2010-Mar/Apr - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2010

The Galapagos Islands The photo of the huge tortoises, for which the Galapagos Island are named, was taken by Dr. George Meyer, a member of the SSVMS Editorial Committee. The other two photos were taken by Dr. T.W. Hard, of Santa Rosa, on an entirely different trip to the Islands. See Dr. Hardâ&#x20AC;&#x2122;s story on page 15.

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MEDICINE 3

PRESIDENT’S MESSAGE County Psychiatric Beds are Disappearing

BOARD MEMBER PROFILE Michael Flaningam, MD

Stephen F. Melcher, MD

A Posit on Email Communications

LETTER TO THE EDITOR Rage, Rage Against…

EMTALA — the Cornerstone of Health Reform

Topping God

BOARD MEMBER PROFILE David Herbert, MD

Board Briefs

A New Approach to Primary Care Shortages

Sebastian Conti, MD 13

EXECUTIVE DIRECTOR’S MESSAGE What Our Members Think

Bill Sandberg 15

An Update on Autism

F. James Rybka, MD

All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

Janelle Marshal, MS II

Here Be Dragons…

T.W. Hard, MD

New State Laws of Interest to Physicians for 2010

CMA Staff

Jim Hinsdale, MD 9

Voices of Medicine

Del Meyer, MD

34 35

New Applicants A Visit to Argentina

George Meyer, MD 36

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.

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SSV Medicine is online at www.ssvms.org/magazine.asp This image of the Chaetomium fungus is the second in a series of covers by pathologist Gordon Love, MD. Chaetomium is a mold spread by bodies known as perithecia, which float in the air and which may be large enough to be seen by the unaided eye. When they settle, they release spores (more accurately ascospores) which sometimes cause wound infections; a wound was the source of this photo. The mold digests cellulose, and is often found in the walls of water-damaged houses.

March/April 2010

Volume 61/Number 2 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

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2010 Officers & Board of Directors Stephen F. Melcher, MD President Alicia Abels, MD, President-Elect Charles McDonnell, III, MD, Immediate Past President District 1 District 5 Robert Kahle, MD John Belko, MD District 2 David Herbert, MD, Jose Arevalo, MD Treasurer Michael Flaningam, MD Robert Madrigal, MD Michael Lucien, MD, David Naliboff, MD Secretary Anthony Russell, MD District 3 District 6 Bhaskara Reddy, MD J. Dale Smith, MD District 4 Demetrios Simopoulos, MD 2010 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 Satya Chatterjee, MD Richard Gray, MD Richard Jones, MD Norman Label, MD John Ostrich, MD Charles McDonnell, MD Stephen Melcher, MD Janet O’Brien, MD Kuldip Sandhu, MD Earl Washburn, MD

Alternate-Delegates District 1 Robert Kahle, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Boone Seto, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Reinhart Hilzinger, MD Robert Madrigal, MD Mubashar Mahmood, MD Rajan Merchant, MD Connie Mitchell, MD Anthony Russell, MD Gerald Upcraft, MD Vacant Vacant

CMA Trustees 11th District Richard Pan, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, MD Very Large Group Forum Paul Phinney, MD

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

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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.

Ted Fourkas Melissa Darling Planet Kelly

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

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PRESIDENT’S MESSAGE

County Psychiatric Beds are Disappearing By Stephen F. Melcher, MD IMAGINE COMING TO WORK ONE DAY to discover that 50 percent or more of your operating budget has been cut. The phrases “do more with less” and “work smarter not harder” just don’t seem appropriate. Welcome to the disappearing social safety net of California. My friends in public health services tell me this is what they are dealing with right now — and they expect more cuts in next year’s budget: child protective services, adult protective services, law enforcement, mental health services, etc. Just about any department or service that is not mandated will likely be cut. How the cuts are distributed can mean a world of difference to our patients, their families and us. Currently, many of these cuts are not felt by individual providers not working in a hospitalbased practice. But ask emergency room physicians about the changing nature of their practice and I think you will be surprised. The United States has approximately one psychiatric hospital bed for every 2,500 residents. California has about one psychiatric hospital bed for every 5,000 residents. Because of budget problems, Sacramento County’s psychiatric hospital recently went from an effective census of 125 to 50; it essentially closed 75 beds. The County is planning to add 12 beds in late March, but with further budget cuts, which appear inevitable, I expect more beds to close. I truly hope I am wrong. The patients have not disappeared. With less help available and their illness untreated, many will commit petty crimes and end up in jail. This is in part why the Los Angeles County jail is essentially our nation’s largest psychiatric hospital.

In the acute phase of their illness, psychiatric patients are largely ending up in Sacramento County’s emergency rooms. Many of them spend days in the ED as staff try to find a psychiatric hospital bed. In some states other than California, they can spend weeks in the ED. In general, psychiatric patients are less dangerous than nonpsychiatric persons. But a very small number of psychiatric patients do get violent when their illness exacerbates. Unfortunately, they have seriously injured some ED staff who were trying to help, as well as some psychiatric hospital staff. Incidents like this only feed misperceptions about psychiatric illness and make non-psychiatric providers more hesitant to help them. Some hospitals have discussed training their nursing staff in the management of aggressive/ assaultive behavior. Just as we require CPR training for hospital staff, we may need to require more basic psychiatric training to deal with this patient population in the EDs and medical hospitals. Training will not eliminate all violence, but can help reduce it. Security personnel are very limited in what they can do to always prevent someone from leaving an emergency room. Some people have come, or have been brought, to the ED for help only to escape and harm themselves. If security staff try to stop the patient from leaving, they can be charged with assault and battery. If patients leave and cause harm to themselves or others, the ED that “let” them go can be held liable. Sacramento County says it has no money to provide these services. Since our county continued on next page

March/April 2010

...psychiatric patients are largely ending up in Sacramento County’s emergency rooms.

LETTER TO THE EDITOR

Rage, Rage Against… The May-June issue of this journal had an article by Dr. John McCarthy. The title caught my eye: “Do Not Go Gentle into That Good Night”. I looked up Dylan Thomas’s poem and thought, this is talking to me. Do not go gentle into that good night. Old age should burn and rave at close of day; Rage, rage against dying of the light. As tolerance for exertion and then angina progressed, I thought a lot about Thomas’s poem. Angiogams showed that stents were impossible. But coronary bypass grafts would be impossible at 87 years — or were they? Consult with my son, an intensivist, and

the cardiac surgeon and careful evaluation of all factors involved made the choice easy. Only 5 days in the hospital and no problems caused me to write an addendum to the poem: And now, Old man, shards of morning light pierce the darkness. No longer rage and rave against the dying of the light! Rejoice the brightness of the light. Welcome the light of days to come. It is a new world !! — Buren Krahling, MD burenk@aol.com

Disappearing continued from previous page no longer has a crisis unit, most acute psych patients are accessing emergent psychiatric evaluations through the emergency rooms. Our emergency rooms have become the county’s psychiatric crisis unit but without the psychiatrically trained staff and the legal ability to prevent someone from leaving. The EDs also lack the showers, shared bedrooms and physical space to provide treatment. With the closure of county beds, the emergency rooms and the psychiatric hospitals have also become an extension of the county’s inpatient psychiatric hospital. The federal EMTALA law requires a hospital, medical or psychiatric, to stabilize a patient in an emergency. Frequently, this stabilization requires involuntary hospitalization in a psychiatric unit. The medical hospitals don’t have — and don’t want to open — psychiatric units. With the exception of a medical-psychiatric unit, I agree that this would not be a good use of

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scarce resources. Psychiatric hospitals, EDs and physicians all expect to provide some care for free; however, the scope of the county closures and reductions will likely affect the quality of care that they can provide for everyone. They now have additional responsibilities with no additional resources. As a physician group, we can’t stop the budget cuts and hard decisions that have to be made, but, hopefully, we can influence them. Further cuts to public health, specifically Sacramento County’s mental health system, need to stop. Call your elected representative, attend a public hearing, volunteer in a clinic, join a SSVMS subcommittee, but please get involved in the health policy discussion in our county. We all took an oath to do no harm. Not getting involved would be just as wrong as personally deciding to make more cuts to mental health yourself. stephen.melcher@gmail.com

