physicians with community collaboratives to improve community health. I am a SSVMS PastPresident, CMA Trustee for our region and a past-Chair of the CMA Council on Legislation, a Past-Chair and member of the AMA Council on Medical Education, and Vice-Chair of the California American Academy of Pediatrics. In the community, I chair and co-founded Healthy Kids Healthy Future, a five county nonprofit that provide health, dental, and vision coverage for children; am a board member and Chair of the Impact Council Chairs for the United Way California Capital Region; a board member of BloodSource; and served on the Sacramento First 5 Commission. Awards I have received for my accomplishments include the Sierra Sacramento continued on page 20

Ami Bera, MD, (D) Congressional District 3 Dr. Bera responded to the SSVMS questions with the following statement. In April 2009, I became a candidate to represent my district, our state and our nation in California’s 3rd District in the United States Congress. This decision was not taken lightly, and was only arrived at after months of contemplation, discussion with friends, family members and colleagues. My motivation in running for Congress reflects the reason most of us enter the medical profession — a desire to serve and a desire to heal. I am the beneficiary of the American dream. My parents immigrated to California in the 1950s and, through opportunity and hard work, were able to provide stability and security for themselves and my two older brothers and me. I benefited from strong public schools, communities where neighbors watched out for one another and a University of California system that allowed me to complete my undergraduate and medical training with minimal debt. My wife, Dr. Janine Bera, and I were able to find secure jobs and careers, buy an affordable home and build a family together. Yet, I worry about the future we will leave our daughter. As I talk to my neighbors and future constituents, most share this same concern. I have been blessed to work in many aspects of our health care community: as a practicing physician for MedClinic (now Mercy) Medical Group; as medical director for Care Management for the five hospital Mercy Healthcare Sacramento system; as Sacramento County’s chief medical officer and medical director and most recently as associate dean for admissions at the University of California, Davis School of Medicine. Outside of health care, I have been

involved in addressing our community’s social and economic challenges, leading and facilitating discussions on the homeless; affordable housing; distribution of limited social resources and recreating a viable and accessible system of education. It is these varied experiences that provide the foundation upon which I now run for Congress. As physicians, we must take a leadership role in changing the tone of divisive dialogue concerning health care redesign. We are given the privilege each day of patients and families sharing their struggles and joys with us and seeking our guidance and help in restoring their lives. We are trained to address these issues in a compassionate and empathetic manner, but we are also trained to address these challenges with direct, honest and authentic conversation. We do not have the luxury of avoiding the difficult conversation. We must name the challenge, discuss it openly and find a workable solution to serve those seeking our guidance. This is exactly how we were trained. And this is exactly what is missing in our political leadership today. The core planks of my campaign are as follows: We must build a health care system that has a compassionate baseline that is available and accessible for every American. Second, we must rebuild our educational system to teach students to think and make sure it’s flexible enough to allow for many career paths, from trades, to technology, to college. Third, we must create an economy that rewards employment and creates career pathways that allow for a secure and sustainable future over a lifetime. And last, we must have an environmental and energy policy that builds for

September/October 2009

generations to come. I encourage you to visit our website, www.BeraForCongress.com, or come to one of our community chats. You can get involved in the campaign by making a donation, hosting a house party, helping with a voter registration canvass or in a variety of other ways. Be well.

Richard Pan, continued from page 18 Valley Medical Society Medical Honor Award, American Academy of Pediatrics/American Medical Association Abraham Jacobi Memorial Award, United Way California Capital Region Clarence La Rue Outstanding Volunteer Award, Campus Compact Thomas Ehrlich Faculty Award for Service Learning, California School Nurses Organization Lydia Smiley Award, Child Abuse Prevention Council of Sacramento Hearts and Hands Award, and the University of California, Davis Chancellorâ&#x20AC;&#x2122;s Achievement Award for Diversity and Community.

What Would You Want to Accomplish? I will fight for a healthy change in California where the state encourages the creation of jobs and new businesses, where quality education

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from preschool to vocational school and graduate school is available to create a stronger workforce, and where quality health care is accessible to all Californians. To address Californiaâ&#x20AC;&#x2122;s problems, voters need to be engaged in a dialogue about the value of the activities of our state government and how they should be supported.

How Can Physicians Help? A recent poll showed that I will win if the voters learn who I am. As a political outsider, I need you, my fellow physicians, to contribute and volunteer to get my message to the voters. Please go to my website at www.panforassembly. com to learn how to help. Your contributions to my election are deeply appreciated.

Airiel The first patient who died in my care.

By David Gunn, MS III, UC Davis School of Medicine Thirteen-year-old Airiel came to the ED in the late afternoon with a fever, rash, shortness of breath, worsening weakness and muscle pains. She was a dark-skinned girl with a Latina mother, white adoptive father and AfricanAmerican biological father. The family was concerned this could be a flare-up of her juvenile rheumatoid arthritis, diagnosed a few years ago. “What can we do to help her pain?” they asked. The entire family was warm, welcoming and helpful, fully attentive and active in her care. “What do you recommend?” They looked to us with an open trust that is the celebration and burden of a caregiver. We began to treat her pain with naproxen and her rash with steroids. A chest X-ray would be taken to assess for possible pneumonia. She would rest while we consulted the imaging and devised a plan to keep these flare-ups better controlled in the future. There are always other patients to see, and today was no different. Hours passed with gunshot wounds, vomiting, delirium and dementia. As I caught my breath it was time to reassess. Was the gunshot victim in Bed 6 stabilized and prepped for the OR? Was Ben, the vomiting patient in Bed 4, receiving adequate hydration? What about that X-ray for Airiel? I pulled up the imaging, and immediately saw the mass in her chest. This was not arthritis. This was cancer.

