2009-Nov/Dec - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2009

CMAâ&#x20AC;&#x2122;s House of Delegates in action

The CMA House of Delegates meeting held in mid-October in Anaheim. SSVMS is part of the District XI Delegation.

SSVMS Delegates listen to deliberations. From the left are Elisabeth Mathew, MD, Richard Jones, MD, and Barbara Arnold, MD.

Alfred Gilchrist, the incoming chief executive officer of the California Medical Association, speaks before the House of Delegates. To the right is outgoing CMA President Dev GnanaDev, MD. Gilchrist took over CMAâ&#x20AC;&#x2122;s top post on November 16, after 5 years as CEO of the Colorado Medical Society and, earlier, 16 years as director of state and federal governmental advocacy for the Texas Medical Association. s

Richard Pan, MD, CMA Trustee for the District XI Delegation and an SSVMS Past President, makes a point at the microphone.

Sierra Sacramento Valley

Medicine 3

PRESIDENT’S MESSAGE iHistory? – The iTunes of Family History

Announcing the Third Annual Essay Competition

Charles H. McDonnell, III, MD

Voices of Medicine

Rationing of Health Care Richard L. Johnson, MD

Del Meyer, MD

A Posit on Who Should Provide Primary Care SSVMS Election Results

Another Great House!

Richard N. Gray, Jr., MD

Dealing with the Risks of Medical Imaging

1491

John Loofbourow, MD

CMA’s Legislative Wrap-Up

Dustin Corcoran

Board Briefs New Applicants

Nathan Hitzeman, MD

Venezuela’s Medical Care and its Cuban Influence

George Meyer, MD

It’s Not About Me

David Gunn, MS III

A Bad Time to Make Momma Cry

The Right Proposition for the Health Care Debate

Dennis Marks, MD

David J. Gibson, MD, and Jennifer Shaw Gibson

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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 Placerville orthopedic surgeon Greg Joy took this image of Mont SaintMichel in April, 2007, with a digital camera, using an 18-55 mm lens. “This interesting and historical site in northern France is overrun by tourists and tour buses during the day yet virtually abandoned at night.” he said. “The breath-taking display depicted here is missed by most tour groups and is reserved for the wily tourist who arrives after others have gone home.” The tide was beginning to come in when the photo was taken, creating the unusual reflection in the foreground.

November/December 2009

Volume 60/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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

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AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee John Loofbourow, MD, Editor Robert LaPerriere, MD William Peniston, MD Gerald F. Rogan, MD Gordon Love, MD F. James Rybka, MD John McCarthy, MD Gilbert Wright, MD Del Meyer, MD Lydia Wytrzes, MD George Meyer, 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

iHistory? – The iTunes of Family History By Charles H. McDonnell, III, MD The history of a patient’s music collection can be filed and organized in a personal computer via a little thing called iTunes. Now it’s time for the medical industry to do the same thing with health history. Music isn’t life or death. So you’d think organizing a patient’s medical history, accessible in a way to determine a family history of cancer, would have been done by now. Nevertheless, I am optimistic that the ongoing integration and maturation of electronic health records, and health information technology in general, will improve the quality of health care in many ways — just as iTunes has for everyone’s music collections. Specifically, I believe that incorporating family history into a routine digital interaction with patients at points of access to health care will allow patients at high risk for familial cancers to be identified before they develop cancer. This is a song we can all sing along with.

and bone). Not only has PACS allowed us to deal with the ever increasing number of images per exam, but PACS has allowed the typical radiologist to review many more exams per day than a decade or two ago. An example of quality improvement is that PACS provides for instant and automatic retrieval of priors for comparison (assuming the priors were performed by the same institution). There are also further benefits PACS (and Electronic Health Records) will likely soon provide, such as an accounting of a patient’s cumulative medical radiation exposure, which may influence the number and type of imaging studies that are prescribed. Another benefit on the horizon is for PACS systems, in different institutions, to communicate to provide for prior exams, so they may be more readily available regardless of where they were performed. Currently, PACS administrators from all the major health systems in our area have begun working together on this.

A Picture is Worth a Thousand Words

Breast Cancer and Family History

The component of electronic health records, that I use daily as a radiologist, is PACS (picture archiving and communication system). PACS has already demonstrated significant advantages, such as productivity and quality enhancement. For example, when I started as a radiologist the average abdomen CT scan consisted of approximately 50 images to review. Now a multiphase abdomen CT could have up to 150 images to review (not including those with window and level settings optimized for lung

Family history is not an area typically discussed when talking about PACS (or even EHR). However, there are important potential benefits to be realized from one’s history of cancers. As I am writing this article, it is October (breast cancer awareness month) so breast cancer will be my illustration. While most women who develop breast cancer are sporadic cases, we know that approximately 7 percent of breast cancers are thought to be associated with mutations of BRCA1 and BRCA2 genes. Carriers of the BRCA mutations face up to an 80 percent lifetime risk of develop-

November/December 2009

One solution is to put the burden on the patient to enter the data.

ing breast cancer and up to 40 percent lifetime risk of developing ovarian cancer. Approximately 90 percent will develop breast and/or ovarian cancer by age 70. Furthermore, the breast cancers that some BRCA1 mutation carriers develop tend to be more aggressive. Both the breast and ovarian cancers occur at earlier ages for these mutation carriers. For example, up to 50 percent of BRCA mutation carriers develop breast cancer by age 50. As a result, the most and all too common scenarios are that these patients are identified only after having presented with a malignancy. The only chance of identifying many of these high-risk women before they develop cancer is through family history. This is so important because there are now management options for these high-risk individuals, including risk-reducing surgery, chemoprevention and intensive screening protocols. Such measures promise to reduce morbidity and mortality related to these cancers. For example, prophylactic oophorectomy has been shown to reduce the risk of ovarian cancer by up to 96 percent in women with BRCA mutations. In addition, screening breast MRI has been shown to be much more sensitive than mammography and ultrasound in detecting tumors in women with inherited susceptibility.

The Wave of the Future Historically, EHRs have just had a field for text under family history. Eventually they will

My Thanks to the Staff and the Board I wish to express my sincere appreciation to SSVMS Executive Director Bill Sandberg, Associate Director Chris Stincelli and the rest of the wonderful SSVMS staff for making this year so special for me. I would also like to thank the supremely talented and devoted physicians comprising the Board of Directors. It has truly been an honor and pleasure to serve as SSVMS President this year. Finally, my thanks to editor Dr. John Loofbourow for his leadership of this magazine, and to managing editor Ted Fourkas, for making my articles a bit more readable.â&#x20AC;&#x201D; C.M.

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all likely incorporate automated risk calculators based on family history, and automatically draw pedigrees. The problem then becomes how to efficiently obtain the family history and enter it into the EHR. This is especially problematic, as healthy high-risk people may have no reason to access health care, and, therefore, not have an opportunity to be identified through family history. Furthermore, routine H&Ps performed by primary care physicians are not obtained for many people because of lack of insurance and/ or the growing tendency to access health care via emergency departments. Primary care physicians are also under tremendous time constraints to see more patients faster. One solution is to put the burden on the patient to enter the data. Initially this sounds farfetched and even silly â&#x20AC;&#x201D; but not that long ago the concept of arranging oneâ&#x20AC;&#x2122;s own airline travel without a travel agent also sounded ridiculous. People have embraced and even prefer to make their own reservations online. Increasingly, patients are becoming used to using the Internet to obtain health care information and are even communicating with their physicians online in lieu of an office visit.

Mammography: an Opportunity to Obtain Family History Millions of women are screened in the United States annually. Screening mammography is generally believed to be one of the most successful screening programs of modern medicine. Typically, the mammography technologist takes a cursory family history. This is usually recorded by hand and not digitally archived. It is usually not systematically done in a way to allow for precise risk calculation or pedigree generation. Nevertheless, obtaining a family history during mammography has been shown to be a powerful way to identify women with high enough risk to warrant genetic counseling. Furthermore, mammography (typically beginning at the age of 40) provides an opportunity to obtain family history before most high-risk women will develop breast or ovarian cancer.

Putting It All Together So imagine if patients coming for mammography (and other imaging studies) digitally entered family history data while waiting for their exam, which could be integrated into their EHR. Risk calculations could be performed and a pedigree generated. For those patients with risk above a set threshold, letters and/or e-mails could be automatically sent to the patient and their physicians suggesting referral for genetic counseling. A similar scenario could also occur while patients were waiting to see their primary care doctor or specialist. Each time patients had another exam or doctor visit, they would have an opportunity to update their family history. This utopian scenario may sound like the distant future. However, some breast centers already have kiosks in their waiting rooms where patients enter family history data to calculate their level of risk. Mammography reporting and software systems are starting to imbed risk calculators and archive family history data.

Gail models. Colorectal cancer risk is also calculated via CRCAPro and Weijnan combined models. The application automatically generates letters (or alerts) for those patients at high enough risk to warrant genetic counseling. The Sutter Institute for Medical Research is currently funding a local pilot project (which I am involved with) using this application in an outpatient diagnostic imaging setting. EHRs will continue to present us with many challenges, not to mention investment costs. Nevertheless, I am optimistic that health information technology will improve the quality of health care in ways that we have yet to imagine. mcdonnell@surewest.net 1 Hughes riskAppsâ&#x201E;˘. Available from URL: http://www.hughes riskapps.com/default.htm

The Future Is Now Hughes et al recently developed an open source computer assisted self-interview application (which is currently free) called Hughes riskAppsâ&#x201E;˘.1 This allows patients to provide a detailed family history using a tablet PC at the time of registration for a medical appointment or examination. The application uses question branching as it asks about personal and family history of various cancers. It also asks about age of diagnosis for cancers. Then it asks questions about the numbers of relatives so that a pedigree can be generated. All of this takes no more than a couple of minutes. The data is automatically pushed to a remote server database. The application currently calculates risk of mutations using BRCAPro1 & 2, Myriad, Claus and

November/December 2009

Open Wide...

With Confidence!

It’s Open Enrollment time for the Sierra Sacramento Valley Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees. • Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on December 31, 2009. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.