EMTALA — the Cornerstone of Real Health Reform By James G. Hinsdale, MD, FACS Dr. Hinsdale is a trauma surgeon in Santa Clara County and President-elect of the California Medical Association. AFTER MORE THAN A YEAR of healthcare reform debates, here’s one acronym that may be more important than all the others and may still not be widely understood. EMTALA. It stands for the Emergency Medical Treatment and Active Labor Act. Those who care for emergency patients know it quite well. EMTALA was enacted in 1986 as part of the Consolidated Omnibus Act. It is a federal statute, primarily affecting hospitals, and is also known as the “anti-dumping” law. It is administered by the Center for Medicare & Medicaid Services (CMS) and has undergone many changes in the past 24 years. Most Americans know they can’t be refused access to their local ER. EMTALA is the reason. It directs every hospital to provide a screening exam for anyone who arrives and orders ambulance services to get people there. It requires that every hospital must “stabilize” the patient. If the hospital does not have the services to do so, it must transfer the patient to a facility with such service. Furthermore, facilities capable of this “higher level of care,” such as trauma centers, must accept such patients if requested. EMTALA was enacted in 1986 during the presidency of Ronald Regan. The most common version of the case that raised national awareness and sparked reform involved an indigent woman in labor who was transferred out of a hospital ER to a facility well down the road. She then gave birth to a “bad baby” (malpractice language for a neurologically impaired

infant). The house of medicine was appalled and shamed. Physicians rose up to change the systems with the ER doctors leading the charge. Not all physicians embraced EMTALA, but, arguably, most did. Over time, EMTALA truly improved access to care. It required that no one would be allowed to die or be put in jeopardy in our ERs because of insurance or money. Of course, there was no funding for all of the uncompensated care that accrued. Emergency rooms began to do much more than ”emergency care” and became neighborhood walk-in clinics. Just about everyone in the county understood this. Toward the end of George W. Bush’s presidency, a reporter at a news conference asked: “Mr. President, if the proposed health reforms don’t go through, what will happen? Where will patients go?” Mr. Bush shrugged his shoulders and answered as any American might: “What? They’ll go to the emergency room.” By now, all of the many ramifications of EMTALA are known. The regulatory power and might of the government has enforced and refined EMTALA substantially. An entire culture has evolved around its interpretation and administration. Law schools offer courses for students and super-specialists in EMTALA law. Hospitals live in mortal fear of $50,000 fines that can be assessed and hire their own lawyers and administrators to counter false claims. Cost shifting has become a universal practice. Hospitals charge more to their other paying sources to balance the losses of the indigent care they are mandated to provide for free in their ERs. All the insurance plans do the same. Additionally, specialists providing back-

March/April 2010

Average Americans do not know “EMTALA,” but do know they can’t be refused access to the local ER.

up care to ERs either resigned from hospital staffs or had to be paid to be available and provide back-up call for patients during their entire hospital stay. Such payments are routine throughout all of California for scarce specialties such as general surgery, neurosurgery, orthopedic surgery, plastic surgery, and cardiology. Another major consequence is gaming by the insurance firms. Essentially, they will sign up hundreds and thousands of patients for whom they do not have adequate networks of physicians. They then dump them on the ER’s who are forced to care for them by EMTALA rules. Major conflicts evolve when on-call physicians do not have contracts with patients’ health plans. California’s remedy for this was to prohibit such on-call physicians from sending their bills to the patients they were compelled to care for. This enables the insurance industry to use EMTALA to extract profits from the system. And finally, there is gaming by some individuals. The gang-banger who I recently treated for multiple gunshot wounds knows where to go for top flight service when the bullets fly and the blood flows. He expects to be treated — and is. He expects not to pay — and doesn’t. And the group of younger Americans — ages 20–35, sometimes described as ”the invincibles” — resist buying insurance because they can’t imagine ever needing much health care. But if they do, there is always the ER, thanks to EMTALA. EMTALA was always the massive invisible elephant in the room in recent healthcare reform battles. Politicians who were gung-ho for reform, religious leaders who declared that health care is a “right,” unions and advocacy groups who demanded universal coverage, perhaps even some opponents of various aspects of health care reform — everyone involved could make all kinds of claims and counter-claims knowing full well that EMTALA’s unfunded mandate guaranteed access to care. Until the true costs of EMTALA are understood and factored into proposals for reform, then the health care system in America will continue to resemble a botched computer program. More consultants are hired. More hacks and workarounds are written. More costs accrue. But no

EMTALA was always the invisible elephant in the room in recent healthcare reform battles.

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one bothers to deal with the core issues. So, what’s the point? I argue that EMTALA has always been the single, most pivotal “reform” that our medical system has provided. It was promulgated 24 years ago and relentlessly refined along the way. The house of medicine has never been recognized for proposing EMTALA. Nor has it crowed about it, because it is an obvious aspect of the values that exist in every doctor and every other health care worker — nothing more. What doctor, nurse, or attendant would deny care to those in need? As a surgeon who provides a monumental amount of EMTALA care, I appreciate the fact that I get to do what is my life’s work in some of the most difficult and challenging moments in a family’s life. These are real emergencies, where everything hangs in the balance. The thanks that I and my fellow professionals receive from our patients keeps us going. But the cost of that care is enormously high. And it gets shifted by insurance interests and other insiders to a shrinking pool of payers. The pool will never expand if the economy remains slack and if EMTALA isn’t factored in, clearly and explicitly, as a cost to be shared by all. And that, as they say, is my bottom line: everyone has to chip in and pay something. Mitt Romney picked up this idea and ran with it, with prodding from many local groups in Massachusetts, including the Greater Boston Interfaith Organization, an affiliate of the Industrial Areas Foundation. Everyone means everyone — the middle class and further down. Until we know the real costs and pay a fair share, we won’t all “own the very real crisis that will continue to plague our nation in the area of health care. Only then will we be committed to solutions that are real and lasting. After years of rhetoric and posturing, it seems odd to say we need to take the time to do a lot of new thinking. Part of that new thinking will involve educating all Americans on the benefits, costs, and consequences of EMTALA. DrHinsdale@aol.com

“Cadavers, Camera, Action!” That phrase is from a New York Times Book Review of a new book of old photos: “Dissection: Photographs of a Rite of Passage in American Medicine 1880-1930,” by John Harley Warner and James M. Edmonson. These two photos, provided by James Edmonson, are among 138 appearing in the book.

March/April 2010

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Topping God By Sebastian Conti, MD Dr. Conti, a vascular surgeon, first drafted this this short story for a creative writing class. AN OLD JOKE HAS THE POPE IN HEAVEN, expecting, of course, to receive special treatment, but disappointed at the modest accommodations provided. A chauffeured white limousine arrives at the Pearly Gates. Out steps a resplendent figure in flowing silk robes, with a stethoscope around his neck. The Pope is irate, demanding to know why this doctor is treated so royally. St. Peter whispers, “That’s not a doctor, that’s God; sometimes he likes to play doctor.” This joke has special significance for Robert Simon. Dr. Simon has been asked to see a young man with diabetes and gangrene. “Hi Julie, what can you tell me about our patient?” he asks the head nurse. “He’s 38, but looks 58. Dr. Juarez transferred him two days ago. The x-rays and records are over here.” Dr. Simon looks at the x-rays and points out the problem. “This is not good.” Scanning the chart he says, “The surgeon at Valley General wanted to do an amputation but the patient and his mother refused. They’ve come here for a second opinion. So, let’s go give him one.” “Good morning, Mr. Harris. I’m Dr. Simon,” he says, walking into the patient’s room. “Hi, please call me Bill.” He is seated on the bed with his right leg hanging over the edge. He is short and portly, has a receding hairline, yellow teeth, a sallow, wrinkled complexion, and nicotine-stained fingers. In Dr. Simon’s practice, 95 percent of his patients with vascular problems are smokers, 2 percent are non-smokers, and 3 percent are liars. “Bill, I’m going to ask you some questions

about your medical history, examine you and explain what your x-rays show. Then, together, we’ll decide what treatment is best. Okay?” There is fear anchored on Bill’s face. “Can you save my leg?” “I don’t know, but I’ll sure try my best. Tell me, Bill, how did your toe became infected.” “Well, I have diabetes. I didn’t notice a cut on my big toe, and it got infected. I fell asleep in the recliner last week and I didn’t have no shoes or socks on. I guess my puppy got interested in my toe because of the infection and the smell, and she chewed on it. But I don’t got no feeling so I don’t know she’s doing it. Well, the little bastard chewed off part of my toe, and here I am with the gangrene.” “Let’s have a look.” Dr. Simon gently removes the foul-smelling, brown-stained bandage. Bill winces as the last bit of gauze is removed. The front half of the toe has indeed been eaten away, the bone is exposed and the skin there and on top of the foot is swollen and brown-black. Dr. Simon is unable to feel a pulse in the foot. He feels behind the knee — there is no pulse there, either, but there is a good one in the groin. As he begins writing in the chart, Bill’s mother enters. He smiles and shakes her hand. “Hello, Mrs. Harris. I was just about to explain some things to Bill. Please be seated.” “There are serious problems here — infection, gangrene, diabetes and artery blockage — and they’re all connected. Your artery blockage prevented enough blood getting to your toe to fight the infection and gangrene has set in. “Bill, you have a double whammy — the diabetes and your smoking. Diabetics who smoke are 10 times more likely to get gangrene and need amputation. As you know, amputation was recommended at Valley General, and