How It All Began I first heard about Airiel on the first day of my Hematology/Oncology pediatrics clerkship. Monday had given me a lot of adjustments and it was all I could do to keep absorbing what

those around me were discussing in fragmented speech. Connecting the dots was a demanding job, let alone decoding how to proceed; I couldn’t bother to help Airiel until I could keep up with the current state of flux. But one thing stayed constant. Her name was uttered on morning rounds with such consistency of affection by our normally harried senior resident that I began to follow her story after I had seen my regular patients. It was a natural inclination, to be curious in her story; in her. Crawling my way through the weeks of progress and consult notes I began to piece together the events that brought Airiel to us. She had just transferred onto the Hem/ Onc service from the pediatric ICU. Airiel had a 3 year history of systemic JRA that was well controlled until 10 days prior to admission. A rash, myalgias and fever consistent with a flare up had brought her to our ED. Her symptoms were successfully treated with naproxen, and she was being set up for Medi-Cal and a rheumatology clinic for follow up. We did some perfunctory blood and urine cultures to rule out an occult infection, and a chest X-ray and EKG to rule out pneumonia and pericarditis. Things were looking up until the X-ray came back. It showed a mediasteinal mass that was determined to be Hodgkin’s lymphoma. Despite the huge shock, the family remained positive and optimistic for Airiel’s future. The family consented to chemotherapy. Chemotherapy is never a problem until it’s a problem. Sure, nausea and alopecia can be real problems, but when compared to the cancer or a disseminated infection, they are comparatively minor in consequence. After starting her chemotherapy, Airiel began

September/October 2009

Things were looking up until the X-ray came back.

to have difficulty breathing, and her blood pressure began to drop, and did so quickly. Her immune system was being shut down to attack the Hodgkin’s lymphoma and now it looked as though she’d caught a bacterial infection. She was transferred to the pediatric intensive care unit for more intensive support. Even after being given aggressive antibiotic therapy and respiratory and circulatory support, her heart stopped working and she had to be put on ECLS, extra-corporeal life support. Fortunately, the intervention worked and she remained in the PICU for several weeks before recovering enough to breathe on her own and begin to rehabilitate on our Hem/Onc service.

“That

Recovery and Eye Problems

is medicine,” she explained, “making decisions on incomplete sets of information. You do the best with what you have.”

I met her family when they returned to the ward. All three parents were staying in her room, reading, using the computer, talking with Airiel. Her mom was positive, attentive and involved in her daughter’s care. Her two fathers were equally positive, they were easy friends with each other, despite what might have been a complex family dynamic. It seemed as though they had come so close to losing their daughter that every day with her was a blessing to be celebrated. That seemed to me to be living life the way that we all try to do when we become inspired. Airiel was the same way — happy, goofy, had a crush on John, the intern, and was a fun patient to visit. When asked to smile for her cranial nerve exam, she grinned from ear to ear, and then just as quickly pretended to regain her composure as a smaller smile crept back out. Later in the exam, she emphatically stuck her tongue out at our gruff and dour attending to prove cranial nerve 12 was still intact. For a week after Airiel was taken off of ECLS she was intubated, which prohibited her from talking to her mother about the changes she was experiencing. We were giving her anti-hypertensives to correct her high systemic blood pressure. The internal carotid had been sacrificed for ECLS and left her ophthalmic artery with a decreased blood flow. The combination of the two was lowering blood pressure to her eye to the point where her optic nerve began to atrophy. Sierra Sacramento Valley Medicine

Only after we removed the tube was she able to speak. She had noticed she wasn’t able to see out of her right eye while intubated, but thought the eye had been taped shut as it had been earlier. Now that her strength had returned and she could move her arms, she knew the blackness in her right eye was not due to a bandage. She had lost the vision in her right eye. Was it from the ECLS? Was it from the hypertensive medicine? Was it from the JRA? We couldn’t tell. I thought that was a pretty lame answer. How could we protect the vision in her other eye if we didn’t know what had caused her to lose vision in the first place? “There aren’t answers to all the questions,” my attending said. “We have to care for her with the information we do have, incomplete information, but all that is known. That is medicine,” she explained, “making decisions on incomplete sets of information. You do the best with what you have.” A lot of people think that doctors know everything, but we don’t. We have seen a lot of patients, and use this experience to guide our judgment in the face of incomplete information. It might not always be the right choice, but it is the best choice we can make at the time given the information we have. I went to see Airiel to examine her for myself, before ophthalmology arrived, so that I could compare my observations with theirs. If I was going to help people, I needed to be able to observe finer details. The best clinical reasoning is worthless if the physical exam overlooks a key clinical finding. I explained to the family that I was the 3rd year medical student on the Hem/Onc service and that I would like to examine her eyes, to help make sure she didn’t lose her remaining vision. Her family was very happy to have me there. Airiel was cooperative and engaging, yet uncharacteristically quiet. I gave my examination and noted my observations, thanked the family and left. Ophtho came and went. They thought the other eye was good and would remain so. And so began Airiel’s rehabilitation. Each day that week our team would visit each

of the patients on our service and see how they were progressing along the treatment plan we had devised with the family. Continued antibiotics, physical therapy, chemotherapy or pain medicine — each patient was different. Every day Airiel would be there with her family, smiling at us and goofing around with the attending. She was receiving daily chemo to make sure the lymphoma didn’t return, and was tolerating the treatments very well. She began to breathe better, and walk around. Her family was so happy that she had made it through, and we were all happy for her.

Unexpected Seizures That Friday of the first week I came home and relaxed for a bit. After a while, I checked the EMR system to see how my patients were doing. I saved Airiel for last; she had been doing so well there really wasn’t too much going on with her. There was a flurry of progress notes from Stacy, the R2, the nurses and even the attending physician. This couldn’t be good. Just about the time I had been enjoying a pizza and cola, Airiel began to have a seizure out of the blue. Stacy did an emergency physical exam to ascertain the origin of the seizures. Were they from an electrolyte imbalance? Undiagnosed epilepsy? The chemo? A febrile seizure? Had Airiel caught a bug? I quickly scanned the progress notes for answers. Within two minutes she had stopped seizing. There must have been a moment of tense calming for the team that was attempting to manage the unknown. I imagined what was going through their minds: What to do? What caused this in the first place? In my mind I put myself there in the tension and anxiety of making decisions on incomplete information, and the relief I felt knowing that as a medical student I would not have to. As much as my faith in the “all-knowing” physician has been shattered, I realized I still wanted to let myself have faith in my superiors. Just as quickly, two minutes later she seized again. She was given antiepileptics to stop her muscles from contracting, and she relaxed, but was unresponsive. They transferred her back to the PICU where she had been for over a week,