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Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

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d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC Companies, including Kroll, Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

Rationing of Health Care By Richard L. Johnson, MD Dr. Johnson, the former editor of this magazine, was the Medical Societyâ&#x20AC;&#x2122;s president in 1978. He recently uncovered a cassette tape about a film he reviewed in August of that year. It was on rationing of health car, and shown at a conference at Sutter General Hospital. The more things changeâ&#x20AC;Ś This is an excellent film. It is disquieting and provocative. It gives answers and asks questions; many more questions than answers. Probably the best commentary I can make on this film is to ask more questions. Health is politics, big politics, and we, as physicians, must be more interested in politics. The ever-increasing cost of health care has become a leading concern of many politicians. There are demands for cost containment. Organized medicine prefers the voluntary approach. Certain politicians, including our President, feel mandatory controls are needed. So far Congress has opted for the voluntary approach. Before we go any farther, let us ask one question, are we spending too much money for health care? After all, health care is one of the leading growth industries. A few years ago health care took three or four percent of the gross national product. Now, it approaches ten percent. It is a labor rich industry, probably the only one hiring more and more people each year. If the auto industry doubled its sales, it would be applauded, but, if it doubled its employees it would be demonized. Are we spending too much for health care? No one has the answer. At some point in time, society will decide that health care costs too much. What will happen then? Health care will be rationed. Who will do the rationing? Will it be physicians, hospital administrators, health care specialists or just plain bureaucrats? We donâ&#x20AC;&#x2122;t know but the answer will come eventually. David Mechanic, a professor of sociology at

the University of Wisconsin, published a most lucid discussion of rationing of medical care in the current Center Magazine, a publication of the Center for Study of Democratic Institutions. He describes three basic types of rationing of medical care. Fee for service rationing puts an economic barrier on the consumer. Some devices used by this means are co-insurance and deductibles. Implicit rationing establishes limitation on the available resources. That is by restricting budgets, limiting the number of beds, restricting specialists or specialty physicians. Examples are the National Health Services of England and HMOs, especially closed panels like Kaiser. Explicit rationing refers to direct administrative decisions that lead to exclusions of coverage in health care plans, restrictions to particular subpopulations, limitations on specific procedures, pre-review of certain procedures and utilization review at intervals during provision of services. This sounds like a PSRO. Ours was probably based on the concept of explicit rationing. The author of this article stresses that in any type of rationing, the sophisticated recipient gets much more than his or her share of services. Recently I saw a new patient in my office. She was a 66 year-old woman with many complaints. A careful history and a meticulous physical examination plus basic laboratory screening procedures failed to disclose any significant organic disease. Nevertheless, she had a lot of symptoms that troubled her. During the past year she has seen a family practitioner, internist, allergist, ophthalmologist, otolaryngologist, urologist, gynecologist, orthopedist and neurologist. About the only specialist she missed was a psychiatrist, perhaps the specialty she needed most.

At some point in time, society will decide that health care costs too much.

drrlj@colusanet.com November/December 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

Another Great House! This is a brief recap of CMA House of Delegates’ Actions.

By Richard N. Gray, Jr., MD, Vice Chair, 11th District Delegation, California Medical Association If you have never attended the CMA House of Delegates (HOD), you have missed out! However, your chance is coming: we will be meeting in Sacramento next year. What is so exciting about the HOD? This is where CMA policy is made through an incredibly democratic process that has to be seen to be believed. It has been said that getting doctors to work together is like herding cats. That may be so, but the HOD is where 294 cats headed in one direction this year, and there was a united outcome. Though this is not legislation, this is CMA policy and what we will strive to make “the rules” through legislation, working with government agencies, working with specialty societies, or otherwise. Among 158 items considered, the following are some highlights of this year’s policy: • That CMA support the proposal of the Centers for Medicare and Medicaid Services to begin paying for HIV testing when done as a screening test for infection. (Currently, Medicare pays only for treatment, not screening.)

• That CMA advocate for the physician’s right to collect up to the usual and customary rates for Medicare patients covered by supplemental or Medigap plans. • That CMA support allowing physicians to claim a tax credit for uncompensated care. • That any health care reform legislation that includes community rating and guaranteed issue must be combined with an individual mandate. (So if there is federal health care reform, there must still be private options available.) • That CMA continue to educate its members on how to form direct financial relationships with patients as an alternative to the traditional third party payor model. • That CMA work with regulators to investigate non-reimbursement by health plans of physician handling fees associated with clinical laboratory services. • That CMA work with appropriate regulators to address the issue of health plans and insurers inappropriately sending patients outside of the service area for health care services available locally with contracting physicians.

This is where CMA policy is made through an incredibly democratic process that has to be seen to be believed.

Delegate Tom Ormiston, MD, smiles during a discussion. To the right is Bill Reeder, MD, of Redding, chair of the District XI Delegation.

Douglas Brosnan, MD, (left) and Robert Forster, MD, both members of the District XI Delegation, confer on a pending resolution.

November/December 2009

This reference committee considered insurance and physician reimbursement. The second member from the right is District XI Delegate Demetrios Simopoulos, MD, of Placerville.

SSVMS PresidentElect Stephen Melcher, MD, waits at the microphone for his turn to speak.

(Insurers should remember that the patient is the priority!) • That CMA continue to work with regulators to ensure that health plans properly reimburse online and telephone services that health plans have identified as reimbursable services, and the CMA continue to support appropriate billing of patients for online and telephone services that are not reimbursed by health plans. • That CMA [work on] malpractice protections for physicians providing voluntary, unpaid service. • That CMA continue to oppose legislation that would expand use of the term ”physician” to persons other than DOs and MDs. • That CMA reaffirm existing policy on

loan forgiveness for medical education. • That the criminalization of marijuana is a failed public health policy and that CMA explore the public health risks of changing current policy regarding illicit drug use. (This is a HUGE step: not endorsing the use of illicit substances, but recognizing that our current attempts at enforcement are not controlling behaviors. So, a public health approach with regulation and education might be better.) • That CMA encourage the state to maximize the time allotted for physical education classes during the school week according to CDC guidelines. • That CMA encourage local health departments, federal OSHA and Cal/OSHA to investigate and control occupation exposures to infectious disease in the adult film industry and to enforce workplace regulations in a timely manner. (Yes, we even consider the health of workers in the adult film industry!) The sharing of ideas was refreshing, as was meeting with colleagues in various specialties and modes of practice throughout our great state. Though none of us got to win every battle, we did leave the meeting knowing that united we can accomplish so much more for our patients and the profession than any of us can do alone. We can look forward to a good year enacting these policies and also look forward to meeting again next year in Sacramento. rgraymd@comcast.net Dr. Gray is a board-certified family physician working for the California Prison Health Care System. Views expressed are not necessarily those of the California Department of Corrections and Rehabilitation, or California Prison Health Care System.

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Dealing with the Risks of Medical Imaging Advances in radiology are invaluable — and fascinating — but the radiation exposure can be more than trivial.

By Nathan Hitzeman, MD Don’t get me wrong. As a family doctor, I think radiology is fascinating. As a medical student and resident, I relished field trips to the radiology department to see elusive diagnoses exposed on film. Now with electronic records and online radiology results, I enjoy toggling through online CT scan images from the convenience of my computer and dragging a “virtual” magnifying glass over suspicious infiltrates on chest films. Patients, of course, enjoy the technology, getting results, and having their problems taken seriously.

Risks and Benefits However, I am increasingly called upon to weigh the risks and benefits of medical interventions for my patients — whether it be checking a PSA, prescribing warfarin, or discussing hormone replacement. Two recent studies in the New England Journal of Medicine have given me pause about my radiological prescribing habits.1,2 The following is a review of these studies and suggestions for ways we can decrease radiation exposure for patients. In their 2007 study, Drs. Brenner and Hail examined epidemiological data from atomic bomb survivors and from 400,000 radiation workers in the nuclear industry to estimate the cancer risks from CT imaging in the United States.1 The increased usage of CT imaging is striking: from 3 million scans in 1980 to over 62 million scans per year currently. An estimated 6–11 percent of scans are being done in children, often to rule out appendicitis.

The organ radiation dose from an adult abdominal CT is 10 millisieverts (mSv) whereas that from a single chest film is 0.01 mSv. Hence, the radiation is 1,000 times greater. Brenner and Hail conclude that “there is direct evidence from epidemiological studies that the organ doses corresponding to a common CT study (two or three scans, resulting in a dose in the range of 30 to 90 mSv) result in an increased risk of cancer. The evidence is reasonably convincing for adults and very convincing for children.” Moreover, the authors calculated that up to 1.5 to 2 percent of all cancers in the United States may be attributable to the radiation from CT studies.1 They cite a reference suggesting that up to 1/3 of CT scans are being done unnecessarily.3 Among the root causes of over-imaging may be the convenience of scans; their use in quick, defensive medicine; and duplication of work in a fragmented healthcare system with poor communication. They also cite surveys of emergency department and radiology physicians, a majority of whom answered that they did not believe CT scans increased the lifetime risk of cancer.4 I did not want to believe it. And reading the follow-up letter to the editor from a radiologist, others did not want to believe it either. Still, it was the reputable New England Journal I had read. I could not shake the image of someone sitting in a scanner and receiving the equivalent of 1,000 chest x-rays. I get a little anxious when my dentist wants

November/December 2009

The increased usage of CT imaging is striking: from 3 million scans in 1980 to over 62 million scans per year currently.

to take films and those are small fry doses! Still, time passed and I continued to enjoy my magnifying glass on my computer.

Newer Data

I have had patients come in asking for scans with undertones of, “If you miss something, doc, by not ordering this test, there will be consequences,” along with a story about a family member whose diagnosis was “missed.”