March/April 2010

actually may still be the only option here.” He pauses to let this sink in. “My recommendation is this. At surgery tomorrow, I’ll look at the artery in your foot, and if it is open enough, I’ll perform a bypass operation. You need to understand this usually requires hours and hours of surgery and carries a lot of risk. And after all that, it still may not work. But there is a chance that it will. If the bypass is successful, you must stop smoking, because if you don’t, it won’t stay open, and all the work we do, and the risks you are taking, will be for nothing.” Bill says, “Okay, I promise, I will.” Dr. Simon knows it’s unlikely he will. Bill’s mother asks, “Is there any other treatment besides a bypass or amputation?” “The only other option is to do nothing, but the infection and gangrene will spread, and lead to an amputation higher in the leg.” Bill turns to his mother. “Ma, I’m scared, I don’t want to lose my leg.” She pats his hand, “It’s in God’s hands now and I know He’ll help us make the right decision.” Dr. Simon rises from his chair. “I’ll check back later this afternoon after you’ve had a chance to talk. Do you have any questions before I leave?” Mrs. Harris asks, “Doctor, if Bill was your son, what would you do?” “I would do exactly as I’ve recommended.” Dr. Simon read early in his career that what separates the craft of surgery from the art of surgery is judgment — good judgment that is. Good judgment comes from experience, and experience comes from bad judgment. What 25 years of experience has taught him is that if a surgeon can honestly answer “yes” to this question, his judgment and decisions will usually be correct: If this were a member of my family or a friend, would I recommend the same thing? Bill agrees to have surgery. The operation begins at 4 p.m. the next day. The anesthesiologist administers a spinal anesthetic. Dr. Simon makes a one-inch incision in Bill’s foot and finds an artery irreversibly calcified by diabetes and arteriosclerosis.

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He still can’t feel a pulse, but placing a Doppler probe over the artery, he hears a signal indicating the artery is open and therefore decides to proceed with bypass. He doesn’t for a moment consider the paltry amount Medi-Cal will pay for this effort to save Bill’s leg, that it will take six months or more to be paid, and what he receives will be the same regardless whether it takes 4 hours to complete or 12. Should it take more than 8 hours, he will earn less per hour than the scrub nurse does. He then makes a five-inch incision in the groin through four inches of fat to reach the femoral artery, which, though rock hard, has a good pulse. He disconnects the saphenous vein in the groin and sews it to the artery. When a vein acts as a vein, valves keep blood flowing in one direction toward the heart. These valves must be cut for the vein, acting as an artery, to carry blood down the leg. The next step is to find and ligate branches of the vein so that none of the flow is diverted away from the foot. He clamps the now pulsating vein at the top and sews the bottom end to the foot artery. It is a difficult operation in someone like Bill. The obesity of diabetes makes access to blood vessels and dissection difficult. Passing fine needles through calcified arteries can be impossible. Needles bend or break, so heavier ones are needed but these are bigger, and more blood escapes from needle holes. Sewing a 1/4-inch diameter vein to a 1/8-inch artery requires magnifying loupes, precise placement of sutures the size of a human hair, steady hands, intense concentration, stamina and perseverance. Finally the vascular clamps are removed, but Dr. Simon is concerned because flow into the foot is not as vigorous as it should be. He considers the possible causes — a clot blocking the vein, a kink, a still-intact valve. He is exhausted, but knows he must find and correct the problem. First though, his aching, swollen bladder needs relief and he takes a five-minute break. He had the good sense to eat before beginning, knowing that one can’t predict how long these operations might take. Scrubbing back in, he

shoots an x-ray that reveals a kink in the bypass graft. Another incision is made to correct this. Removing the clamps, he now feels a strong pulse and the foot becomes pink. Pleased with this success, he finishes the operation by removing the infected, gangrenous toe. Dr. Simon leaves the operating room and stops in the surgeons’ lounge for a cold juice drink. He sits to rest a few moments and as he does, feels a profound fatigue enveloping him, like a shroud. But there is also exhilaration, knowing he can report good news to Bill’s mother. Complex cases don’t always end this well, though. Some end in sorrow, when, despite his best efforts, he is unable to save a leg, or a life. Surgeons often feel they have failed somehow if an outcome ends badly. Intellectually, they know that death, or loss of limb, is sometimes inevitable, even with the best anesthesiologists, the best imaging technology and a supportive surgical team. Yet it’s impossible to wholly let go of the notion that perhaps, had something been done differently, the patient might have survived. The most difficult task a surgeon faces is

to inform family members that a loved one has died on the operating table. To witness the shock, pain, suffering and sorrow of those who have just heard they’ve lost a beloved family member is indescribably sad. But tonight, Dr. Simon feels buoyant as he joins Mrs. Harris in the waiting room. “Your son is okay,” he says, holding her hand. “I’ve been praying to God the whole time Bill’s been in surgery,” she says. He explains it was a terribly difficult operation but the bypass is working and he is hopeful the foot will heal. She clasps her hands together, tilts her face upward and cries, “Thank you, God, thank you, God.” Then, almost as an afterthought, she looks at Dr. Simon adding, with much less enthusiasm, “And thank you, too, doctor.” He stares at her, not quite believing what he’s just heard. “And thank you, too, doctor,” he repeats silently. He debates the appropriateness but says what he’s thinking anyway. “Mrs. Harris, it’s 3 in the morning. I’ve just spent 10 hours in surgery saving your son’s leg. Don’t you think I merit top billing?” veinexpert@gmail.com

Occhio

I tell you, Doc, we will only tax greedy millionaires to pay for free medical care for all !

Sounds good! Big problems need big solutions! And we can’t tax the poor!

It works! Everyone is a millionaire when an office visit or a meal costs $2 Million.

Yes. We’re all equal. Equally poor millionaires! And equally healthy!

March/April 2010

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EXECUTIVE DIRECTOR’S MESSAGE

What Our Members Think By Bill Sandberg THE MEDICAL SOCIETY LAUNCHED a webbased, 30 question membership opinion survey on January 20, which concluded on February 16. SSVMS surveyed the 1,434 active members for whom we had email addresses, out of our total 1,669 active members. A total of 513 surveys were completed. Age, gender and practice size were collected as demographic information. We are presenting highlights of the opinion survey findings here and encourage anyone who is interested to look at the complete survey results at http://www.zoomerang.com/Shared/SharedResultsPasswordPage. aspx?ID=L24642DQPMMN s )N THINKING ABOUT THEIR PROFESSION IN this region, members were asked if things were getting better or worse. 52 percent felt that things were getting worse while 39 percent said things were staying the same or improving. More physicians in group practices tended to feel that things were getting better or staying the same. s 7HEN ASKED HOW SATISFIED THEY WERE WITH their practice, 44 percent were very satisfied and 46 percent somewhat satisfied. This question has been asked the same way five times since 1989 and “satisfaction with your practice” is at its highest level. Satisfaction increases by as much as 10 percentage points in group practice. s PERCENT OF PHYSICIANS WOULD STILL CHOOSE to be a physician, and 81 percent would choose the same specialty. These numbers are the highest they have been in five previous studies. s 7HEN ASKED IF TOO MANY ADMINISTRATIVE demands are taking precious time away from patient interaction, 42 percent strongly agreed and 40 percent somewhat agreed. Physicians in group practices tend to somewhat or strongly disagree with the statement. s 7HEN ASKED TO SELECT THE FOUR FROM A LIST of 12) most challenging things about being a physician in today’s environment, keeping a

work/life balance topped the list at 66 percent, legal and regulatory issues were at 61 percent, high patient expectations was 46 percent and rising medical cost came in fourth at 44 percent. Malpractice was 40 percent. s 7HEN ASKED HOW BIG A CONCERN IT WAS TO perform tests and procedures to protect from liability, 45 percent of total respondents said it was a “very to extremely significant” concern. There was little difference in this response between solo and small group physicians and group practices. 13 percent of the males said it was an extreme concern compared to only 6 percent of females. s 7HEN ASKED IF THE PROPOSED HEALTH CARE reforms will improve care in our region, 49 percent were somewhat to very pessimistic. Women were 10 percent more optimistic than men on this question. s PERCENT OF THE RESPONDENTS SAID WE will not have enough primary care physicians if we increase the number of insured by 15 to 20 percent in the next five years. When asked the same question about specialty care, there was an exact 50-50 split between yes and no. s 7HEN ASKED IF HEALTH AND INSURANCE reform will reduce costs, 67 percent were somewhat to very pessimistic. 18 percent were somewhat to very optimistic. Women in the sample were nearly twice as optimistic. s 4HE SAMPLE WAS EQUALLY SPLIT AT on the question of whether the individual was looking more favorably on national health insurance now than 40 years ago. This question has been asked five times since 1989 and had a low yes of 41 percent in 1989 to a high yes of 61 percent in 2001. s 7HEN ASKED HOW THEY FELT ABOUT THESE reform options, the combined response of “very to very important” were: 46 percent to keep the current system, mandate coverage and stop March/April 2010