where she received ECLS. Back where she lost her vision. That was the last progress note on EMR. I would have to wait until the morning to find out what her course would be. I came back the next morning, and the first thing I looked at was the EMR for Airiel. Some hours after I had gone to sleep, while she was in the PICU, she had an EEG measuring her brain activity for seizures. The EEG was totally flat. There was no activity in Airiel’s brain — she was brain-dead. Airiel had been in septic shock from bacteria, and blood flow to her brain had been cut off from the massive swelling that was a consequence of the bacteria’s exotoxin. Her head and neck swelled and the pressure had occluded her remaining carotid artery. I was stunned. Our attending physician came up to our team and told us what the course over the past day had been. That didn’t make it any easier. I felt myself start to cry, and turned away towards my computer. He would have to go tell the family what the EEG showed. As he walked away I looked after him, wanting to be there for the family when they heard the news. Halfway down the hall he turned and saw me still looking, “Did you want to come; were you following this patient?” “Yes, I was, I’d love to come.” As soon as the words left my mouth I was struck by the contradiction — I was experiencing eagerness in the presence of such great loss and tragedy. Was this okay to feel? I followed him into the family conference room where our attending, the PICU attending, and a fellow medical student and I waited for the family to enter. As we were waiting, the PICU attending told us three things. The first was we would tell them what we knew and what their options were. The second was that we should be seated; there was evidence to show that families thought their doctors spent more time with them when they were sitting, even if standing doctors actually spent more time than sitting doctors. And third, we would be seated between them and the door, in case they became violent. The family filed in, and a somber hush fell over the room and the PICU attending asked the family what they already knew. He filled in the

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Every day Airiel would be there with her family, smiling at us and goofing around with the attending.

He said it’s a horrible thing to have to do and it never gets any easier.

gaps, and danced around the word brain-dead. The mother started to cry horribly, and her grief filled the room and pushed the words out of his mouth. He started speaking again before I would have, and told them about the course of the near future. “But she was a perfect little girl,” the mother cried, “she was perfect. You know that,” she said to my attending. “Yes, she was,” he replied, “I knew her and she was a wonderful girl.” The mother asked if there was any hope left at all, any at all. Although the neurology fellow had not read the EEG yet to say 100 percent that Airiel was brain-dead, the PICU attending could tell that there was no activity whatsoever on any of the brainwaves. If there were any family members who wanted to say goodbye, now was the time to call them. We could arrange religious services for them, and a social worker to help them with anything they needed. We would return to follow up after they had time to be together and talk about the situation. As my attending and I silently walked down the hall, I asked him if there was anything he wanted to teach me about that experience. He said it’s a horrible thing to have to do and it never gets any easier: “You tell them what you know and what you can do.” We came back to our team, and had a moment together, just being together. After a minute or so, we each looked up and knew that there were other patients who needed our help. And so we went on and did what needed to be done. There was a new 11-year-old boy here with a long history of sickle-cell disease who was in a pain crisis, Christopher. Did I want to take him? Yes, of course I did.

The Funeral Services I went to the funeral. The rest of the physicians thanked me for coming. I was surprised by that. I kept getting the feeling that they felt I was coming to the funeral on behalf of UC Davis. Why else would they be thanking me? To encourage that positive quality in me that drove me to want to visit? Can you encourage that in someone else, or is the quality innate? Honestly, I came to the funeral because Airiel was such an amazing person, who filled

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me with so much positive energy I couldn’t help but want to go. In fact, that was what I wrote for the family when they asked for a memory of Airiel to be written down for their scrapbook. But the surprising part of the service was that everyone shared that same feeling — Airiel made them feel that same way. It was really awesome, impressive, that everyone would get the same feeling from this person. Her personality was so strong and positive. I was sad that Airiel died, because she had such an amazing spirit. We need more people like her in the world. Of course, if we had more people like Airiel, would I be as impressed with her? Is the rare and beautiful still beautiful when it is common? Is a beauty proportional to its rarity? Or is there something more fundamental to beauty that isn’t reliant upon scarcity? At the end of the service I said goodbye to her aunt. I told her I had planned to speak at the funeral and share my impression of Airiel’s tremendous spirit with others, but the more I listened the more I heard people say the same things that I would have shared. She asked if it was common for a physician to come to a patient’s funeral. I got the impression that she was asking if her niece’s personality was common. I told her it was very rare for physicians to attend their patients’ funerals. Airiel was very special and would be missed terribly. We shared an embrace and I left. In the parking lot one of the attendings made it a point to thank me again for coming to the funeral; she said it really showed a lot about my commitment to my patients. I think it showed less about me and more about Airiel. dgunn11235@gmail.com David Gunn is a medical student at UC Davis and the Class of 2011’s co-president. He is currently searching for an opportunity to practice international rural medicine with a primary care physician. He holds an M.F.A. from Mills College, and a B.S. from The University of Oregon, both in electronic music. He previously worked for Leapfrog Toys designing the HHS’s Interactive Afghan Family Health Book.

The New POLST Form Physician Orders for Life-Sustaining Treatment document patients’ treatment preferences.