This year, in a retrospective cohort study, authors Fazel et al. examined claims data over a three year period on 952,420 nonelderly adult patients of UnitedHealthcare HMO.2 “CT and nuclear imaging [mainly myocardial perfusion scanning] accounted for 21.0% of the total number of procedures and 75.4% of the total effective dose” of radiation during this time period. With this large sample size, the authors conclude that approximately 4 million nonelderly adult Americans are subjected to cumulative radiation doses exceeding 20 mSv per year which they consider in the “high” level. In a table in the article, the highest doses of radiation per single procedure include myocardial perfusion imaging, CT chest angiography, and percutaneous coronary intervention — 15 mSv each, or approximately 700 chest films [these authors assigned a slightly higher dose of radiation to a plain chest film compared to the 2007 study]. One can only imagine the annual radiation doses in the Medicare population; perhaps researchers are mining that data as we speak. I had to lean back in my chair and take a deep breath after this article. I see so many patients get their annual “Cardiolyte” scan for atypical chest pain, or one or more CT scans of the abdomen for vague complaints. I have patients with small spots in their lungs who have serial CT scans ordered by their pulmonologist every several months for 2 years straight. How much is too much? I am not pointing fingers. Most patients and doctors mean well. They both want a timely diagnosis using the latest medical technology — and let’s face it, we live in an “immediate gratification” society where watchful waiting is becoming less acceptable. Furthermore, we all have stories of a surprise finding on imaging that ended up changing the management of a patient’s condition. Nevertheless, a certain

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adage from medical school still rings true in my head: 80–90 percent of diagnoses come from the history and physical alone. Despite many good intentions, there are some unfortunate forces at work that are contributing to the problem. I have seen ample duplication of tests done over the years due to my patients being “diverted” to other hospitals because our emergency department was full. I have had patients come in asking for scans with undertones of, “If you miss something, doc, by not ordering this test, there will be consequences,” along with a story about a family member whose diagnosis was “missed.” Direct consumer marketing of coronary calcium scoring and whole body scans is big business with no proven benefit over traditional risk assessment.5 Not only can they cause unnecessary worry with incidental findings, but they carry radiation risks. Lastly, well-meaning radiologists — who work in a field high in liability risk — often dictate “cannot rule out disease X, consider further imaging with study Y if clinically indicated.” As imaging has gotten precise down to the millimeter, we struggle to interpret the relevance of small and borderline findings.

Tips to Minimize Radiation As physicians, we took an oath to “first do no harm.” And while many may not agree on the magnitude of the harm of medical imaging and whether it outweighs the benefits, I think every physician would want to minimize radiation for themselves or their loved ones whenever possible. Here are some practical tips I have to inform patients of the risks of medical imaging and to order tests more responsibly. 1. Know the radiation doses associated with common procedures. Radiology centers often inform patients of this, but by then, patients have pretty much committed to having the test done. I have a macro on our electronic records that translates the radiation dose per procedure into “# of chest x-rays” and gives a baseline of how much background radiation a person gets from just living in the United States (3 mSv/

year) or taking a coast-to-coast airplane flight (0.03 mSv/roundtrip).6 My patients are often surprised by the amount of radiation involved and sometimes think twice about getting a test. These discussions enhance patient education and promote shared decision-making. 2. Take a good history and do a thorough physical. Writing a quick order for an imaging test can save time in our busy lives, but it may be doing a disservice to a patient when we could have taken the extra time to get that key history or to discover a surgical scar on exam that precluded the need to do imaging. 3. If the patient’s complaint is not urgent, try to obtain the old records or outside records. It is sad to think studies are duplicated because we cannot get our hands on records or because patients do not remember the details of previous studies. 4. Do not forget to use ultrasound/Doppler modalities and, when appropriate, more expensive magnetic resonance imaging (MRI), which have no harmful radiation. A stress echocardiogram rivals myocardial perfusion imaging in terms of predicting future cardiovascular events, and has the bonus of giving information on the heart valves.7 A renal Doppler for a nonobese patient is an excellent option for evaluating for renal artery stenosis. An abdominal ultrasound is good for evaluating many organs and should be considered as an initial imaging option to rule out appendicitis in children. 5. Use the d-dimer test more — even for patients you are sure need CT scanning. A recent article estimates that 25 percent of CT scans could have been prevented had a d-dimer been checked prior.8 In this study, the d-dimer had a negative predictive value of 100 percent, so it is incredibly valuable at ruling out thromboembolic disease when the test is negative. However, given the poor specificity of the test, for some very low risk patients, a falsely positive d-dimer can influence the provider to order the subsequent CT scan. Again, rely on the history and physical first and foremost. 6. Do not reflexively order a follow up study suggested in the radiologist’s dictation. It is your

patient, and you know the clinical picture better than anyone! Call the radiologist and discuss the situation. They are often happy to get some contact with the outside world, and they should be used as true consultants like any other specialist. If you do decide to do the suggested study, discuss the radiation doses with the patient that those studies would entail. 7. Do not forget plain films. They are quick, often do not need approval from insurance, have 1–2 orders of magnitude less radiation than CT scans, and can give useful information. A simple KUB can tell you if a patient’s suspected urinary stone will be too large to pass spontaneously. A KUB can also confirm constipation in children with periumbilical pain who were on their way to the CT scanner to rule out appendicitis. Good initial PA and lateral plain films of the chest can often reveal a diagnosis for chest pain/respiratory problems. 8. Be especially mindful of the radiation risks in children and reproductive age women. Even seemingly innocuous lumbar plain films expose the ovaries to the radiation equivalent of getting a chest film daily for an entire year.9 I can count on the fingers of one hand how often plain films on a young person with atraumatic back pain has revealed anything that would have changed my management, and current guidelines do not support this practice.9 I hope the above points serve as constructive and helpful guidelines. I love looking at medical imaging, and I respect my radiology colleagues who so adeptly navigate through the images and explain the findings. Yet, we need to be mindful of the risks of reflexively ordering tests. We should not order tests just because we can, or out of pure convenience, or because of patient pressure. Think of it this way: the Women’s Health Initiative data on hormone replacement decimated the market for HRT. This paradigm shift was based on a small excess risk of composite endpoints (19 out of 10,000 women over a 5 year period or 0.19 percent).10 Should not a theoretical 1.5–2 percent cancer prevalence from modern day imaging promote a little more

November/December 2009

Be especially mindful of the radiation risks in children and reproductive age women.

discussion and restraint? I would hope so.

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hitzemn@sutterhealth.org 1 Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007;357:2277-84. 2 Fazel R et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 2009;361:849-57. 3 Slovis TL, Berdon WE. Panel discussion. Pediatr Radiol 2002;32:242-4. 4 Lee CI et al. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 2004;231:393-8. 5 Bonow RO. Should coronary calcium screening be used in cardiovascular prevention strategies? N Engl J Med 2009;361:990-7. 6 http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray#3 7 Amici E et al. Usefulness of pharmacologic stress echocardiography for the long-term prognostic assessment of patients with typical versus atypical chest pain. Am J of Cardiol 2003;91:440-2. 8 Gupta RT et al. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol 2009;193:425. 9 Chou R et al. Diagnosis and treatment of low back pain. American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-491. [consensus guidelines] 10 Rossouw JE et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288(3):321-33.

Venezuela’s Medical Care and its Cuban Influence By George Meyer, MD I recently returned from participating in the 15th Venezuelan Congress of Internal Medicine on the island of Margarita, north of the mainland. I have become convinced through my travels that good doctors practice good medicine in every country. Some have more and expensive tools. The ones without expensive toys are as effective using the history and physical examination tools that we should be teaching our students. The Venezuelan medical education system is similar to that seen in most other countries. It is a 6-year program beginning after high school. Prospective doctors spend the first five years as students and on the wards in their schools. Then they do a sixth year rotating through internal medicine, surgery, pediatrics, and ob/ gyn (probably the equivalent of our subinternships). They also do an obligatory four months in rural medicine. After graduation they must do a year in rural medicine before they can get a license or go into a residency program. There have been 12 medical universities in Venezuela, which graduate anywhere from 2,000–2,500 students per year. This has always seemed to be enough graduates to care for the population of the country. However, recently there has been a downward trend in the numbers of residents entering, not just internal medicine, but most of the other important specialties in medicine. This downward trend started several years ago but hit a new low this year. Many graduates are emigrating to Spain, Portugal, the United Kingdom, and Canada. Only a couple of residencies were filled this year, one of which is plastic surgery. One only

need look at the young women in the country to understand why this is so. It has been said that, if a boy pays for his girl friend to have a breast augmentation, she often leaves him. (Is this like the saying that if a girl knits her boy friend a sweater, he leaves her?) Recently the government opened several new medical schools, with the idea that these graduates will perform community care similar to that practiced in Cuba. These schools are only half way through their 6-year curriculum, with the government planning to graduate 100,000 students by 2015. In the meantime, many Cuban doctors are giving care in the barrios, or poorer communities. Of about 10,000 doctors in the barrios, roughly 90 percent are Cuban. It appears the level of care may not be the same as that provided by traditionally trained Venezuelan doctors, and that the patients often go around those barrio doctors to the tertiary hospitals. Consequently the tertiary hospitals are overcrowded. I was told that at least a third of the Cuban doctors no longer practice in Venezuela, though I do not know the reason. The Venezuelan people are wonderful. The Chavistas — supporters of President Hugo Chavez — are easy to identify from their red shirts. (I avoided wearing my red “T” shirt while there). We tried to go to Angel Falls in Canaima (Paradise Falls in the new Pixar movie UP), but it was not in season and the cost was extremely pricey. I have seen some pictures of the National Park in Canaima, and it is an extraordinary place. geowmeyer1@earthlink.net November/December 2009

It’s Not About Me By David Gunn, MS III, UC Davis School of Medicine

So I wait, watching them. Watching them think, cry, and stare into space.