This question has been asked the same way five times since 1989 and “satisfaction with your practice” is at its highest level.

recisions; 36 percent single payer; 34 percent Medicare for all; 50 percent state and regional purchasing pools; and 49 percent government sponsored health plan. s PERCENT SAID THEY WOULD TAKE MORE Medi-Cal patients if rates were brought up to Medicare rates. s 7HEN ASKED IF THE QUALITY OF CARE IN Sacramento is being threatened by an over emphasis on cost containment, 40 percent indicated “agree” to “strongly agree.” This number has declined steadily since its high of 84 percent in 1996. Physicians in large groups tended to disagree with the statement much more than those in solo and small group. s 4HE LEADING REASON TO JOIN #-! AND SSVMS was “to support organizations that advocate for all physicians,” at 79 percent, followed by “to hear about what going on in my profession” at 46 percent. s PERCENT OF ALL THE RESPONDENTS SAID that SSVMS was fulfilling its mission while 36 percent were uncertain.

s PERCENT OF THE RESPONDENTS SAID THAT we should not endorse political candidates compared to 34 percent who thought we should. (Our existing policies do not allow us to endorse candidates.) s 4HE -EDICAL 3OCIETY S PUBLICATIONS Sierra Sacramento Valley Medicine and On Friday received generally positive responses. s PERCENT SAID THEY NEVER USE OUR PICTORIAL membership directory, 24 percent use it once a year, 13 percent once a quarter. SSVMS conducts surveys every few years; they help us plan necessary changes, evaluate programs and remind us of what our members are thinking and feeling. We sometimes think we know what you think or want — and we know we are often wrong. Studies like this keep us on track. Evolving survey tools like Zoomerang make it very easy for us to ask for you opinion. So if you have a question you would like to ask our members, lets us know what it is! bsandberg@ssvms.org

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Here Be Dragons… By T.W. Hard, MD This article is reprinted from the Winter 2010 issue of Sonoma County Medicine. The archipelago consists of ten principal islands of which five exceed the others in size. They are situated under the equator and between five and six hundred miles westward off the coast of America. — Charles Darwin, The Voyage of the Beagle, 1839

August 7, 2009 It is six o’clock in the evening. A crescent moon glows above our starboard bow. To the west an island squats, its cloud-covered shoulders glinting silver in the setting sun. We are on the deck of the Mary Anne, a 216-foot barquentine schooner, gliding into the coming darkness. The smell of ocean pulses through our nostrils, as soft trades caress our skin. The temperature is deliciously warm. This is a second trip to the Galapagos, a return to those islands cartographers once thought unanchored — lands that drifted aimlessly through the mists of the equatorial seas. The “Enchanted Islands” they were called: mysterious, magical places where giant tortoises roamed, where dragons swam in the surf, where the birds were so tame they perched in the palm of your hand. Since their discovery by Fray Tomas de Berlanga in 1535, little has changed. This is my 17th day off these lava-encrusted shores. The first trip was one of introduction, exploration. Now I have come back to better understand what happened here. 2009 is the bicentennial of Darwin’s birth, the 150th year since he published On the Origin of Species, a landmark treatise that forever changed our view of the biological world. The seeds of Darwin’s theories germinated here. Why is this place so unique? Why does it have unique forms of life found nowhere else in

the world? Why were the islands never inhabited before? The answers are not always easy to find. Like the igneous crust that formed these shores, the secrets lie buried in an ocean of stone. Time seems to have forgotten this land.

August 8 Nothing could be less inviting than the first appearance. A broken field of black basaltic lava, thrown into the most rugged waves and crossed by great fissures, everywhere covered by burned brushwood which shows little signs of life.1 The seas are rough. Most of the traveling is done at night. I chose the Mary Anne because I wanted a sense of what it must have been like to explore these waters with compass and sail. Nonetheless, our schooner is luxurious compared to Darwin’s Beagle. We are spaciously fitted with 12 cabins, each with a private bath. At 96 feet, the Beagle was less than half our size, with 10 cannon and a crew of 70. My son and I are the only Americans on board. Last evening, after a full dinner and several glasses of Chilean wine, we had a spirited discussion on evolution translated into three languages (Spanish, German and French). Before retiring, I sat in the afterdeck going over camera gear. One of the guests stopped by to see what we had brought. I had little time for greetings before I bolted for the railing and chugged. I suppose my seasickness is a christening for crossing the equator. Darwin had it worse. “One continuous puke,” he wrote as he rounded the Straits of Magellan and headed up the South American coast.

August 9 Here both in space and in time we seem to be brought somewhere near to that great fact — that mystery of mysteries — the first appearance of new beings on this earth.1

March/April 2010

This morning we sail toward a beautiful, low island with a long spit of dazzling sand. From a distance, numerous boulders seem to line the beach. I assume they are rocks, but on closer approach they begin to move. Anchoring off shore, we come through the surf in a Zodiac. I set off down the beach with a camera, walking among scattered clusters of sea lions. Several are playing in the surf. Wading up to my knees, I take a wide-angle lens and slip into the water. Three sea lions come roaring out of the waves. Somewhere I have read about a dominant male, a “beach master,” who attacked a sailor and almost killed him. I back away with a twinge of fear, but there is no maliciousness to their approach. Brushing past, they gallop onto the sand. In a few moments they are sound asleep, their soft snores lost in the rumbling surf. More remarkable are the mockingbirds that Darwin called “mocking-thrushes.” The island has no water, and I am told these birds quench their thirst through flowering plants. As I sit surveying the beach, a mockingbird approaches and begins to poke around my feet. Suddenly, he flies up and pecks at my water bottle. Pouring a bit of water into my cupped fingers, I hold out my hand to see what he will do. Incredibly, he perches on my wrist. Hopping onto my hand, he takes a long gulp of water, sipping the fluid like ambrosia. Then with a cluck he is gone. Giving water to these birds is taboo. The Ecuadorian government has done much to preserve the islands in their original state, and feeding the animals habituates them to humans and decreases their ability to survive. Later, I apologize to our guide, yet the experience lingers in my mind. Never have I had a wild bird light on my hand. I feel like St. Francis of Assisi. Giving nourishment to this small, innocent being brings a wonderful sense of joy.

August 10 The vice governor, Mr. Lawson, has declared that the tortoises differed from different islands and that he could tell from which island one was brought.1

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Today we have come ashore on the inhabited island of Santa Cruz to visit the Darwin Research Center. Here lives Lonesome George, the most endangered creature in the world. He is the last giant tortoise from the island of Pinta. During the 16th century, mapmakers called the islands “Galapagos” because of the huge tortoises that inhabited the archipelago. The word comes from the early Spanish referring to their “saddle-like” shells. At one time more than 200,000 lived here, with different species found on all the major islands. When whalers arrived in the 1800s, they discovered the tortoises provided an “unending” supply of fresh meat. The fact that the tortoises could live in a ship’s hold for months without food and water sealed their fate; some vessels carried off 200 at a time. On Santa Cruz, only 3,000 remain. In 1835 Darwin brought three young tortoises back to England. One, named Harriet, was eventually donated to the Australian National Zoo. Here she lived the rest of her natural life. When she died in 2005, she made world news as the passing of the earth’s oldest breathing creature. She had reached the ripe old age of 175!