By Kathy Glasmire, Associate Director, Center for Healthcare Decisions Sarah Anderson is a 78-year-old woman with severe lung disease. She lives in a skilled nursing facility after a hospital stay for pneumonia. She develops increasing shortness of breath and decreased responsiveness. The SNF staff call 911 for patient transport to the hospital. The ER physician cannot find any code status information so Mrs. Anderson is intubated and transferred to the ICU. Later, it is learned that Mrs. Anderson did not want aggressive treatment. Sound familiar? Far too often patients’ wishes about medical care are not known. Advance health care directives may not be accessible, clear or honored by healthcare professionals. As a result, patients may experience overtreatment, and unnecessary pain and suffering. A new California law seeks to alleviate these situations with Physician Orders for LifeSustaining Treatment (POLST). POLST is a voluntary form that documents patients’ treatment preferences. All healthcare professionals and providers — including hospitals, nursing facilities and first responders — are required to honor POLST when presented with a completed form. The law gives immunity to providers who follow POLST in good faith. The California POLST form is two pages (the front and back of a sheet of 65 pound Pulsar Pink paper stock) and includes these features: • immediately actionable medical orders on a standardized form; • orders that address a range and level of intensity of life-sustaining interventions; • brightly-colored, clearly identifiable form; and • portability across treatment settings. Designed for seriously ill or medically frail patients, POLST clarifies patient decisions about treatment, including CPR, hospitalization, arti

ficial nutrition and other medical interventions. An important component to ensure the effectiveness of POLST is a comprehensive discussion about goals of care. Once completed, the form must be signed by the physician and the patient or legally recognized decision maker. POLST differs from an advance health care directive because it does not name a health care decision maker, is intended primarily for people with advanced illness and puts into operation wishes set forth in an advance directive. In August, the Center for Healthcare Decisions held a multi-organizational meeting of regional physician leaders and representatives from emergency medical services, hospitals and skilled nursing facilities. The group began discussing ways they might collaborate to ensure widespread use of POLST, including sharing best practices, providing education opportunities, enhancing communication across care settings, and raising visibility around this important new communication tool. For more information, contact CHCD. POLST was developed in Oregon in the early 1990s and is used in more than 25 states. Research shows that POLST instructions are generally followed and the form accurately conveys patient preferences (www.POLST.com). The California Coalition for Compassionate Care (CCCC) is the lead agency for POLST implementation in California. glasmire@chcd.org (916) 851-2828. Download the POLST form for printing, as well as other helpful materials, at www.capolst.org. The official POLST form for California is approved by the Emergency Medical Services Authority in cooperation with CCCC. September/October 2009

Voices of Medicine Why we need to strengthen and expand Medicare, and what it means to be a physician.

By Del Meyer, MD

Health Reform? Build on our History.

So, it becomes operant upon us to work to strengthen and expand Medicare.

Stephen Kamelgarn, MD, Editor of The Bulletin of the Humboldt-Del Norte County Medical Society gives us his changing views of single payer healthcare in the February 2009 issue. His article is entitled, “Can We Get There from Here? Should we Listen to our History?” Over the years I’ve written a number of diatribes expressing a need for the United States to adopt a “Single Payer” Health Care System. We’ve finally inaugurated a president who is, at least somewhat, amenable to listening to a variety of plans for health care reform. This would seem to be a time that we single payer advocates can push our agenda; or is it? In the Jan 26, 2009, issue of The New Yorker Atul Gawande (one of the magazine’s medical correspondents) has written an intriguing article about health care reform. While he is in favor of single payer, he feels that we are in the grip of past precedents and history. He makes a very persuasive case for “listening to our history.” This holds true not only for health care reform, but for any transformative technology or practice in a society. He briefly traces the history of single payer in both France and Great Britain and shows why their plans have taken the form that they have… In the article he states: “Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.” His point being that no matter what we Single Payer monomaniacs may

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want, we are going to have to build it upon what we already have. If we attempt to get “too radical” too quickly we will wind up with a gigantic failure on our hands. I remember reading an interview with President Obama early in the past presidential campaign where he tried to defend his health care proposal. He stated that if he were to design a health care delivery system from the ground up, it would definitely be a single payer system. But he doesn’t have that luxury and must “patch” our current system… Aside from the fact that we’re dealing with the most political of processes, with vast amounts of money at stake — money no insurance entity will willingly surrender — we also have to take into account all that’s gone before. Massive change “by fiat” will usually fail — witness the disaster of Part D Medicare… The point being that we, as health care reformers, will have to adapt that which we already have, rather than coming up with something de novo. Besides the hundreds (if not thousands) of different health insurance plans we have in the US, we also have several government funded plans: Medicare, Medicaid and the VA to name but three… Medicaid is so horribly underfunded that it doesn’t answer anybody’s needs except the very poor. So, it becomes operant upon us to work to strengthen and expand Medicare. To me that seems to be the least traumatic, most equitable alternative. It also has the greatest chance of success, being an adaptive change to an already existing system, rather than something brand new… Read Dr. Kamelgarn’s entire editorial at www.humboldt1.com/~medsoc/images/bulletins/

Calling? Career? Job? Philip R. Alper, MD, discusses whether physicians view their work as a Calling, a Career, or a Job and how it changes over our professional life in the March 2009 Issue of the Bulletin of the San Mateo County Medical Association. His article is, “Would You Choose Medicine Again?” Back in 2001, Barry Sheppard polled the SMCMA membership on a set of questions dear to his heart: essentially, how do colleagues view their work as a physician? Is it a calling, a career or a job? Has the answer changed since graduation from medical school? And would you still become a doctor if you knew then what you know now? Barry was impressed by the 28% response rate and intrigued by the number of doctors who modified the questions before they answered them. Most of all, he was impressed by the high level of positivity of the responses, something he said he would not have predicted. On graduation, nearly half, 46% of the respondents to be exact, viewed medicine as a calling, while 52% considered it a career. Only 2% voted for “a job.” Once in practice, 30% still considered medicine a calling, while 56% now described it as a career. Job-minded physicians increased to 14%. In all, two thirds of physicians who responded did not change their mind with the passage of time. And a striking 70% said they would still become physicians all over again, even with the benefit of hindsight. There was a hint that more recent graduates would be less inclined to choose medicine again than older doctors, but even they voted “yes” 59% of the time. Dr. Sheppard brightened at the end of his introspective analysis and spoke of “our strong and, for the most part, abiding love for our chosen profession.” Even though I myself have often grumbled about what could be much better in medical practice, I must admit that I too was pleased with the results. I don’t know that at any time I’ve considered medicine a “calling.” For me at least, the idea is