I don’t really feel as though I’m helping my psychiatry patients improve their lives, or even just feel better – because I’m not doing anything. I listen to what they tell me, imagine how that must feel, and react accordingly. I don’t talk — even when it’s tense — I just ride out the moment. I wait to see if they’ll trust me to go a little further with their feelings. They may just be figuring out what they’re feeling at that moment, for the first time. Maybe they haven’t even had an opportunity to get that deep into their thoughts until just that moment. So I wait, watching them. Watching them think, cry, and stare into space. And if they don’t come back to me, I keep my mouth shut, as much as I might want to give advice, or ask for clarification, or otherwise “prod” the conversation along. My first week in clinic I met a short Hispanic woman in her late fifties with a bleached blonde crew cut and a turgid face — and a long history of depression and psychosis. She was 7 months out from her 21 year-old son committing suicide. She was hearing voices, and had tried to hang herself with a belt. Obviously it hadn’t worked, and she was bringing herself in for help. After the intake, I recommended to my preceptor that we prescribe some antipsychotics. I made an appointment to see her again the following week. For the next two weeks her depression and psychosis persisted. Soon she became unable to sleep. We we’re trying everything we could think of, and still no sleep. The third week I decided I wanted to rule out bipolar and anxiety disorders, so I asked her some screening questions. She opened up about how all she does is worry about her life,

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her family’s life, their past, her brother’s failed life, her son’s suicide, her role in it, on and on and on. She said all she thinks about is how horrible her life has been, about all the terrible things that have happened to her and her family, and how she worries about what the next horrible thing is going to be. I kept silent, and she kept crying. She remarked at how she’d never thought about all this before. She seemed honestly shocked and surprised at herself, at having never thought about this giant miserable part of her life. She gave me a quick glance, and started to repeat parts of what she had just said, so I went out on a limb and spoke. “If you don’t try and find something positive in your life to look forward to, to enjoy for the future, you’re going to end up with a life full of negative memories.” Her eyes opened a little wider. “I hadn’t thought about that before, but you’re right,” she said. I tried not to get excited, and thought this was probably going to just be an empty realization that wouldn’t actually change behavior, as is so often the case. We wrapped up the meeting shortly thereafter. She came in my last week on service, and we had our talk about how her week went, how her meds were, what her symptoms were. When I reminded her that this would be the last week that we saw each other, she said that I really helped her. ”Really?” I tried not to sound too surprised. I didn’t want her to think I didn’t think she was better. “Would you mind telling me what I did, because as a student I’d really like to know what I am doing right.” “I’m really going to miss you. You aren’t like the others. You listen. You care. I can see it on

your face. You let me talk and don’t rush me like the other doctors did. It really helped me.” Now that’s the thing about helping people. Usually you are an active participant. You are consciously acting, and that action has a positive effect on someone. That effect shows us we can make a difference — that we can manifest our will. Sure, we enjoy seeing the positive effect on others, but there is also pleasure in seeing the effects of our actions in the world and on people. But in this case my will was pretty ”won’t.” I was consciously acting, but my action was inaction. If we’re not acting, then are we making a difference? And if we’re not making a difference, how can we feel good? Yes, I spoke, but that wasn’t what she recalled. She thought I was good because I listened. I was good because I did nothing. So why should I feel good if I haven’t done anything? How can I see my value to others if I am not actively doing? It’s true that part of my identity is tied up in expressing myself and affecting others. I’m tempted to believe that if I’m not doing, I’m not doing good. But I was doing good, she told me so. So how do I reconcile that dichotomy? I’m taking solace in knowing that her life was improved, and she sees it as a result of something I did. In this instance, I can attempt to recreate that positivity because she told me “specifically” what I did. But in other situations, I might not have that knowledge to take with me. What then? To be satisfied with my life, I either have to change what satisfies me, find a way to be satisfied without expressing myself, or go into another line of work. I like the idea of being content and happy with just the notion that I helped someone, without understanding how I helped them. It reminds me of trust and faith in God. I can’t understand God, just

as I can’t understand how I might help some people, but there is value in the attempt to believe that is real, even if I can’t understand it. Sometimes we’re successful in that attempt, and sometimes we’re left empty handed. There is value for me in that trust and faith. It puts my mindset in a better place, and I know that because of that attempt, I’m a happier person to be around. I have more love, joy, peace and patience. I am more kind, good, gentle and have more self-control. All through this attempt for trust and faith in something I don’t understand. So, I’ve accepted the fact that, really, it doesn’t have to be about me, as long as I’m helping people. Come to think of it, if I look at it that way, why does it have to be about me when people are irritated with me? Maybe I’ll think about that one the next time it happens.

I was good because I did nothing.

dgunn11235@gmail.com

November/December 2009

The Right Proposition for the Health Care Debate We are trying to make a 20th century analogue financing system work on a 21st century digital world.

By David J. Gibson, MD, and Jennifer Shaw Gibson The first lesion learned by any student matriculating into a debate class is the importance of the proposition. The proposition sets the parameters for the debate. The reason health care reform debate is faltering can be directly attributable to our not selecting the proposition more carefully. The proposition under debate is: “Be it resolved, the United States should guarantee health insurance coverage for all of its citizens.” The resulting debate has become progressively non-productive while generating misplaced acrimony. As a result, the Schwarzenegger/Nunez health care plan’s demise in California two years ago has now become a harbinger of events unfolding in Washington. In reality, we are trying to make a 20th century analogue financing system work on a 21st century digital world. Health insurance was designed to meet the needs of World War II era beneficiaries. Little has changed in the design of this product over the ensuing 70-years. This financing system has outlived its usefulness and no longer meets the needs of Americans today. The fundamentals of this analogue system can be summarized as follows. • The system drives health care inflation at a rate far beyond the rest of America’s economy and has done so throughout most of its existence. These trends are destabilizing government from the federal to the local level. • The system is based upon opacity — today, no one, not even your doctor, knows how

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much goods and services cost. The table on the next page, taken from a recent Mercer Survey, illustrates the pre-ordained arbitrary pricing that flourishes in an opaque contract based system.1 • The system does not account for individual beneficiary needs. All enrollees in a health plan are restricted to a contracted panel of doctors, hospitals and pharmacies. Furthermore, the medications available are restricted by an insurance company-derived formulary. None of this accommodates the individual needs of the patient. • The system drags productivity to unacceptable levels. Recent studies have shown that practicing physicians now spend up to a halfday per week or more of their office time filling out insurance company-generated forms. That represents approximately $72,000 per year in non-productive time for primary care physicians — who are already in short supply.2 • The costly medical management infrastructure, which employs an army of middle managers at the insurance company and provider levels, has demonstrated no economic value. Rather, their involvement in mediating health care has resulted in an arms race between payers and providers; sophisticated software is now used to game the system for maximizing reimbursements. With near universal agreement on the need to restructure the current health care financing system, how can we get the debate back on track?

The answer, change the proposition. The proposition we should be debating is as follows: “Be it resolved that the current system for financing health care in the United States should be replaced by a digital system that will meet the needs of society in the 21st century.” By changing the proposition, America’s system for financing health care would join the rest of our economy in leveraging the benefits of currently deployed information technology. The following represents but a few of the characteristics such a system would incorporate. • Real-time pricing and performance data will be available on every doctor, hospital, pharmacy, pharmaceutical product and durable goods in the market. Any individual selecting a good or service will have the same level of information available that is currently enjoyed throughout the rest of America’s economy. • Individual service and product providers will have the ability to update their pricing information as frequently as they deem advisable. Thus, provider pricing will be based upon their estimate of worth in a hyper-competitive spot market rather than upon yearly renegotiated discount contracts with insurance companies. • Health plans will enter the market by posting their maximal reimbursement schedules. • Insurance centric decision-making will devolve back to the individual patient and his/ her doctor. • Individual beneficiaries can choose any doctor, any hospital, any drug store and any pharmaceutical product based upon what the prior record for effectiveness with full knowledge of the financial exposure they will incur when choosing a provider or product priced above the fee schedule. • Mediation of health care transactions will likely migrate to financial services. The infrastructure for moving actionable information to individuals at the point of decision making does not exist within health care. Yet financial services routinely deliver decision supporting information over the internet or at your neighborhood ATM.

• Hundreds of thousands of non-productive insurance employees will no longer be needed. Product distribution and mediation will be internet based. Contract based provider panels will cease to exist. Pharmaceutical formularies will no longer serve any purpose. • Doctors, armed with the same pricing and performance data that their patients have, will be able to return to their preferred role of assisting the patient to make cost and performance based decisions rather than spending time in combat with insurance companies. This digital product is being introduced in Houston Texas. It will be priced 40 percent below similarly comprehensive existing product in the market. The reality, thus far not appreciated in the current debate, is that an informed consumer is the only force in the market than can rationalize pricing and discipline runaway cost trends. Informed consumers have driven dislocating restructuring within every other industry within our economy over the past two decades. We have the technology to arm the consumer. It is now time to recruit these consumers and harness the market force they represent. We need to stop using typewriters and incorporate digital management of data to finance health care going forward. djgibson@winfirst.com 1 http://www.pugetsoundhealthalliance.org/resources/documents/ Consumerism.032006.pdf 2 http://www.ama-assn.org/amednews/2009/06/01/bil20601.htm

November/December 2009

The reality, thus far not appreciated in the current debate, is that an informed consumer is the only force in the market than can rationalize pricing and discipline runaway cost trends.

Voices of Medicine The importance of words, two sides of dual practice, baby boomers’ role in health care, and questions about Congress and health care.

By Del Meyer, MD

Words Make a Difference

He said I had never been hungry.

Sonoma Medicine devotes the summer issue to Cross Cultural Medicine. This article, “Care in Translation,” is by Rick Flinders, MD. Don Felipe was one of the campesinos I got to know best during the two years I lived in South America. He was short and dark-eyed and was one of the wisest farmers among the new homesteaders on the Paraguayan subtropical frontier. One day as we were riding horseback to visit his parents in his native village, I made the mistake of saying I was hungry. He corrected me, saying that what I had was appetite, and that hunger was a term reserved only for those occasions when one had gone for two or three days without food. He said I had never been hungry. When we arrived in his parents’ village, we learned that little rain had fallen that spring and that the mandioca crop, his people’s staple food, had failed. His parents hadn’t eaten in six days. That, Felipe reminded me, was hunger. He made me promise that I wouldn’t forget the meaning of hunger when I returned to my own country. If so much can ride on the meaning of a single word, what are we missing in the daily exchange of language with our patients from Asia, Africa, Europe, Central America and South America? And even if we understand the language, what meaning do those words convey in the context of cultural differences that can splinter the meaning of such basic concepts as illness, health, life and death? We can barely agree on these terms inside our own medical and cultural paradigms. In this issue of Sonoma Medicine, we explore the reality and needs of cross-cultural medicine

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from a variety of experiences and perspectives… To review Dr. Flinders’ synopsis go to www. scma.org/magazine/articles/?articleid=407. The Table of Contents for the summer issue is at http:// www.scma.org/magazine/?vol=60&num=3 Dr. Flinders, a clinical professor of family and community medicine at UCSF, chairs the SCMA Editorial Board.