August 11 I was always amused when overtaking one of these great monsters as it was quietly pacing along to see how suddenly it would draw in its head and, uttering a deep hiss, fall to the ground with a heavy sound as if struck dead.1 We are hiking the verdant highlands of Santa Cruz. A dozen giant tortoises lumber in a large meadow. Occasionally, a bird flits from the trees and lights on a tortoise’s back or grabs a bug they have disturbed. As we move among these gentle giants, I reflect on Darwin’s remarkable insights. Born in 1809, Darwin came from a wealthy English family. The son of a physician, he started medical school in Edinburgh in 1825 but left after two years. He switched to a career in the clergy, yet his wanderlust and his fascination with beetles led him to apply for a position on

the Beagle. Convinced this was another example of his son’s idleness, Darwin’s father refused to finance the travels. “Bring me one, just one, sane man, who thinks this voyage is worthwhile, and I will consider it,” he ordered. After much coaxing, Darwin persuaded an uncle to speak on his behalf. Signing on as the ship’s unpaid “naturalist,” Darwin joined Captain FitzRoy in a mapping expedition of South America. He was 21 at the time. The voyage lasted five years, but Darwin was only in the Galapagos for 37 days. Little was known about genetics or continental drift or the double helix of DNA when Darwin set sail in 1831. A perplexing riddle of the time was how frogs — who cannot live in salt water because of permeable skins — could inhabit the widely separated continents of Africa and South America. The answer? Because God created life this way. Conventional wisdom came from the Book of Genesis. The world was created 4,000 years ago; the plants on Day Three; the fish and birds on Day Five; the animals on Day Six. To think that different species might evolve from primitive life forms was not only preposterous but heretic. To challenge the prevailing wisdom was perhaps why Darwin held back publishing his On the Origin of Species for another 20 years. “It was as if I had killed off one of my good friends,” he later reflected.

August 12 The remaining land birds form a most singular group of finches related to each other in the structure of their beaks, short tails, form of body and plumage…the most curious fact is the perfect gradation in the size of the beaks.1 This morning, I am strolling along a quiet path running parallel to the sea. There is dense foliage on either side, and groups of finches flutter through the trees. The males are black in color, and I have a wonderful opportunity to observe them up close. Darwin’s descriptions of the varying beaks of finches are among his most famous. Despite the existence of 13 different species of finch from 13 different islands, there is a consider-

able crossing of species, and even experts have difficulty telling some of the birds apart. At the beginning Darwin merely categorized them as small “black birds.” It wasn’t until the specimens were brought back to England that ornithologist John Gould examined the birds and determined different beaks came from different islands. All of the finches are now thought to have come from a single, common ancestor.

One of the famous finches of the Galapagos Island. Photo by the author.

travishard@aol.com Dr. T.W. (“Ted”) Hard, who directs the emergency medicine department at Sutter Santa Rosa, has published three short stories in the Saturday Evening Post and two novels, Oasis and SUM VII. He received the Rupert Hughes Award for fiction at the Maui Writers conference of 2007. References 1 Darwin C, The Voyage of the Beagle (1839). 2 Darwin C, On the Origin of Species (1859).

March/April 2010

An Update on Autism By F. James Rybka, MD

The earlier a child with this disorder can be diagnosed and treated, the better.

IF YOU GRADUATED from medical school before 1990, unless you are a pediatrician or neurologist, the chances are that your concepts about autism were like mine — seriously outdated. We had been taught that autism was a rare congenital mental disorder in which the child had severe learning and social disabilities, could not communicate with parents or therapists, and usually required institutionalization. What we were taught was correct for the severe, lowfunctioning form of autism first described by Leo Kanner of Johns Hopkins in 1943. What we did not know was that there was a different form, a high-functioning autism described by Hans Asperger of Vienna in 1944. In this case, children usually have normal or above-normal intelligence and, with therapy and protection, many can eventually function in society. However, Asperger’s paper was not translated into English until 1981, and thereafter gained recognition only slowly. These two variations of autism, the lowfunctioning classic autistic group and the high functioning Apserger group are grouped together as Autism Spectrum Disorders (ASD). Autism (Greek for autos or “self”) is not rare. In fact, it is increasing at an “explosive” rate. Explosive? Well, in California there was a 600 percent increase from the early 1990s until 1999, and another 600 percent increase from 1999 until 2004. In the U.S. today, it has an incidence of about 1 in 110 live births. Most of this increase is found at the high-functioning, or Asperger end of the spectrum. Certainly, a major part of this huge increase is due to improved recognition, but most neuroscientists believe that this sharp rise is above and beyond that. The diagnosis is not made by any hematological, genetic, or neuro-imaging test, although

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this may be the case in the not-too-distant future. Rather, it is made by clinical observation of the child’s behavior by autism neuroscientists who follow an established list of symptoms listed in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV). The fifth edition of the DSM is currently being edited and controversy has arisen because of plans to eliminate “Asperger syndrome” and merge this group into Autistic Spectrum Disorders or ASD. It may be difficult because the term has become entrenched. Some patients with the condition call themselves “Aspies,” perhaps to avoid the negative implications of “autism.”

The Importance of Early Diagnosis Infants and young children with an autistic spectrum disorder (ASD) may show evidence of abnormal behavior even as young as 12 months. For example, they may resist being picked up or held, and may not gesture, babble or make eye contact with others. The earlier a child with this disorder can be diagnosed and treated, the better. Early identification allows better differential diagnosis, catches early regression (which can worsen in early childhood,) and allows earlier behavioral training and therapy which has been shown to alter the course for many. If parents or a primary care physician has concerns that a child is demonstrating these signs, there should be little delay before he is referred to a pediatrician or an autism specialist for evaluation. I say ”he” because autism affects males about five times more than females. There is a genetic link to autism, but it is not dominant. Most children with ASD are born to parents without any autism known in their families. But if parents have a child with autism, their risk for another rises 25 percent. Although most children have ASD as their only disorder,

there are about 60 different metabolic, genetic and neurological disorders that can be associated with autism, so the initial evaluation will include ruling out other conditions. The two hemispheres of the brain have different specializations. Verbal and abstract powers are associated with the dominant left hemisphere (LH), and perception, music and calculation with the right hemisphere (RH). In fetal life, this domination is reversed; the RH develops earlier, so at birth, perception, calculation and music are ahead of those for language. It has been theorized that some damage to the still-developing LH is the cause of autism. For example, testosterone slows the development of the LH and, since male fetuses are exposed to more of it, this might explain the male predominance. It is not that simple, however, and part of this theory has been thrown out. The LH vs. RH differences are valid, but new studies show that LH dysfunction alone, sparing the RH, is not. The dysfunction has been shown to be widespread across many cortical and subcortical areas. The developing brain is hyper-sensitive to external exposures. There are thousands of synthetic chemicals to which children are exposed, two hundred of which are neurotoxic in adults, but fewer than 20 percent have been tested for neurodevelopmental toxicity.1 Epileptic activity and clinical seizures are not uncommon in ASD, with seizures occurring in 10 to 30 percent and abnormal EEGâ&#x20AC;&#x2122;s in 50 to 60 percent of cases.2 Currently there is considerable interest at looking into auto-immune mechanisms that could be a causal factor. Environmental pollution might be suspected as causal, yet the sharp increase is worldwide â&#x20AC;&#x201D; even in Iceland, which has almost no pollution in comparison to us. What is now shown not to be a cause is the mercury (thimerosal) in vaccines, primarily the MMR (measles, mumps, rubella) vaccine. As physicians, we must encourage any parents holding doubts to get their children vaccinated. Evaluation of autism is a primary concern

at the Sutter Neuroscience Institute. Its team of pediatric neurologists and neuropsychologists with special training in autism is led by Michael G. Chez, MD, a pediatric neurologist and author of a guide book for parents and professionals.3 This diagnostic team screens for conditions that overlap autism such as genetic conditions, seizure disorders and other metabolic or psychiatric conditions. The UC Davis M.I.N.D. Institute (Medical Investigation of Neurodevelopmental Disorders) originated from the fervor of six Sacramento families who had children with autism. They obtained a grant from the State of California to fund their building. It is primarily a research institution striving to find the causes of autism, fragile X and other neurodevelopmental disorders, but it also accepts referrals of children who may need evaluation and testing. With a staff of over 250, it has interdisciplinary experts in neuroscience, immunology, genetics, molecular psychology and developmental pediatrics. In 2006, it launched its Autism Phenome Project that will enroll 1,800 children aged two to four years, half with autism who will undergo analyses of their immune systems, brain structures, genetics and environment that will go on for several years in search for answers. The MIND Institute also offers post-doctoral training for MD and PhD fellows for careers in autism research, and has an excellent series of lectures by renowned scientists.

March/April 2010

What is now shown not to be a cause is the mercury (thimerosal) in vaccines, primarily the MMR (measles, mumps, rubella) vaccine.

ASD at Various Age Levels

The failure of a child with ASD to take protective action against a threat may not change with adulthood.