too pretentious, implying more things than I think I’ve given to medicine or my patients. But neither has it simply been a career for the 52 years since I graduated from medical school, much less a job. I know I took — and take — the Hippocratic Oath seriously. Respect for patients, honesty and doing my best for them go without saying. Perhaps “a sacred trust” rather than “a calling” comes closest to the mark, though that too is rather pretentious. Were I to take Barry’s quiz now, I probably would have tried to change the questions because they are too hard to answer as given. Would I choose medicine again? That’s a more straightforward question. The answer is “yes,” but I’m not entirely sure why. I’ve been a doctor so long that the role seems to fit naturally. I’ve never been free to abstractly choose whether or not to become a physician again. What would I take myself for if I did something else? There is a big problem with opinion polls like these. It’s not clear whether negatives represent healthy grousing like the attitude portrayed on TV in M.A.S.H., how deeply the sentiments are felt and whether they would lead to action… One thing I miss is the number of people in health care who were willing to help me fulfill my role as a doctor. The pharmacist who dropped everything when I called years back has been replaced by the pharmacy technician who explains that the pharmacist is busy counseling a patient and that I will have to wait. Old-time nursing home directors like Mrs. Huntley in Magnolia Gardens, where often nurses made rounds with me and knew “our” patients intimately.… Diagnostic tests, surgical procedures and drugs are getting ever-better. But it is tougher for many of us personally. Still, the work seems to be getting done, patients are grateful and medicine endures. Yes, I would become a physician again, even if I’m not entirely sure why. To read Dr. Alper’s entire editorial go to www.smcma.org/bulletin/issues/BULLETIN09MarchR5.pdf

Yes, I would become a physician again, even if I’m not entirely sure why.

DelMeyer@MedicalTuesday.net September/October 2009

Allowing Natural Death vs. “Do Not Resuscitate” By Cecilia M. Hernandez, MD, SMCS Director of Medical Affairs

The challenge is to remember that life belongs to someone else and we are only really here to serve that person.

This article first appeared in the May 2009 issue of SMCS Physician; it has been lightly edited. When should we speak to patients about the end of life? And how? These questions seem to be coming up more frequently lately, maybe because hospitalized patients are sicker than ever. In any case, it seems that society is more comfortable as a whole with the idea that physicians can and should facilitate one’s death even as they strive to save lives. Tough place to be, no doubt, but not impossible. Perhaps we need to talk about it among ourselves, as we don’t seem to be as consistent in our approach as patients and caregivers need us to be. This issue first came to my attention about a month ago as one of the chaplains expressed her concern that families are not being given options that include end-of-life care. She saw how one family in particular suffered with the guilt of continuing what they believed to be futile efforts while their physician kept telling them and the patient that it was too soon to discuss palliative care. The patient did, in fact, die during that hospital stay, but the patient and the family never had the option of preparing for death with the support of hospice. The family was plagued with guilt at not honoring their family member’s need for a peaceful death at home. I understand that as we push the envelope of science that we are able to bring back people from the brink of death despite horrific odds and despite utter and complete debilitation, but shouldn’t the patient and family be the ones to decide just how horrific and how compromised they are willing to go? Aren’t we obligated to give them the support they need to tolerate the

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suffering that goes along with hovering over that brink for longer and longer periods of time? Perhaps the best way to mitigate the conflict between giving up completely and pushing through months of pain and suffering is to partner with our colleagues best equipped to navigate the end of life — our palliative care team and chaplains. At the very least, they can have the conversations these patients and their families need about meaning and purpose as they choose to face down death. Further, they can help patients and families individualize their end points and define how they want their final days and weeks to be when that time comes. That time will inevitably come, whether it is weeks or years down the road. As a physician, I understand my physician colleagues’ need to gird themselves with resolve in the face of the impossible. It is ultimately what saves lives. The challenge is to remember that life belongs to someone else and we are only really here to serve that person. There comes a time in every life when the best medicine is to care and to support, not to push and to force. The excellent healer is the one who has a big and varied toolkit to serve his patients. We must all strive to develop the skills that heal the soul as well as the body. In the end, the best we can do is to continue to serve and to not abandon, to be present as a human being and as a witness to the most profound transformation a human being can experience. Furthermore, we must empower family members to do the same, to lovingly ease the way as they acknowledge what their family member meant to them and to the world, to continued on page 30

SPIRIT Matters By Kristine Wallach, Program Manager As the Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) Project works its way through the 17th year of providing service to the under and uninsured in Sacramento County, it is a good time to take stock and recognize the people who do all of the work! The past eight months have seen Sacramento County healthcare system undergo devastating cuts that can’t help but impact the lives of their patients.

Through all of these changes, which have included staff cuts and clinic closures, SPIRIT volunteer physicians have continued to serve, reconfirming their commitment by demonstrating flexibility in the face of volunteer sites closing and loss of their cherished support staff within the county system. SPIRIT volunteer physicians have stepped up. In the second quarter of 2009, SPIRIT volunteer physicians treated more patients than in any of the previous nine quarters.

Please join me in recognizing and thanking the following active SPIRIT volunteers: Ruenell Adams, MD Sallie Adams, MD Franklin Banker, MD Lawrence Bass, MD Robert Bellinoff, MD Joanne Berkowitz, MD Carol Berry, MD Gregory Brott, MD Matthew Carnahan, MD Donald Clutter, MD Ed Denz, OD Joyce Eaker, MD Guy Guilfoy, MD Andrew Hudnut, MD

Richard Jones, MD Diamond Kassam, MD Paul Kelly, MD David Kissinger, MD Joseph Lash, MD Michael Lawson, MD Michael Leathers, MD Roger Lieberman, MD Aloysius Llaguno, MD Eric London, MD Allen Lue, MD Elisabeth Mathew, MD George Meyer, MD Alan Mortiz, MD

Patricia Ostrander, MD Vicente Quan, MD Ivan Rarick, MD JaNahn Scalapino, MD James Sehr, MD Daksha Shah, MD Elaine Silver, MD Christian Swanson, MD Kirk Van Rooyan, MD Horst Weinberg, MD Patricia Will, MD Mike Wolford Derek Wong, MD John Young, MD