Why a Dual Practice? Philip R. Alper, MD, discusses “Should the Subspecialist be a Primary Physician?” in the San Mateo County Medical Association JulyAugust 2009 Bulletin. The provision of substantial primary care by specialist physicians is a uniquely American custom. Arguably, it has upgraded primary care and narrowed the often substantial quality gap between hospital-based specialty practice and office-based general practice that is common in other countries. However, any mention of the benefits of dual practice has been drowned out by allegations that, in the United States, we have too many specialists and not enough generalists — and the result is excessive costs. Internal medicine is the best example of a specialty that has blended a commitment to primary care with concomitant subspecialty practice. I comment on this situation having spent 30 years in the practice of general internal medicine with a subspecialty in endocrinology — principally thyroid disorders and diabetes. I value the subspecialty portion of my practice because it offers me intellectual stimulation, contact with colleagues, and the opportunity to do something “special” for patients.

There are trade-offs. For example, although endocrinology appeals to me greatly, I would hate to practice only endocrinology because I find the rest of medicine so fascinating. And whereas treating a wide range of patients enhances overall clinical acumen, it does narrow the scope of the specialty conditions that I feel qualified to treat. There are also compensations: By offering primary care to those endocrine patients whom I do follow, I see more of them and put their specialty problems in better perspective. How does my interest in a subspecialty disqualify me from effectively taking responsibility for their overall health?… To read the entire article by Dr. Alper, go to http://www.smcma.org/bulletin/issues/BULLETIN09JulyAug.pdf

Health Care and the Baby Boomers John Kitzhaber, MD, Director of the Center for Evidence-Based Policy at Oregon Health and Science University, writes about “Health Care to Health: The Unfinished Business of the Baby Boom Generation—Part I,” in the Bulletin of the California Society of Anesthesiologists. His article is based on an earlier address, the full text of which is available at www.ohsu.edu/som/alumni. In this article, I would like to accomplish four things: impress on you the urgency of the growing crisis in our health care system, provide a context for why our current system is so dysfunctional, suggest what we need to do to fix it and discuss how you might assume a leadership role in meeting this challenge. Are you between 43 and 61 years old? We are the Baby Boom generation, the 30 percent of the U.S. population born between 1946 and 1964. Most of us are the children of those who weathered the Great Depression, served in the Second World War or who helped rebuild the world in its aftermath. They built our system of higher education, created the interstate highway system and the transmission grid, went to the moon, cured polio, eradicated smallpox and put in place the great social programs of the 20th century: Social Security, the GI Bill, Medicare and Medicaid. As a result, our generation has enjoyed more promise and more opportunity than any other generation in the history of our

nation. I want you to think about what our legacy is going to be — about the kind of world we are leaving to our children and grandchildren. And on our current trajectory it is not a pretty picture. Consider the fact that last year Congress voted to raise the statutory debt ceiling to accommodate a $10 trillion national debt. Do you know how much a trillion dollars is? The number is so staggering that it is impossible to comprehend without some frame of reference: A million seconds ago was last week. A billion seconds ago, Richard Nixon resigned the presidency. A trillion seconds ago was 30,000 BC. Our national debt now exceeds $9 trillion and is escalating even as the population ages. And while Congress is worried about Social Security, the real problem is Medicare. Social Security represents around a $5 trillion problem, but when the Baby Boom generation fully reaches the age of 65 — starting less than three years from now in 2011 — the unfunded entitlement in Medicare is estimated to be over $67 trillion. And we are financing this huge debt by selling securities to China and to other countries still willing to purchase them, not only threatening the fiscal stability of the American government and giving enormous leverage to some of our major international competitors (who at some point may simply refuse to continue underwriting U.S. deficit spending), but also casting a dark cloud of debt over our children’s future. If we fail to address this — if we fail to act boldly — this will be our legacy. We have been the major beneficiaries of the investments and sacrifices of the greatest generation and now it is our turn to give back, to ensure that we leave our children not a legacy of debt and degradation but a world of promise and opportunity and hope. How we meet this challenge will be the defining issue of our time. It is the unfinished business of the Baby Boom generation and it is inescapably intertwined with the future of the U.S. health care system. To resolve this crisis, two things are necessary. First, we need a shared vision, a set of agreed upon objectives that capture the desired purpose of the U.S. health

November/December 2009

And while Congress is worried about Social Security, the real problem is Medicare.

care system. Second, we need an accurate diagnosis of the underlying problem in our current system… Read the entire article at http://www.csahq.org/ pdf/bulletin/hlthcr_58_4.pdf

What is Congress Up To? Cynthia Bermann, MD, provides an “Update on Health Care Reform” in the September issue of Vital Signs, the journal of The Fresno-Madera and Kern Counties Medical Societies. The obvious subject this month is “what is the Congress trying to do?” The chimeric and rapidly growing legislation is morphing from providing health insurance for the uninsured to a complete overhaul of how medicine is provided. The proposals are changing so quickly that it is impossible in an editorial to address them in any kind of rational manner. I would like to instead take a step back and ask the following: If the goal is to cover ten to twenty million absolutely uninsured (as opposed to those between insurance, self-insured, or ineligible for coverage as a foreign national), does it make sense to change the way that the remaining 280-290 million citizens receive their health care?

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How can insuring the uninsured take over 1000 pages of legislation? Why would the government spend a dime (much less the millions of dollars actually being spent) on ADVERTISING to push for passage of a bill that is not even completely written? Given the failure of German, British, and Canadian experiments in health care, the failure of Tenn-Care and the Hawaiian health system, why as scientifically based physicians would we support repeating the same experiment? Would you want to receive care from a health system that Mr. Obama states would be the equivalent of the USPS as compared to FedEx? Here are the CMA points on WHAT WE MUST HAVE to continue to protect patients and provide excellent health care. Read them, consider them, and tell your elected representatives what they must do to prevent the devolution of health care in the United States of America… Read more of Dr. Bermann’s comments http://www.fmms.org/index.php?id=148 DelMeyer@MedicalTuesday.net

A Posit on Who Should Provide Primary Care “Subspecialists are qualified to provide primary care.”

Results: Agree - 52: Disagree - 35: No Opinion - 1 Comments - 32. While the Family Practice Board Exams make it clear that the practice of primary care requires a defined scope of expertise and ongoing training with periodic recertification, a majority of responders to this posit hold that almost any physician can be a qualified primary care specialist. That assertion raises some questions: Is primary care a specialty? And, can many non physician professionals who have access to online medical information and telemedicine consultation also be qualified providers of primary care? — J.L. For another view, see the Voices of Medicine article on “Should the Subspecialist be a Primary Physician?” by Philip R. Alper, MD, on page 22 of this issue. Someone trained in-depth in a limited area is not very likely to know the latest care guidelines for other [medical problems]. — Hal Renollet, MD (Agreeing) Just as a pediatrician should be allowed to provide the types of service the subspecialist gives if he/she was trained to do so, e.g., give allergy shots, as I did. —Dennis Marks, MD A subspecialist can be a primary physician if they take care of the WHOLE patient, including health care maintenance. In my opinion there are few subspecialists who really want to do this, so few would qualify. — Darin Latimore, MD I disagree with the posit because of the feedback I have gotten from subspecialists working

in the free clinics as a student. Often, subspecialists appear uncomfortable dealing with primary care scenarios as they are out of practice. If subspecialists continued their primary care provision after residency, then, of course, it seems appropriate that they provide primary care to their patients. However, currently, many subspecialists do not provide primary care, and as such they may not be up to date on the skills and knowledge appropriate. — Srihari K. Namperumal, MS II I think the older generation of subspecialist is still very good about providing care. On the other hand, most of the new generation of subspecialist cares only about their respective specialty. — Vong Lee, MD I think we are capable of providing primary care, but we are more effectively used as specialists — especially at Kaiser where there are more services available to the primary care doctors. — Barbara Livermore, MD Subspecialist training is too narrow for good primary care. — Norman Eade, MD The information explosion over the past 25 years makes it impossible to practice top quality general primary care. That is why I limit my practice exclusively to my specialty. — William Bargar, MD Is the endocrinologist up to date on primary care issues — preventive care, cancer screening, etc., and can he/she work well with the other subspecialists? If so, he/she may be able to do both, but it is hard to do them both well. — Thomas Curran, MD Not all subspecialists make good primary care physicians. An internist with primary care experience who wants to do both — that’s fine. November/December 2009

Subspecialist training is too narrow for good primary care.

Many subspecialists have continued to practice primary care as part of their practice and should continue to do so.