As children get to kindergarten the cardinal signs pointing to autism are: speech delay, a non-interest in others and an obsession in their own interests — such as music, puzzles, or geometric forms. They may display repetitive motions, like flapping their hands or rocking their heads. When they speak, they may sound pedantic, like little professors. They may “zone out,” similar to having a petit-mal seizure, and temporarily withdraw from their surroundings. Older children with ASD usually lack the back and forth flows to propel a conversation and, again, have poor eye contact; they may issue a monologue on their special interest or else sit silent and stone-faced. Some will develop extraordinary talents in some area, and a few may become “savants” in calculation or music. But even if they have this window of brilliance, they will still have difficulties in socializing. They do not reciprocate socially, do not thank for favors, and show no empathy for the problems of others. Frequently they are not liked and are shunned or ridiculed by others for reasons that they cannot understand. They interpret language literally and fail to capture indirect speech. If they answer a telephone at home and the caller asks, ”Is your mother home?” the child with ASD may answer, “Yes,” and then hang up. He fails to connect that the caller might wish to speak to her. As pre-adolescents, they frequently are unable to play any sports that involve balancing, running or pitching because they have large motor incoordination. Indeed, this cerebellardirected activity is classic for autism. They lack self-protection. If attacked or pummeled by other children, the child with ASD will not fight back, and may be found standing alone with tears. Some adults who have been thought to have high functioning autism include Albert Einstein and Bill Gates. High functioning adults, particularly the most gifted, may pass as being nonautistic until tripped up by some event. The failure of a child with ASD to take protective action against a threat may not change

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with adulthood. One goal for him is to live independently from his parents, but he and his family must keep in mind that, although he can learn better habits, he will never grow out of his basic disorder, so he needs some protection. A serious problem can occur if a threat arises that he does not perceive as dangerous. We recently were told about a boy diagnosed late in childhood with ASD. As a young man, he was able to land a job and live on his own in Sacramento, where his parents lived. After several days when they could not reach him, they went to his apartment and found him dead. An autopsy revealed he had died from the flu. Even though his father was a doctor, this young man apparently did not realize that he could take any counter-action against the sickness; he just sat it out alone. We know autistic children do not fight back when bullied, and a lack of self-protection in adult life must issue from this same trait. What is surprising is that this powerful characteristic overrides whatever common sense that the person has developed. Young male adults usually develop a close friendship with another person, typically a strong-willed girlfriend, who can help guide and protect them through decisions in life that most of us take for granted. In February, El Dorado County established an anonymous registry of adolescents and adults with ASD to help inform law enforcement officials and provide peace of mind to families of autistic adolescents and adults. Young people with autism sometimes get lost walking around while “zoning out” in deep thought about their particular interest. They can be found walking along the highway, poorly oriented, and can easily be victimized. They are naïve and trusting and have almost no prejudices. Because they rarely have animosity against others they haven’t met, they do not suspect strangers have evil designs against them. In addition to helping these people get back home, the registry could help a law enforcement officer who might misjudge a lone figure who is slow and curt in his answers as if trying to hide something, or high on drugs. Some with high-functioning autism who

have written about their disorder tell how they have suffered because of their social difficulties. They never feel a part of society but always walk parallel to it.5 They may require medications and therapy as well as basic medical care.6 The Sutter Transition for Autism and Neurodevelopmental Disorders (STAND) Clinic, led by Dr. Chez, is the first in Northern California to be dedicated to patients 18 or older with ASD. Where were these young people 20 years ago? Probably out there, but unknown

to us. However, now we do know, so we must try to help. imrybka@hotmail.com 1 Nicholas D. Kristof, “Do Toxins Cause Autism?” New York Times op ed, 2/25/2010 2 Michael G. Chez, MD, personal communication. 3 Michael G. Chez, Autism and its Medical Management (Philadelphia: Jessica Kingsley, 2008) 4 Daniel Tammet, Born on a Blue Day, New York, Free Press, 2006. 5 Tim Page, Parallel Play, New York, Doubleday, 2009 6 Sally Osonoff, PhD, Geraldine Dawson, PhD, James McPartland, PhD, A Parent’s guide to Asperger

Board Member Statement and Profile Our Medical Society is among the largest in California. The Board of Directors includes the officers of the society, and representatives from each SSVMS membership district and the CMA and AMA. All are elected by the membership, so that information and access is vital to a well-run and representative organization. For a complete listing of names and addresses of board members please log on to www. SSVMS.org. This is the first of a series.

Michael Andrew (Mike) Flaningam, MD Chicago Medical School: 1997 Internal Medicine SSVMS, Representative for District #2, Central Sacramento Why do I serve on the Board? To get involved with our medical community Please contact me by email at: flaninm@sutterhealth.org

I grew up in the wonderfully diverse city of Oakland, CA, the son of a general internist. I came to appreciate the close relationships my dad had with his patients, and decided I wanted to go into primary care so that I could share those same experiences. Despite it being so mentally grueling, I can think of no specialty or profession in which I’d rather be involved. I am the luckiest person in Sacramento to have the son and daughter I have. I enjoy a wide range of hobbies, from opera and wine tasting to baseball and wakeboarding. My involvement with the Board is my first experience involving medicine outside the clinic. It has opened my eyes to the overwhelming amount of differing opinions and experiences those of us in our profession have. I wish we could better agree on how medicine should be practiced and that our collective voice could more effectively drive the absolutely necessary changes that must occur in our county’s health care system.

March/April 2010

A Posit on Email Communications “Email provides economical, effective, and efficient communication between me and many of my patients.”

Email is much more efficient than phone calls and most patients prefer the use of email over the phone.

This posit sought opinions chiefly from members who use, or have used, email for communication with patients. However, members considering the option of using email may find the posit results helpful. Overall, email user comments were positive; 98 respondents agreed, 29 disagreed. A minority expressed fear of the HIPPA Hippo, or a possible breach of confidentiality. Others objected to email intrusiveness by patients. Commentary from 26 members follows: I agree and with some of my patients I use texting. Patients, especially the younger generation love this format. The only disadvantage of texting is you cannot document the communication into the electronic chart by copy-pasting, you have to document it separately. — Kamer Tezcan, MD Not only does email service provide these advantages but secure emails expedite treatment where medication changes are necessary in a short amount of time and leave patients satisfied… — Maria J. Caparas, MD I agree but need more desk top time to accomplish adequate responses. — June Le Pham, MD Email is much more efficient than phone calls and most patients prefer the use of email over the phone. — Robert J. Ruxin, MD Email can save a lot of marginal office visits, but there needs to be a way to ensure the privacy of the communication. One cannot just send out patient information over the net. Be sure that you have a secure system. — Jeffery J. Rabinovitz, MD Email is another way for me to be bombarded without restriction by demanding patients. — Roger E. Mendis, MD Sierra Sacramento Valley Medicine

I disagree. For yes and no answers to direct questions, and for documentation that the patient got a message he/she can’t refute, it’s fine. For explanations, for the answers, it is impossible. If medicine is supposed to involve patients in decision-making and achieve informed consent, there should be a give and take. This involves MANY emails back and forth that take a huge amount of time, especially since most of us don’t type as fast as we talk. I’m doing emails with selected patients and it is a huge time drain. — Ann L. Gerhardt, MD I have had experience with this important improvement in patient care in the last two years and can say without a doubt that it contributes to strengthening my relationship with patients and improves their care overall. There must be continued vigilance to be sure that we don’t provide this professional service (evisits as contrasted with simple messaging) for free. Our professional advice is valuable and we should seek appropriate compensation for dispensing it in whatever form. — Thomas N. Atkins, MD [I agree] Since everything is patient satisfaction these days, if patients like it, it must be good! — Nathan C. Hitzeman, MD As a patient who uses email with my TPMG primary care provider, it is efficient and saves me from scheduling appointments for nonurgent issues and/or returning to discuss lab reports. — Ralph F. Sett, MD In the system I work in it is not something that is available to patients but for future office services I provide I think I will be very useful. — Richard C. Lynton, MD