In addition, please join me in welcoming new SPIRIT volunteers whose volunteer applications are being processed: Tony Cantelmi, MD Kenneth Chan, MD Cecelia Hernandez, MD Lawrence Laslett, MD

John Loofbourow, MD Robert Meagher, MD William Pevec, MD Gerald Rogan, MD

1-800-901-5830 • • • • • •

33 years of medical experience 1,600 Northern California physicians 45 well-trained & professional operators State of the art computer technology Discounted rates for new SSVMS accounts Spanish, Chinese and Russian spoken

September/October 2009

On a personal note, I would like to thank the members of the SPIRIT Management Committee that was created to develop and oversee the collaborative partnerships between the organizations involved in funding and in-kind support of SPIRIT. Sr. Clair Dalton, CHW Andrew Hudnut, MD, (chair), Sutter Medical Group Richard Jones, MD, private practice Charles McDonnell, MD, SSVMS Pinky Patel, UCD Health System Dorothy Pitman, MD, Sacramento County Jack Rozance, MD, TPMG Bill Sandberg, SSVMS Carol Serre, Kaiser Petra Stanton, The Effort Keri Thomas-Cavner, Sutter Medical Center Fay Young, Northern California Lions Sight Association John Young, MD, Mercy Medical Group Finally, I would like to recognize the community organizations that make SPIRIT possible. SPIRIT gets financial support from Blue Shield of California Foundation, Kaiser Permanente,

Mercy, Sierra Sacramento Valley Medical Society, Sutter Medical Center Sacramento/Sutter Medical Group, and UC Davis Health System. We also receive in-kind support from Central Anesthesia Exchange Medical Group, Diagnostic Pathology Medical Group, Northern California Lions Sight Association, Radiological Associates of Sacramento Medical Group, Sacramento Anesthesia Medical Group, and Sacramento County Dept of Health and Human Services. I would like to extend a special thank you to John Chuck, MD, and the Serotonin Surge Charities for their generosity year after year. Without the dedication and commitment of those listed above, neither the 28,000 plus patients treated by SPIRIT volunteers to date, including 475 surgeries, nor the 24,000 hours donated or the $6.5 million in services donated would have been possible. A hearty and heartfelt thank you to everyone involved! To learn more about the SPIRIT Project or to become a volunteer, visit us at www.ssvms.org, or contact Kris Wallach at 916-453-0254 kwallach@ssvms.org

Natural Death, continued from page 28 thank him and honor him by not making his departure a failure on his part, and to reassure him that all is well. Even in death there can be healing. In fact, I would say that in death there must be healing if we are to be of the utmost service to our patients. Is it possible that physicians avoid end-oflife discussions because the language currently available to us denies our need to save lives? Recently, Adam Burroso, one of our nurses on 5 South, asked me to read an article suggesting we reshape our end-of-life conversations to “allow natural death” instead of “do not resuscitate.” The article posits that “‘Do-not-resuscitate’ sounds cold, cruel — as though the health care team has given up.… ‘Allow-natural-death’ sounds softer, more comforting, warmer — even

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though it contains a form of ‘the D word.’ It says that the team cares and will continue to care for the family member.” This appears to be supported by a study conducted in 2004 at the University of HoustonVictoria in Texas and included 687 participants. The article, “‘Allow natural death’ vs. ‘do not resuscitate’: three words that can change a life,” can be found in the Journal of Medical Ethics 2008;34:2-6. The conclusion of the study is that framing the conversation in the context of allowing natural death increases appropriate end-of-life care. Maybe that is a place for us to start. hernanc@sutterhealth.org

Charitable Giving and the Holiday Sharing Card The Medical Society and Alliance have joined in holiday charitable giving for 54 years.

By Jerilyn Marr and Marilyn Skinner, Co-Chairs for the 2009 Holiday As many of you are aware, the mission of the Sierra Sacramento Valley Medical Society Alliance (SSVMSA) is to improve the health in our community by supporting medical and nursing education, the funding of health projects, and community education in collaboration with the Sierra Sacramento Valley Medical Society (SSVMS). The annual Holiday Sharing Card has been a vehicle for the Alliance to solicit funds from the medical community in support of our mutual goals. A spirit of charitable giving began when the AMA Foundation formed a partnership with the Alliance in 1955 to “raise money for the country’s struggling medical schools.” Post WWII medical schools faced “skyrocketing costs” to train new physicians. The AMA Foundation established the Holiday Sharing Card in 1956. An attractive holiday greeting card was sent to all who contributed. Blank copies of the greeting card could be purchased and are still available for purchase on the web site www.amalliance.org. Over the years, the SSVMSA has created our own unique Holiday Sharing Card to recognize and thank our individual donors, and to honor talented artists from the medical community, Alliance membership, or medical family members. All of the artists donate their artwork for the cover of the Holiday Sharing Card. A contribution to the AMA Foundation goes to worthy medical students attending a U.S. school. Since 2005, the Sacramento medical community has provided financial support for medical students in 33 medical schools across

the country. In 1962, the Sabin Oral Sunday program provided polio vaccines through donations collected by the SSVMSA. William Dochterman was the Medical Society’s Executive Director and served in that position for 27 years. The polio vaccine program was very successful and generated an excess of funds. The William E. Dochterman Medical Student Scholarship Fund was established in 1966, using the excess proceeds to help area residents finance their medical education. These scholarship funds continue to benefit high school graduates of El Dorado, Sacramento and Yolo Counties currently enrolled in accredited American medical schools. Since 2007, 104 students have received scholarship grant money totaling $171,000. Of these recipients, 22 have returned to the Sacramento region to practice medicine. Prior to 1983 the Alliance, then known as the Auxiliary, supported community charities with funds raised from Fashion Shows. Alliance members Carol Morris and Carol Doersch established the Alliance’s Community Endowment Fund (CEF) in 1983 to increase funds to improve the community’s health and support educational endeavors. The foresight and hard work of these dedicated members allowed the Alliance to be granted a 501(c)(3) charitable tax status from the IRS, which we cherish today. The new tax status and the advent of the very successful fundraiser Sacramento Cooks! in 1983, provided the Alliance with more resources to expand into September/October 2009