But a subspecialist that hasn’t done anything but his or her subspecialty for quite some time, is not going to make a good primary care doctor. Many OB-Gyns try but are not terribly successful, at [providing] primary care for their patients. Family Practice is a specialty for a reason — it is not something that anyone can just dabble with without the training. — Joanne Berkowitz, MD As volunteer medical director of Clinica Tepati, a student-run free clinic serving local indigent Latino population, I am fortunate to work with both primary care and specialty physicians who volunteer their time each Saturday. My experience with specialists treating bread and butter problems like diabetes and hypertension in this population has been very positive. I think they gain an appreciation for the various ways to manage and finesse basic chronic diseases, and they often educate me on their area of expertise. As a Sutter physician, I am able to electronically communicate with specialists using EMR to bounce ideas back and forth.— Nate Hitzeman, MD Most subspecialists I work with are not keeping up the clinical literature to take care of the wide breath of problems seen by primary care physicians. — Dineen Greer, MD If a subspecialist began their training in internal medicine and specialized beyond that, they have the skills and knowledge to care for patients as a primary care giver, providing they have appropriately maintained their basic skills and medical education. Obviously, a surgical sub-specialist would not qualify for primary care because their foundation was not there. — Donald Hause, MD …Cognitively subspecialists are qualified to provide general primary care. However, most subspecialists do not have the appropriate systems in place to be able to deliver primary care. — Rajan Marchant, MD This certainly depends on physician comfort level. While some physicians enjoy and excel at mastery and treatment of a broad spectrum of issues including primary care, there are those who have chosen a subspecialty specifically because they prefer to narrow their scope and

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excel in a limited area. Therefore, some subspecialists ARE and some ARE NOT qualified to provide primary care. — Holly J. Haight, MD (Disagreeing), Especially when subspecialties are [not general] medicine, pediatrics, obgyn etc. — Frank A. Brown, MD The problem is that not all specialists want to or are capable of doing this. Plus, if you are already extremely busy, who has the time? — Paul A. Bilunos, MD (Agreeing)…[Provided] they finished an Internal Medicine residency before fellowship. — John Wiesenfarth, MD [I disagree] with a few exceptions. — Allan Galbreath, MD I think a subspecialist can provide primary care if he or she has been keeping up that part of their profession. How much time [is required]… in primary care versus subspecialty is hard to say to keep up with both. There are Med-Peds residency programs that emphasize both internal medicine and pediatrics so you have to be good in both in private practice. — Henry Kano, MD (Agreeing) If…their main training is in a field qualifying as ”Primary Care”.... The new Health Care Bills will sort this all out! — James Farley, MD An Internal Medicine trained subspecialist should be able to provide high quality primary care so long as the subspecialist has kept up with medicine outside the subspecialty area. Given the shortage of primary care physicians, encouraging such a practice would be beneficial. — Mark Blum, MD I agree, but after doing it for twenty years I am happy to be out of that business. — James Brode, MD Many subspecialists have continued to practice primary care as part of their practice and should continue to do so. Many subspecialists do not continue in primary care and have lost that skill. Often, patients with significant subspecialty problems, such as cancer or heart failure, do not need to see a primary care physician as their specialty problem is overwhelming, and the limited primary care they need can be provided by the specialist. As with most of medicine,

there is no one size fits all. — William Lewis, MD As a child psychiatrist, I have always felt that I needed to be sure that there were no medical problems causing or worsening my patients’ psychiatric symptoms and to make sure they are medically clear. I also have felt comfortable in providing primary care for relatively simple medical problems that my patients have, in most cases contacting the pcp about my findings and interventions or referring them for an urgent visit with them. — James Margolis, MD Occasionally taking care of muscle aches or flu symptoms is OK, but for a subspecialist to offer the full scope of primary care would just make it more difficult for others to get in to [see] that subspecialist and…over the long haul, decrease the quality of care. — Jose Cueto, MD This depends on the training and experience of the subspecialist. A good internist, who has taken a fellowship in endocrinology, may have the necessary skills and experience to do a good job, but that would limit the number of consults he would be able to do. So, this would likely only work professionally if he lived in a relatively rural area where he did primary care for some, and did all the endocrinology for the area. — Richard Gray, Jr., MD Internal medicine subspecialists have all been trained in general internal medicine. Most should be able to be successful primary care doctors. — George Meyer, MD With a brush-up course specialists could do general medicine. After all, we all started there. However, you might feel a little concerned as you watched an ophthalmologist getting scrubbed up to do an appendectomy on you! — Byron Demorest, MD As an internist with a subspecialty, you should be able to practice primary care. — Richard Murray, MD Subspecialists are qualified to provide primary care. — Del Meyer, MD Not all subspecialists like or choose to provide primary care. — Maria Caparas, MD

SSVMS Election Results 2010 Board of Directors President: Stephen F. Melcher, MD President-Elect: Alicia Abels, MD Immediate Past President: Charles H. McDonnell, III, MD District 1, North: Robert Kahle, MD District 2, Central: Jose Arevalo, MD, Michael Flaningam, MD, Michael Lucien, MD District 3, South: Bhaskara Reddy, MD District 4, El Dorado County: Demetrios Simopoulos, MD District 5, Permanente Medical Group: John Belko, MD, David Herbert, MD, David Naliboff, MD, Robert Madrigal, MD, Anthony Russell, MD District 6, Yolo County: J. Dale Smith, MD 2010 CMA Delegation District 1, North: Jon Finkler, MD, Delegate; Robert Kahle, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Margaret Parsons, MD, Alternate District 3, South: Barbara Arnold, MD, Delegate; Katherine Gillogley, MD, Alternate District 4, El Dorado County: Ronald Foltz, MD, Delegate; Demetrios Simopoulos, MD, Alternate District 5, Permanente Medical Group: Elisabeth Mathew, MD, Delegate; Boone Seto, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Karen Hopp, MD, Alternate At-Large, Office #7: Alicia Abels, MD, Delegate; Mubashar Mahmood, MD, Alternate At-Large, Office #8: Stephen Melcher, MD, Delegate; Gerald Upcraft, MD, Alternate At-Large, Office #9: Norman Label, MD, Delegate; Robert Forster, MD, Alternate At-Large, Office #10: Satya Chatterjee, MD, Delegate; Reinhardt Hilzinger, MD, Alternate At-Large, Office #11: John Ostrich, MD, Delegate; Alternate (Vacant) At-Large, Office #12: Kuldip Sandhu, MD, Delegate; Rajan Merchant, MD, Alternate At-Large, Office #13: Earl Washburn, MD, Delegate; Ulrich Hacker, MD, Alternate At-Large, Office #14: Charles McDonnell, MD, Delegate; Robert Madrigal, MD, Alternate At-Large, Office #15: Richard Jones, MD, Delegate; Connie Mitchell, MD, Alternate At-Large, Office #16: Richard Gray, MD, Delegate; Anthony Russell, MD, Alternate At-Large, Office #17: Janet O’Brien, MD, Delegate; Alternate (Vacant)

November/December 2009

SPIRIT is the Sacramento Physicians Initiative to Reach out, Innovate and Teach. Our mission is to engage volunteer physicians in the delivery of quality, compassionate medical care to the uninsured so that they may lead healthy and productive lives. Established in 1995, SPIRIT was designed to offer physicians innovative ways to improve the health of Sacramento residents through education and access to services. SPIRIT is proud to offer a new volunteering option. We have been asked by The Effort to help them find volunteer physicians to care for their patients. We are looking for primary care physicians, podiatrists, orthopedic physicians, and GI specialists. The Effort opened the doors of its Free Clinic in downtown Sacramento in 1970 and has grown into a full-service Community Health Center with integrated medical and behavioral health services. The Effort serves the uninsured, indigent, working poor, and homeless. The major health care needs that The Effort addresses are: improved access to care; preventive care; and effective treatment of disease. SPIRIT and The Effort seek physicians interested in donating (at least) one four hour shift per month to provide primary care services. The Effort will provide support staff and liability coverage for SPIRIT volunteer physicians at their clinics. The Effort currently has three locations, The Effort Community Health Center on J Street, the Birth and Family Health Center on Marysville Blvd, and the new Oak Park Community Health Center. In addition, The Effort has plans to open two additional locations, one at Calvine and Highway 99 and one in North Highlands in the near future. If you are interested in this volunteer opportunity or have questions, please call SPIRIT Program Manager, Kris Wallach, at 453-0254. Your neighbors right here in Sacramento County need your help!

â&#x20AC;&#x153;Physicians donating expertise to the communityâ&#x20AC;? The SPIRIT Project is part of the Community Service, Education and Research Fund (CSERF), a 501(c)(3) non-profit organization that exists as a vehicle to involve physicians in their community. CSERF is a collaborative effort of the Sierra Sacramento Valley Medical Society, Kaiser Permanente, UC Davis Health System, Mercy Healthcare Sacramento, Sutter Medical Center Sacramento/Sutter Medical Group, and Blue Shield of California Foundation.

5380 Elvas Avenue, Suite 219 * Sacramento, CA 95819 * (916) 453-0254 * (916) 453-0256 fax

Book Review

1491 By John Loofbourow, MD 1491: New Revelations of the Americas Before Columbus. By Charles C. Mann, 2005, Vintage, ISBN -10:I-4000-3205-9, 541 pages. Based on extensive objective evidence from the last few decades, the author makes a solid and well documented case that our common concept of the Americas before ”discovery” is hugely erroneous. For example: • The population of many pre-Columbian cities in several areas other than the Maya, Inca, and Aztec, was greater than that of Europe at the time of Columbus. • The inhabitants were usually taller, more hygienic, and healthier than the colonists or conquistadores. • Almost everywhere, the pre-Columbians actively managed their environment — the land, the animals, birds, estuaries, and forests. They burned the forests and grasslands to promote feed and to clear land for farming. They managed game aggressively over millions of acres of land.1 In North America, after the ”Indians” were ”discovered,” and decimated or conquered, the environment which was then no longer managed, changed radically. The open East coast forests retook the land. The deer, antelope, bison and carrier pigeon populations exploded. • During millennia beginning as early as 3500 BC, Pre-Columbians developed the majority of all crops under cultivation in the world today, including corn (maize), all of the squashes, many varieties of beans, peppers and potatoes, tobacco, tomatoes, cotton, peanuts, manioc. Almost all were the result of long cultivation and selection, as were wheat and rice in Eurasia. How corn was developed is still not understood; it is entirely dependant on people because it cannot readily self-propagate. The list of medically active natural material and of domesticated fruits is too long to include here. • Many pre-Columbian civilizations were

skilled in astronomy, writing, and mathematics, including the concept that zero is different from nothing, something that eluded Europeans until the Renaissance. • There were no native ungulates, but the pre-Columbians domesticated the llama, alpaca, vicuna, many birds, and animals including the guinea pig (cui), and hairless edible dog. • They inhabited large regions where the flora and fauna were aggressively managed. These included: the eastern U.S. from the coast to the Appalachians; Florida; Central Mexico; Southern Mexico; Central America; the northeast coast of Brazil; the entire Amazon River basin; the Bolivian and Peruvian altiplano; the entire coast of Peru; and the Serengeti-like flood plains of Eastern Bolivia where there are still hundreds of man-made raised platforms, presumably constructed for farming or living when the land was under water. • When the indigenous Americans were conquered, or decimated by disease, the native flora and fauna took over explosively. For example, when the area of the great mounds near modern St. Louis were first explored by Ponce De Leon, there were many lakes; the natives numbered in the hundreds of thousands, so fierce, haughty, derisive, and hostile that the frightened conquistadores passed by as quickly and quietly as possible. There were few bison. The next large expedition about 70 years later found the place completely abandoned, but inhabited by huge herds of bison. Why? Very likely the people fled from the real conquistadores — foreign microbes and viruses — and the bison population exploded as a result. An almost identical history is repeated over and over and over again in the Americas. • It seems clear that neither gunpowder nor horses nor steel had much to do with the conquest except in the first few days, when they November/December 2009