I agree, but admit that it is somewhat annoying and abused by some patients. — Holly J. Haight, MD It greatly improved patient care and satisfaction! I love it. — For-Shing Lui, MD This is probably a true statement and is most likely in our future, but I think may actually take more time then a quick phone call first by the advice nurse and then by the MD if necessary. Plus for those of us who are not speedy at typing and already challenged by EMR, a phone call is often a nice break. — Jose J. Cueto, MD Since I don’t get paid to communicate by email, I won’t do it. — Sidney Yassinger, MD Yes! This is an excellent example of why the paperless society was created. If things get out of hand, a nurse practitioner or other office personnel may screen patients calls so that more difficult problems are not overlooked. — Byron H. Demorest, MD Need to be face to face to be able to ask questions that would take too long by email. — G. Dennis Lance, MD [I agree] However, it concerns me that it may be used as means of getting treatment instead of coming in for a visit. — Julieta DominguezJones, MD Emails can be efficient, but need control over content to ensure they are not wasting the physician’s time. — Randal W. Anderson, MD Patients want to email their doctors. Just knowing they can is reassuring for them. They tend not to abuse the contact. — Elizabeth M. Gonzalez, MD I’m old. I still prefer to talk to my patients directly. I do use email, but I find it too impersonal for communicating with patients, even though it may be more efficient. — John M. Osborn, MD [I agree] But it can be time consuming! — Allan H. Galbreath, MD Very effective tool (though impersonal) for communication…but when the volume of patients seen is large, it works best if restricted to the care of the body and not additional activities like appt making and numerous, similar ancillary activities; then the use of physician time and expertise becomes expensive and wasted. I see the birth of a new specialty or aspect of the

practice of medicine: cyber-photo-communicative diagnostics. We will then slowly transit into the world of medical robotics. Yippee ! — Elisabeth Mathew, MD Although we do get some email via our website, we do not use email to communicate with patients, unless they live some distance away. I believe a large part of medical care is the practitioner’s human contact (voice and touch). — Debra Johnson, MD I will generally allow patients to have email access. As usual, most are very respectful about it, but there are always a few who are very abusive and expect too much. I also warn patients that it may take me a few days to get back to them if they use email, and if there is a problem requiring immediate attention, they still have to call. Unlike some health care systems, email for me is elective and there is no 24 hour turnaround requirement. — Sidney A. Scudder, MD Saves a tremendous amount of time. No more telephone tag. — John J. Geraghty, MD It could be if insurances fairly reimbursed for the professional service being rendered. — Mark L. Tong, MD I think email is a fantastic way for physicians and their patients to communicate directly, without the (sometimes inaccurate) filtering of ancillary staff. More complicated issues are better addressed via phone or in-office visits, but email takes care of many routine questions. — Gordon S. Garcia, MD [I disagree] Economic, yes, but never as effective as a direct conversation with the patient. — Roseanne E. Pevec, MD [I agree] though confidentiality is not perfect. — Travis A. Miller, MD [I agree] However, it must be kept in mind that emails are not secure. — Charles W. Maas, MD, MPH I agree. Oddly enough, far too many patients are unaware that email is completely insecure. Odder still, when privacy concerns are brought to their attention, they seem indifferent to issues of privacy and security. It seems that the ability to obtain information quickly is the most important concern, and that accuracy of information is taken for granted. — Alfredo Czerwinski, MD March/April 2010

Need to be face to face to be able to ask questions that would take too long by email.

Voices of Medicine A review of various local and regional medical journals.

By Del Meyer, MD

The Devil’s Details

Ambulatory care: Care delivered only to people who can walk and pay at the same time.

Dr. Stephen Kamelgarn revisits the “Devil’s Glossary” in the January issue of The Bulletin of the Humboldt-Del Norte Medical Society. Here are some items at the start of the alphabet. This was a guide originally published by the CMA back in 1993 (during the Clinton Health Care Reform debacle) as an aid for medical journalists covering health care in California. Version 1.0 of the Devil’s Glossary was published way back in 1994. I felt that it was time to revisit the issue. The guide was published using the usual bureaucratic jargon, so (in the finest tradition of Ambrose Bierce) I have liberally provided a translation. Accreditation: A process by which a number of licensed bureaucrats (medical and non-medical) pass judgement on the adequacy of one’s hospital institution. This gives them a feeling of self-importance, and makes the accredited institution feel loved and wanted. See JCAHO Advance Directives: …preferences about life-sustaining procedures. Unfortunately, these are almost never available when the patient is comatose in an emergency department, thereby making their existence moot. All-payer system: A health care pricing or reimbursement system in which all payers, including insurers and government programs, must participate and pay an equal percentage of nothing for physician, hospital and other provider services. In the old days this was referred to as Price Gouging, but we live in enlightened times now… Ambulatory care: Care delivered only to people who can walk and pay at the same time. American Medical Association (AMA): A

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national association of fossilized old men still living out in the medical practice climate of the 1950’s and 60’s…. They claim to be the voice of organized medicine, but since fewer than 20% of practicing physicians belong, they are living in a fantasy world. Today, there are high powered psychotropic medications to dissolve their delusions of relevance… Bio-medical research: One of many ways to tap into government coffers to pursue one’s pet projects. This is usually affiliated with major universities where the president or department chair needs new living room furniture. Budget predictability: The fantasy that one can plan in advance for expenditures over a stated time period. In health care, the relationship between predictability and actual expenditures is tangential, at best, thereby leading to both a credibility gap and health care oversight by CPA’s, bookkeepers, and other bean counters whose knowledge of medicine is gleaned from past issues of Reader’s Digest and The National Enquirer. Capitation: A method of payment for health services that is the darling of Kaiser-Permanente, insurance companies and other HMO health policy wonks. A provider is paid a fixed, less than subsistence fee for each person served over a period of time without regard to how much care that person actually requires… Cherry picking: Yet another clever ploy by insurance companies…. Here, they only accept healthy people for coverage. They then have the option to cancel that person’s policy as soon as he/she gets sick, and really needs the insurance… To read more of the Devil’s Glossary, go to: www.sonic.net/~medsoc/images/bulletins/2010-01%20JANUARY%20BULLETIN_ excerpts.pdf

An Anesthesiology Convention is… Stephen Jackson, MD, editor of the CSA Bulletin of the California Society of Anesthesiologists writes on “A Carnival for Anesthesiologists” in the winter 2010 issue. Because of illness, he could not attend the ASA convention in New Orleans. But he recalled an earlier ASA contention in the Big Easy: …two decades ago when the Loma Prieta earthquake exploded toward the end of the ASA meeting. I recall distinctly how I became aware of the quake: I had been demanding that the bartender change the channel on the big screen TV over the bar to show the San Francisco GiantsOakland Athletics World Series game rather than the incessant panoramic view of smoke rising in a city and a crumbled freeway bridge. Neither he nor I could immediately explain why all the channels had the same aerial view… …the magnificent ASA Annual Meeting truly is…a huge gathering of anesthesiologists from around the world. And, when held in New Orleans, the ASA Annual Meeting (and any other large meeting held there) has been dubbed, appropriately, a “carnival!” Indeed, the anthropologist Lawrence Cohen considers conferences and conventions such as ours to comprise not entirely or even mostly scholarly goings-on, but rather carnivals — “colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries...tourism and trade…the care and feeding of professional kinship, and the sheer enormity of discourse.” Indeed, the popular physician writer, Atul Gawande, in his book, Complications, is of the same mind and comments “that [for] such national meetings…some [surgeons in his case] had come just to be seen, others to make their name, still others for the spectacle of it all…. Yet…one still had the sense that the draw was deeper than mere carnival.” Read the entire article by Dr. Jackson at www.csahq.org/pdf/bulletin/ednotes_59_1.pdf

Screening for Breast Cancer? In the November/December issue of the Bulletin of the San Mateo County Medical

Association, Dr. Philip R. Alper had this response to a colleague’s views on breast cancer screening: Dr. Borofsky’s arguments for not tampering with the breast cancer screening guidelines are impeccable…but they are not the last word on the subject. There are two undisclosed, underlying assumptions made by supporters of the existing guidelines: 1) all services that offer value to individual patients should be provided and 2) there is no trade-off between money and clinical utility in determining overall societal value. Perhaps a third underlying assumption is that the money supply is infinite… The luxury of such thinking has done much to fuel the epidemic of specialism (if I dare be so impolite) that now characterizes American medicine. To do well by unrestrainedly doing good must be highly appealing; the AMA lists 112 Specialty Societies under its rubric of the Federation of Medicine. Only a handful of these concern themselves with primary care. It has essentially been left to primary care to concern itself with integrating competing needs and costs in ways that “right way” and “wrong way” specialty thinking finds alien. Surely it is easier to define one’s horizon by the limits of one’s own specialty obligations and declare everything else “not my area of expertise.” But that leaves both competition for funding and professional freedom in the arenas of politics and public relations. How does this meandering speculation relate to breast cancer guidelines? When the news of the new guidelines came out, I was struck by the complaint that the U.S. Preventive Services Task Force wasn’t composed of experts who presumably know the most about the subject but rather of generalists who — dare we say? — can’t be trusted to provide the last word. Such was the flavor of the comments made by the American Cancer Society and by representatives of the various specialty organizations concerned with breast cancer… Read the article and more on the issue at www. smcma.org/bulletin/issues/BULLETINNovDec09. pdf

It has essentially been left to primary care to concern itself with integrating competing needs and costs in ways that “right way” and “wrong way” specialty thinking finds alien.