Jerilyn Marr

Marilyn Skinner

the community. The CEF now proudly supports nursing scholarships, community health grants, and community health programs. The SSVMSA budget provides $2,500 in yearly financial aid to nursing students in our region. This past year five scholarships were awarded to nursing students attending American River College, Sacramento City College, CSU Sacramento, and two students from UC Davis. Scholarship students are nominated by their nursing faculty and meet a set criteria established by the Alliance. In 2009 the Alliance’s CEF awarded $26,100 in grants to Sacramento charities. The recipients were the Children’s Receiving Home, UCD Medical Student Run Clinics, Sacramento City Unified School District F.A.C.E.S., Breathe California of Sacramento, Sacramento Hospice Consortium, Strategies for Change, SSVMS Community Service Education and Research Fund, Weave, Clean and Sober, and the Stanford

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Settlement. The Alliance facilitates the collection and distribution of donations to the AMA Foundation, the Dochterman Fund, and the Community Endowment Fund, the Alliance’s charitable fund, with a request for donations mailed exclusively to the medical community, not the general public, in October. The Medical Society and Alliance have jointly participated in this spirit of holiday charitable giving for 54 years. We hope this historical review has sparked a renewed interest in these worthy causes, and will encourage you to join our efforts by adding your name to the list of donors on the 2009 Holiday Sharing Card. For additional information, please contact the SSVMS Alliance office at 916-731-4315. j.marr@sbcglobal.net rlybrd2@aol.com

In Memoriam

Otto Neubuerger, MD 1929–2009

It was at about 9 p.m. on Sunday, July 19 when my phone rang and the male voice at the other end identified himself as Christopher Neubuerger. The first thing I said was, “You aren’t calling me with good news, are you, Christopher?” And he immediately replied that indeed he was not. Otto was supposed to have joined Christopher and his wife, Gabriella, at their home for dinner. When he did not appear, Christopher went over to Otto’s place at Campus Commons to see what was the matter. He found Otto dead at the kitchen table, the Sunday crossword puzzle on the table. Otto habitually worked the Sunday newspaper crossword puzzle. He had been close to completing the puzzle when he died. A pencil lay on the table nearby, and he was working on a clue that was something like “Goatherd namesake of Spyri novel.” The answer is “Heidi.” He had filled in the first three letters, H-E-I. Otto’s daughter, Heidi, had died of breast cancer at age 29, on Easter Sunday in 1987. I first met Otto in the summer of 1980 when I came from Los Angeles to join him in practice with Bill Ballou and Bill Hicks. When you met Otto, you definitely met Sheilagh and all the kids — Tina, Karl, Heidi, Holly, Nubbins, and Topher. When I came to town, they were settled into their ark of a house on Crocker Road. My wife, Mary, and I immediately felt as if we were all old friends. Heidi and Christopher frequently babysat for us. The Neubuerger home was always open, and a knock on the door gained admission to a happy, hectic family environment where you were always welcome and refreshments and food and good cheer were abundant.

Otto was born in Munich, Germany on September 2, 1929, and came to the United States at age 9. His father, a neuropathologist, had been born Jewish and converted to Roman Catholicism, perhaps to deflect attention from the Nazi government and also to marry Otto’s Catholic mother, a general practitioner. The Neubuerger family got out of Germany a year before World War II began and settled in Denver, Colorado. Otto attended the University of Denver and then the University of Colorado Medical School. He did a general internship at Rockford, Illinois, Memorial Hospital and completed his general practice training at Ireland Army Hospital at Fort Knox, Kentucky. Otto Neubuerger, MD From there he was assigned for 3 years as a general medical officer at the United States Army Hospital in Muenchweiler, West Germany. After his Army service, he came to Sacramento in 1961 to join Bill Ballou in general practice and alcoholism treatment. He joined the Medical Society in 1962. I worked with Otto for only 5 years, from July of 1980 until September of 1985, but we remained close friends until his death. He was a straight thinker and always made sure his brain was fully in gear before opening his mouth to speak. He always thought things through before pronouncing on a subject. Whether on clinical matters or medical political matters, his opinions were always worth consideration. After Bill Ballou died, he was one of very few doctors in Sacramento who welcomed alcoholics into his practice. He believed fervently in the aversion-based treatment program at

September/October 2009

Meet the Applicants The following applications have been referred to the Membership Committee for review. Information pertinent to consideration of any applicant for membership should be communicated to the committee. — Glennah Trochet, MD, Secretary Barad, Ashis V., Pediatric Gastroenterology, Texas Tech University 2003, Sutter Medical Group, 5301 F St #308, Sacramento 95819 (916) 739-1604 Batiste, Stanley M., Radiology/Interventional Radiology, New York Medical College 1994, Mercy Radiology Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040 Diaz-Arjonilla, Maruja DV., Endocrinology, Universidad Central de Venezuela 1990, Sutter Medical Group, 1020 – 29th St #270, Sacramento 95816 (916) 455-3700 Eandi, Jonathan A., Urology, UC Davis School of Medicine 2002, Sutter Medical Group, 2801 K St #205, Sacramento 95816 (916) 733-5005 Guile, Matthew W., OB-GYN, University of Connecticut 2005, Sutter Medical Group, 1201 Alhambra Blvd., #320, Sacramento 95816 (916) 455-2229

Heller, Mark J., Internal Medicine, University of Iowa 2006, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

Saechao, Soucheun, DO, Internal Medicine, Touro University 2006, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

Huynh, Hieu, Cardiology, Medical College of Wisconsin 2002, Sutter Medical Group, 5301 F St #117, Sacramento 95819 (916) 733-1788

To, My-Le, DO, OB-GYN, Midwestern University College of Osteopathic 2005, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2612

Jedick, Rocky PJ., Wright State University 2009, David Grant Medical Center, 101 Bodin Cir, Travis AFB 94535 (Intern/Resident Member)