The inhabitants were usually taller, more hygienic, and healthier than the colonists or conquistadores.

were strange and frightening. Slow-firing, slow– loading, single shot-muskets or pistols, or steel swords and armor, are no match for hundreds of bows and arrows fired from behind cover; the Araucanos, for example, perceived that, and are only now being conquered bythe attractiveness of modern conveniences. • The same microbial conquistadores were even more lethal than the barbarous cruelty of the Spaniards. Smallpox, for example, made it possible for the English colonists to subdue the natives of the East coast of the U.S.; smallpox also invaded the Incas before Pizarro, having traveled among natives arriving from the north. • Whoever has traveled the Sacred Valley of the Peruvian highland from Lake Titicaca to Cuzco sees thousands on thousands of miles of terraces once irrigated and used for farming. These predate the Inca, evidence of a civilization and many generations who built them. Mr. Mann’s assertions are in sharp contrast to what is still often assumed by the world, and taught in our schools; the findings contradict our view of the American past as a virgin land populated by primitive people who, with few exceptions, lived a nomadic existence in a passive, and reverent, harmony with a timeless and unchanged environment. While this imagined pristine world is one we tend to admire and aspire to recreate, it should not be mistaken for the truth. Mann is not the first author to present these facts, or the conclusions that can be made from them, but he brings them together in a readable and gripping account that can be easily enjoyed by the non-academic reader.

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

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If you are unfamiliar with this material, read his book. It may change your understanding about whether one hemisphere or civilization is ”new” while the other is ”old”; or make more palatable the charges and claims of indigenous North, Central, and South Americans; it can help rationalize the racist-sounding holiday of Latin Americans, Dia de La Raza, (Day of the Race), and help explain why the preservation of Native Cultures is written into the enumerated specific goals of the Mexican Constitution. Lastly, while I will not try to make the case here for lack of space, I believe that when one civilization is conquered by another, the former doesn’t just disappear; it remains, permanently imprinting and shaping the culture that follows. This author helps to explain why the Americas are neither Europe nor Asia, but unique to ourselves. He suggests that we have discovered the Pre-Columbians and they are us!2 john@loofbourow.com 1 I recently returned from a week in the incomparable Chihuahua/ Sonoran desert. The hillsides there often show rough, man-made terracing to slow rain runoff, promoting growth of native plants used for food, fiber, and fuel. 2 Disclosure: My father’s parents were both formally adopted members of the Concow tribe, a branch of the Maidu. Only a few traditional Concow are left today in Round Valley where tribal remnants were confined in 1863.

CMA’s Legislative Wrap-Up By Dustin Corcoran, CMA Senior Vice-President This is the introduction to the California Medical Association’s summary of this year’s state legislation. For details on individual bills of interest, visit the CMA website, or view this article online at ssvms. org. California has perhaps replaced Wimpy as the most famous example of borrowing against the future to address today’s appetite. This year marked another significant erosion of California’s financial situation, forcing the Governor and legislature to grapple with a multi-billion dollar budget deficit. Political observers surely felt that Sacramento had fallen into a time-warp as partisan bickering over-shadowed problem solving leaving Californians to endure another historically late budget. Other pressing matters including prison reform, water shortages, and California’s ever increasing number of uninsured took a back seat to the budget deficit. In 2008 the Governor signed two separate budget accords that were supposed to solve California’s budget woes. Those deals proved to be badly out of balance almost immediately after they were signed. Facing a $40 billion budget deficit, legislators were forced to reconvene in early 2009 and pass a new budget that supposedly would keep California solvent through 2010. That budget contained $15 billion in cuts, $12.5 billion in new taxes, $7.8 billion in federal stimulus money, and $5.4 billion in borrowing. That budget also fell short, causing the state to face a $21 billion deficit by July 2009. The continual focus on the budget and the ongoing need to make massive cuts or find new revenues paralyzed lawmakers for months. Democrats refused to consider any additional cuts and Republicans were equally adamant that they would not support any new taxes.The partisan stalemate forced California to start the new fiscal year on July 1st without a balanced budget

in place. Many thousands of state workers and businesses that contract with state went unpaid, hospitals were left without reimbursement and some patients lost their state-provided health insurance while the Governor and legislators continued to feud over a solution. Finally, on July 28 Governor Schwarzenegger signed a new “balanced budget” that primarily relied on massive cuts and billions in borrowing to fill the deficit. But even that budget is now $4 billion in the red as California’s economy continues to struggle and next year’s budget deficit may exceed $10 billion based on current estimates. It is very likely that the legislature will once again have to take mid-year action to address the deficit now and in the future. To make matters worse, the Governor continued his well worn pattern of veiled threats toward legislators for their failure to act on issues such as the budget, water and prisons. The Governor used a variety of methods to try to force legislators to act. At one point the Governor sent Senate President Pro Tem Darrell Steinberg (D-Sacramento) a bronzed sculpture of bull testicles insinuating that the legislature needed a pair. Not surprisingly, Steinberg and other legislators were not amused. By the end of the legislative session the Governor threatened to veto all legislation sent to him until lawmakers sent him a water deal he found acceptable. That threat caused considerable consternation among Republicans and Democrats alike. Ultimately, the Governor backed off from his threat and acted on the bills before him. The continuing strain between the legislature and the Governor does not bode well as major problems facing the state continue to loom. Is it any wonder that the Field Poll recently found that both the Governor and legislature suffer from historically low approval ratings of 27% and 13% respectively? The only November/December 2009

The continual focus on the budget and the ongoing need to make massive cuts or find new revenues paralyzed lawmakers for months.

Not a single bill we opposed made it to the Governor and every scope bill was defeated in their first committee.

Governor with lower approval ratings than Schwarzenegger was Gray Davis, the man that Schwarzenegger replaced through a recall election in 2003. For CMA, it was another busy year. State budget cuts consumed many hours of hard work as we worked to defend the already abysmally low Medi-Cal reimbursement rates. Ultimately CMA’s Center for Legal Affairs was forced to sue the state to block the Governor’s attempts to reduce rates by ten percent. Fortunately, the court found in favor of physicians and ordered an injunction against the state prohibiting implementation of the cuts. In the Legislature we faced fights difficult and sometimes ugly — fights over scope of practice, peer review, the bar on the corporate practice of medicine and rescission of insurance policies. Fortunately, CMA was able to defeat every bill that we opposed. Not a single bill we opposed made it to the Governor and every scope bill was defeated in their first committee. The pharmacists, nurse practitioners, and physical therapists all pursued scope of practice expansions this year. Pharmacists attempted to get legislative approval to administer vaccines directly to patients without a physician protocol. That bill was overwhelmingly defeated. The nurse practitioners finally abandoned their efforts to establish independent practice and worked proactively with CMA to provide greater

Medical Care in Nepal — a Medical History Lecture in January The Hospital at the End of the World is the story of an American RN’s trip to teach nursing in Nepal. Many nurses and doctors dream of such an experience, but Joe Niemczura lived it in 2007. His book reveals the details of bedside care, the various patients, the challenges, and, of course, the spiritual mystical land, people, and culture of the Himalayan foothills. His presentation at 7 p.m. on January 7 is part of the Sierra Sacramento Valley Museum of Medical History lecture series, and features a slide show, interactive props, a question and answer period, and book signing. For more information, go to the FaceBook fan page for the book and search by title. The lecture is free and open to the public, and will be at SSVMS, 5380 Elvas Avenue. Seating is limited; call (916) 452-2671 to reserve space.

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clarity to their practice protocols. The physical therapist legislation proved to be the most contentious scope bill of the year with their legislative staff asserting that physical therapists were more qualified to diagnose patients than physicians. Needless to say that argument did not carry the day and the bill was soundly rejected. This year the fight to preserve the prohibition on the corporate practice of medicine was difficult to say the least. Three bills were introduced to destroy or undermine the corporate bar and allow for the direct employment of physicians by hospitals. Both the California Hospital Association and the American Federation of State, County and Municipal Employees union sponsored measures to take direct control of physicians through employment. The bills were passed out of the Assembly but were defeated in the State Senate. Both organizations have made it clear that they intend to pursue their efforts next year so the fight will continue. CMA sponsored several bills and ultimately three made it through the legislative process and to the Governor. The first bill, AB 2, would have prohibited insurance companies from rescinding a patients insurance policy without proving that the patient intentionally misled the company when they sought coverage. Unfortunately, this bill was vetoed by the Governor. Our second sponsored bill which would have made needed changes to the peer review system was also vetoed. The Governor did sign our third sponsored bill, SB 606, to expand the Steven M. Thompson medical school loan repayment program to provide additional funding to physicians willing to practice in underserved areas. Overall it was another year that was lost to the budget morass that the State continues to find itself in. It is likely that the final year of Gov. Schwarzenegger’s term will again be dominated by budget deficits. The projected $10 billion shortfall will be extremely difficult to address since the state is out of easy or politically acceptable means of bridging the gap. Perhaps Wimpy will take Minerva’s place on the Seal of the Great State of California.

Board Briefs October 12, 2009 The Board: Voted to support the CMA Resolution by the American Lung Association-California (ALA-C) on Smart Growth and Air Pollution Reduction. Approved retiring the Membership Committee at the end of 2009. The Committee has functioned over the years as a credentialing committee, largely to assure that membership is not granted to physicians with serious issues with their license or other practice-related problems. Staff now has online and other resources available to check and verify credentials for all potential members. The Executive Committee will consider any concerns that arising about a potential member, and the Board of Directors will continue to approve all requests for membership. Approved the Membership Report: For Active Membership — Parminder S. Deol, MD; Maruja D. V. Diaz-Arjonilla, MD; Matthew W. Guile, MD; Hieu Huynh, MD; Joseph A. Karam, MD; Jay H. Lai, MD; Rajan K. Merchant, MD; Yuri Reznik, MD; Mohammed A. Shaikh, MD; Kevin A. Vu, MD; Melissa J. Williams, MD; Kidist K. Yimam, MD. For Reinstatement to Active Membership — Sherellen B. Gerhart, MD. Serving as the Administrative Board to BloodSource, the Board approved the following 2010 slate for BloodSource Board of Trustees and Executive Committee: Board: Esther Aw; Chris Ann Bachtel; George Chiu, MD; Brenda Crum; Angelo De Mattos, MD; Donald Delach; Diana Dooley; Robert Forster, MD; Sherri Kirk, Esq.; Harry Lawrence, DDS; Keith McBride, Esq.; Anthony J. Nasr, MD; Mervin O’Neil, MD; Margaret Parsons, MD; Paul Rosenberg, MD; Larry Salinas; Gerald Simon, MD; Glennah Trochet, MD; Michael Ueltzen, CPA: Jeff Van Gundy, MD.

Executive Committee: George Chiu, MD, President; Keith McBride, Esq., Vice President; Paul Rosenberg, MD, Secretary-Treasurer; Harry Lawrence, DDS, At-Large; Anthony Nasr, MD, At-Large; Margaret Parsons, MD, At-Large; Michael Ueltzen, CPA, At-Large.

September 14, 2009 The Board: Approved permitting Board members, officers and staff to use their SSVMS titles in Dr. Richard Pan’s campaign materials for State Assemnbly if so requested by Dr. Pan. Approved the 2009 Second Quarter Financial Statements and Investment Reports. Approved 2009 grants from the William E. Dochterman Medical Student Scholarship Fund to Monika Mehrens, 3rd year student at Western University of Health Sciences; Kelly Quinley, 2nd year student at the University of Pennsylvania School of Medicine; Aimee Skinner, 1st year student at Kirksville College of Osteopathic Medicine; and Diana Sepehri, 4th year student at Touro University College of Osteopathic Medicine. Approved the Membership Report: For Active Membership — Shirin M. Ahmad, MD; Hemal G. Amin, MD; Ashis V. Barad, MD; Stanley M. Batiste, MD; Florence B. Chong, DO; Catherine E. Dycaico, MD; Jonathan A. Eandi, MD; Mark J. Heller, MD; Jaivant K. Rangi, MD; David J. Ritter, MD; Soucheun Saechao, DO; Michael A. Taylan, MD; My-Le To, DO; Neelima G. Vallurupalli, MD; Maaya A. Wilton, MD. For Resident Membership — Rocky P. J. Jedick, MD; Lynn Yen, MD. For Reinstatement to Active Membership — Mark B. Horton, MD; John H. O’Neal, MD; Paul J. Rosenberg, MD. For a Change in Membership Status from Active to Multiple — Troy Falck, MD. continued on next page

November/December 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 Baladjay-Lindley, Lesley J., DO, Family Medicine, Touro University College of Osteopathic 2006, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-2188

Karam, Joseph A., Surgical Critical Care, Jefferson Medical College 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6474

Phan, Hannah J.G., Pediatrics, Oregon Health & Sciences University 2006, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-5090

Brekken, Raquel R., Pediatrics, UC San Diego 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060

Kumar, Neel R., Emergency Medicine, Albert Einstein College of Medicine 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651

Prentice, Anne M., Vascular Surgery, Albany Medical College 1994, Sutter Medical Group, 2800 L St #260, Sacramento 95816 (916) 733-9556

Chan, Thomas K-P, Internal Medicine, UC Los Angeles 2006, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6464 Chiu, Christopher K., General Surgery, Drexel University 2004, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4144 Chun, Trissy M., Emergency Medicine, John A. Burns/University of Hawaii 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Deol, Parminder S., Radiology, Pondicherry University, India 1994, Mercy Radiology Group, 3291 Ramos Cir, Sacramento 95825 (916) 363-4040 Foskey, Matthew R., DO, Emergency Medicine, Philadelphia College of Osteopathic Medicine 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Fung, Rebecca Y., Pediatrics, Medical College of Ohio 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060 Hou, Lewis C., Neurosurgery, Stanford University 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490 Iovettz-Tereshchenko, Nadia S., Emergency Medicine, Tulane University 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Jones, Melissa M., Emergency Medicine, UC Davis 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651

Lai, Jay H., Family Medicine, Chicago Medical School 2006, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777 Lambourne, Lindsey A., Pediatrics, UC Davis 2006, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 747-7620 McNatt, Sean A., Pediatric Neurosurgery, University of Texas, San Antonio 1999, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 474-2303 Merchant, Rajan K., Allergy/Immunology, American University of the Caribbean 2000, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2600 Moreno-Hunt, Carey A., Perinatology/OB-GYN, University of Illinois 2002, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 474-2522 Oliver, Amy M., Emergency Medicine, Loma Linda University 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Parikh, Swapna R., Pulmonary/Critical Care Medicine, Poona University, India 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-4373 Peng, James S., Emergency Medicine, SUNYDownstate 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Phan, Andrew T., Pediatrics, Oregon Health & Sciences University 2006, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-5090

Shaikh, Mohammed A., Pulmonary/Critical Care Medicine, B.J. Medical College, India 1994, Pulmonary Medicine Associates, 77 Cadillac Dr #250, Sacramento 95825 (916) 325-1040 Sherman, Andrea B., OB-GYN, University of Pittsburgh 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4050 Tran, Hoang N., Orthopedic/Hand Surgery, Harvard University 1993, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2601 Trier, Darin A., Emergency Medicine, St. George University 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6651 Uy, Leo R., Internal Medicine, University of Santo Tomas, Philippines 1995, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4858 Vu, Kevin A., Internal Medicine, Ross University 2006, Mercy Hospital of Folsom, 1650 Creekside Dr, Folsom 95630 Vuddagiri (Kalla), Lavanya, Radiology, Guntur Medical College, India 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6150 Williams, Melissa J., Hematology/Oncology, University of Wisconsin 2001, Sutter Medical Group, 1020 – 29th St #680, Sacramento 95816 (916) 453-3300 Yimam, Kidist K., Internal Medicine, University of Nevada 2006, Sutter Medical Group, 1020 – 29th St #480, Sacramento 95816 (916) 733-3777

Board Briefs, continued from previous page For a Change in Membership Status from Active to Active 65/20 — Richard A. Murray, MD. For Retired Membership — Christine Fernando, MD; Martin Melicharek, MD.

Sierra Sacramento Valley Medicine

For Resignation — James Brumberg, MD; Jason Eberhart-Phillips, MD; Stephen M. Nagy, III, MD; Patricia A. Yost, MD.

A Bad Time to Make Momma Cry By Dennis Marks, MD “It’s old and beat up.” He grunted, While for the owner’s ears he hunted. “How much?” Pop asked, as she approached. “On the tag!” She in turn reproached. The fifteen dollars seemed high to me. Drab wood’s potential was hard to see. Four flights the crib went, part by part. And soon the redo Pop would start. Each end’s side had bowls with flowers. He sanded away for hours and hours. Soon he painted the wood all white, It turned the room from drab to bright. The bowls he painted golden brown. Then the flowers, one by one, with more colors than most florists show. Thus love and beauty we would know. As the ninth month came to a close, The labor pains their time now chose. Off to the hospital they went. Our hopes and prayers with them we sent.

I waited by the empty crib, For word of what Mom’s labor did. Would it bring us a girl or boy, to bring this old crib new joy? They took me to my mother’s bed. There I heard brother was born dead. No tears accompanied the news. To keep heartbreak hid from me they choose. I wandered from my mother’s room. To a nursery I came soon And stared at what was to be ours, Sleeping sound between the flowers. When I returned to see my mom’ She wondered from where I had come. “I was watching the babies sleep.” Into her eyes the tears did leap. So now I had new sadness seen. The flowered crib that might have been. I felt so bad I thought I’d die. A bad time to make Momma cry!

“Because of you, our holidays are much brighter.” Jaime Suarez, father of twin boys who are alive today by the gift of precious blood.

www.bloodsource.org

not-for-profit since 1948

“I’m able to hold these perfect little boys in my arms because the precious gift of blood, and the medical professionals to care for my twins, were there at the critical moment that saved their lives. As a father, you mean everything to me. Because of you, my boys are with me today. Yes, you do save lives.” Watch Jaime’s story at w w w. b l o o d s o u r c e . o r g / h o s t . h t m November/December 2009

Classified Advertising

OFFICE SPACE FOR LEASE Medical Office for Lease. 3,000 sq. ft. — all or sublease with another surgeon. Prime location at Mercy San Juan Hospital. Call (916) 802-2122.

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

POSITIONS AVAILABLE “FLEXIBLE SCHEDUALING OPPORTUNITIES: Provide Psychiatry, Internal Medicine, or Family Medicine in an interesting and dynamic environment. Competitive compensation as an independent contractor or employee. Please call: (800) 822-0686 for more information.”

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

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES

Electronic Claims

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

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

HOSPITALIST needed for Sacramento Area. Mercy and/or Sutter. This position will provide inpatient services to our large Medi-Cal/Healthy Families/Medicare patient base in Sacramento County. For more information contact: Matt Mengelkoch at (916) 612-4387. PART-TIME PHYSICIANS needed for OTC Medical Group (www.keepitoff.com). Openings in Sacramento, Davis, Roseville; one or more days/evenings per week. OTC is a comprehensive medically-supervised weightloss program without the use of pills or shots. Contact: John Hernried, MD (916) 978-0300 or email to: jhernried@keepitoff.com

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 Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

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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

Sierra Sacramento Valley Medicine

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