Vallurupalli, Neelima G., Cardiology, Rajah Huthiah Medical College, India 2001, Sutter Medical Group, 5301 F St #117, Sacramento 95819 (916) 733-1788

Reznik, Yuri, Family Medicine, University Auto De Baja 2005, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

Wilton, Maaya A., Pathology/Cytopathology, University of Hawaii 2003, Outpatient Pathology Associates, 3301 C St #103-C, Sacramento 95816 (916) 444-0889

Ritter, David J., Internal Medicine, Loma Linda University 2006, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

Neubuerger, continued from previous page Raleigh Hills Hospital in Fair Oaks and ran it in a completely ethical matter as medical director — even when its parent company came under fire in the national press and some local physicians publicly denounced the methodology used at Raleigh Hills. He served as a delegate to the California Medical Association and sat on and/or chaired several Medical Society committees. He was chief of staff at American River Hospital, and he was awarded the Medical Society’s Golden Stethoscope Award in 1992. One his most personally satisfying accomplishments was the production and publication of “The Painful Dilemma,” a report prepared for general readership regarding the use of long term narcotic pain medications in patients with chronic pain. It is still very much worth reading. After retirement, Otto remained active at the Society in the Historical Committee and as a medical museum docent. When he died,

Sierra Sacramento Valley Medicine

he was still employed doing military induction physical exams. A few weeks before he died, we met for dinner at one of his favorite restaurants, the nearby Greek Village Inn. He always had the lamb shanks and I almost always had moussaka. Both dishes were always washed down with cheap red wine. As usual, it was a pleasant rendezvous. I always enjoyed his thoughts on life and politics, and I guess he enjoyed my sophomoric humor. After we bade each other goodnight, I watched him limp towards his car. For the umpteenth time, I wished I had asked him about the botched hip surgery, done long before I had met him, that had created what was obviously an unpleasantly antalgic gait about which he never complained. Oh well, I guess I will do that next time I see him… — John Ostrich, MD

Steering Clear of Problems with Pain-Med Prescribing By Mary-Lynn Ryan, Risk Management, NORCAL Mutual Insurance Company and the NORCAL Group The following tips will help you prescribe narcotics/opioids appropriately to patients in chronic pain: Obtain a thorough history and determine the specific cause of pain. In an article on treating patients’ pain, Eliot Cole, MD, a physician associated with the American Academy of Pain Management, advises, “Do not call [a patient’s] pain a headache or backache but try to find a specific pathological process to explain why your patients hurt.” Stephen Richeimer, MD, Chief of Pain Medicine at the University of Southern California, says, “Assessment is a key issue. The history and physical examination provides the information that allows the physician to judge if the patient is legitimately in pain or if the patient is improperly seeking drugs.” Document well. Cole advises, “Chart everything you see, think, feel, and hear about your patients. Leave nothing to the imagination of the future reader…. Explain what you are doing, why you believe opioid analgesics will be helpful or continue to be helpful, what alternatives have been considered, that your patient agrees to the treatment, and how you intend to follow your patient over time.” Richeimer agrees: “Good record keeping is part of good medicine, and it is also your best protection from frivolous lawsuits,” he says. Ask chronic-pain patients to agree to use a single pharmacy. Discussing pain treatment with the patient and getting the patient to agree to certain parameters associated with long-term pain management are mutually beneficial strategies: they

help you avoid inadvertently supplying medication that might be diverted for street sale, and they reassure the patient in pain that he or she can count on obtaining needed medication. An especially useful rule is that the patient will use a single pharmacy for all pain medications. Make use of a written pain medication agreement with chronic-pain patients. A signed agreement by the patient that he or she will follow rules for obtaining pain medication will improve the likelihood of appropriate behavior by the patient. It discourages patients from seeking an unlimited supply of medication and helps staff members verify the legitimacy of refill requests. Monitor patients over time on their needs for and use of pain medication. Richeimer observes that patient trustworthiness “can only be assessed by monitoring the patient over time.” Cole suggests talking with patients periodically to reduce dosage appropriately, as well as periodically ordering “urine drug screens for… patients of concern to document that you are able to recover their prescribed medications.” If you keep controlled substances in your office, establish a reliable process for safeguarding and reconciling such medications and for tracking their distribution. The federal Drug Enforcement Administration (DEA) requires physicians who administer or dispense controlled substances from their offices to have effective controls to guard against theft and diversion. Controlled substances must be stored in a securely locked, substantially constructed cabinet. Using a controlled substances inventory log can help you account

September/October 2009

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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.

continued from previous page for each and every dose of medication that goes through your office. These strategies are aimed at fostering appropriate pain management within the limits of professional practice. Furthermore, they can help physicians and staff consistently meet regulatory requirements on the management of pain medications.

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

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

Membership Has Its Benefits!

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

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

Billing & Collections

Athenahealth 1-888-401-5911

Car Rental

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

Clinical Reference Guides-PDA

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

Conference Room Rentals

Medical Society (916) 452-2671

Credit Cards

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

Office Supplies

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

Practice Management Supplies

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

Electronic Claims

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

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.

• • • • • • •

Healthcare Information KLAS / HIT Consumer Satisfaction Technology Products Reports 1-800-401-5911 Insurance Life, Disability, Health Savings Account, Workers’ Comp, more...

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

HIPAA Compliance Toolkit

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

Investment Services

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

Magazine Subscriptions

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

Security Prescription Pads

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

Professional Publications

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

Travel Accident Insurance/Free

All Members $100,000 Automatic Policy

1 Cole E. Prescribing opioids, relieving patient suffering, and staying out of personal trouble with regulators. The Pain Practitioner. 2002;12(3):5-8. http://www.aapainmanage.org/literature/PainPrac/ V12N3_Cole_PrescribingOpioids.pdf. Accessed June 3, 2009.

Sierra Sacramento Valley Medicine

2 Richeimer S. Opioids for pain: risk management. California Society of Anesthesiologists Online CME Program. http://www.csahq.org/cme2/ course.module.php?course=3&module=12. Accessed June 3, 2009.

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