DelMeyer@MedicalTuesday.net

March/April 2010

In honor of National Volunteer Week, April 18 – 24, 2010, we would like to extend a heartfelt “Thank You” to the our dedicated SPIRIT Volunteers. Sallie Adams, MD Barbara Arnold, MD Franklin Banker, MD Maxine Barish-Wreden, MD Lawrence Bass, MD Robert Bellinoff, MD Joanne Berkowitz, MD Carol Berry, MD Gregory Brott, MD Matthew Carnahan, MD Dennis Chu, MD Donald Clutter, MD Ed Denz, OD Joyce Eaker, MD Guy Guilfoy, MD Andrew Hudnut, MD Allison Jewers, NP Richard Jones, MD James Kagan, MD

Diamond Kassam, MD Paul Kelly, MD David Kissinger, MD Christopher Kolly, DO Joseph Lash, MD Michael Lawson, MD Michael Leathers, MD Roger Lieberman, MD Aloysius Llaguno, MD Eric London, MD Allen Lue, MD Elisabeth Mathew, MD Clinton McClanahan, MD Robert Meagher, MD Mercy Residents George Meyer, MD Alan Mortiz, MD Patricia Ostrander, MD Vicente Quan, MD

Ivan Rarick, MD Harold Renollet, MD Gerald Rogan, MD JaNahn Scalapino, MD James Sehr, MD Christian Serdahl, MD Daksha Shah, MD Scott Siegner, MD Elaine Silver, MD Val Statescu, OD Christian Swanson, MD UCD Pediatric Residents Kirk Van Rooyan, MD Patricia Will, MD Mike Wolford John Young, MD John Zingheim, MD

The 6DFUDPHQWR 3K\VLFLDQV © ,QLWLDWLYH WR 5HDFK RXW ,QQRYDWH DQG 7HDFK 63,5,7 3URMHFW, seeks to engage volunteer physicians in the delivery of quality, compassionate medical care to the uninsured so that they may lead healthy and productive lives and to empower school-aged children, through health education and positive role models, to make healthy lifestyle choices now and in the future. With the help of 63,5,7 volunteers, county and community clinics can provide primary care services to more patients than could otherwise be seen, patients have access to free specialty and surgical services not readily available through the county system, and students in local schools receive education about their bodies and their health. To date in excess of 26,000 hours have been donated, more than 30,000 patients have been treated (including over 500 surgeries), and over 64,000 students have been taught. 63,5,7 is a program of the Community Service, Education and Research Fund of the Sierra Sacramento Valley Medical Society, a 501(c)(3) non-profit organization that exists as a vehicle to involve physicians and the larger healthcare community in community service, education, and research. SPIRIT 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 Sacramento County Department of Health and Human Services. SPIRIT also received in-kind support from Sacramento Anesthesia Medical Group, Diagnostic Pathology Medical Group, Northern California Lions Sight Association, Central Anesthesia Service Exchange Medical Group, Radiological Associates of Sacramento Medical Group, and The Effort. For more information about SPIRIT please call (916) 453-0254 or visit our website at http://www.ssvms.org/cserf/index.asp

New State Laws of Interest to Physicians for 2010 By CMA Staff DESPITE NUMEROUS VETOES from the governor, 2009 produced significant, if incremental, changes to laws affecting the practice of medicine in California. With the health system reform debate now centered in Congress, state policy makers directed much of their attention to discrete issues impacting patient access to health care, the role of allied health professionals, medical records and privacy, physician licensing and discipline, patient safety and professional liability. Below is a summary of some of the most significant new statutes enacted in California, along with references to the most relevant ON-CALL document that discusses the topic more fully. For a more detailed summary of the new laws discussed below and for a summary of other new laws impacting the practice of medicine, see http://www.cmanet.org/newlaws.

Access to Health Care Coverage for Off-Label Medications The law requiring health plans and insurers to cover “off-label” medications was expanded to require coverage where the drug has been recognized for treatment of the condition by one of the listed compendia, if recognized by the federal Centers for Medicare and Medicaid Services as part of an anticancer chemotherapeutic regimen. For more information, see CMA ON-CALL #0507, “Drug Formularies, Prescription Drug Benefit Plans, and Pharmacy Benefit Managers,” and #1071, “Coverage Requirements/Pre-Existing Condition Exclusions.” (AB 830) Rescission of Individual Health Coverage Policies or Plans This new law prohibits a health care service

plan or health insurer from rescinding an individual health care service plan contract or individual health insurance policy for any reason, or from canceling, limiting, or raising the premiums of the plan contract or policy due to any omission, misrepresentation, or inaccuracy in the application form, after 24 months following the issuance of the plan contract or policy. For more information, see CMA ON-CALL #1025, “Denials of Necessary Medical Services,” and #0145, “Payment Denial After Treatment Authorization or Verification of Eligibility.” (AB 108) Medi-Cal Coverage The new law imposes various obligations on hospitals, physicians and other providers with respect to verifying a patient’s Medi-Cal eligibility, billing Medi-Cal beneficiaries, and the reporting of Medi-Cal beneficiaries to consumer credit reporting agencies. (AB 1142) Authorization for Treatment A new law that applies to the Worker’s Compensation system provides that, regardless whether an employer has established a medical provider network or entered into a contract with a health care organization, an employer that authorizes medical treatment shall not rescind or modify the authorization, for any reason, after that treatment has been provided. For more information, see CMA ON-CALL #1929, “Treating Physicians: Payment for Treatment (OMFS).” (AB 361)

Physician Liscensing, Discipline and Oversight Disclosure to Medical Board A new law requires osteopathic physicians

March/April 2010

(like those licensed by the Medical Board) to report to the Osteopathic Medical Board of California (“Board”) at the time of initial licensure any specialty board certification and their practice status. The new law also allows the Board to collect information regarding osteopathic physicians’ backgrounds and foreign language proficiencies. For more information, see CMA ON-CALL #0220, “Disclosure Requirements State and Federal.” (SB 620) Medical Board Enforcement Clarifying that licensing boards for nonphysicians have no jurisdiction to investigate or discipline physicians. For more information, see CMA ON-CALL #1605, “Medical Assistants,” and #0708, “MBC Enforcement Authority.” (AB 1535) Medical Board - Medical Records Requests Existing law establishes a licensee’s obligations to comply with requests or subpoenas for medical records from the Medical Board. That law was amended to apply to “certified medical records,” which are defined as a copy of the patient’s medical records authenticated by the licensee or health care facility. The amended law also allows for penalties of up to $10,000 for failure to comply with a request for a patient’s certified medical records, when accompanied by that patient’s written authorization for release of records to the board, or for failure to comply

The California Medical Association’s Information-on-Demand Service (available online at www.cmanet.org) CMA ON-CALL is the most comprehensive health law and medical practice resource for California physicians. It is an online library that includes most of the Center for Legal Affairs’ California Physician Legal Handbook (CPLH), as well as more specialized information on peer review and other topics, including information from the CMA’s Center for Medical Policy and Economics. These documents are available free to members at the members-only website, www.cmanet.org/member or by calling the member help center at 800.786.4262. Nonmembers can purchase CMA ON-CALL documents for $2 per page in the CMA Bookstore, www.cmanet.org/bookstore.

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with a court order mandating the release of records to the Board. For more information, see CMA ON-CALL #1420 “Administrator and Board Access to Peer Review Files.” (AB 1070)

Allied Health Professionals Nurse Practitioners The Legislature clarified the scope of practice of a nurse practitioner (NP) to provide that standardized procedures may also be implemented that authorize a nurse practitioner to (1) order durable medical equipment, as specified; (2) certify disability after performance of a physical examination by the NP and in collaboration with a physician; and (3) approve, sign, or otherwise modify a plan treatment for individuals receiving home health services or personal care services, after consultation with the treating physician. For more information, see CMA ON-CALL #1615, “Nurses.” (SB 819) Physician Assistants The law provides under which conditions a physician may delegate to a licensed physician assistant (PA) procedures using fluoroscopy and specifies the requirements a physician must meet to supervise a PA in performing the functions authorized by the Radiologic Technology Act. For more information on physician assistants, see CMA ON-CALL #1620, “Physician Assistants.” For more information on x-rays, see CMA ON-CALL #1335, “Mammography Facilities and X-rays.” (AB 356)

Professional Liability Elective Cosmetic Surgery A physician may not perform elective cosmetic surgery procedure on a patient unless the patient has received, within 30 days prior to the procedure, and confirmed as up-to-date on the day of the procedure, a physical examination by, and written clearance for the procedure from, any of the practitioners listed in the statute. For more information, see CMA ON-CALL #0790, “Grounds for Medical Board Discipline,” and #0202, “Surgicenters and Other Outpatient Facilities.” (AB 1116) Immunities for Psychiatric Release The new law extends physician’s immu-

nity from civil and criminal liability to cover the detention of any person who meets specified criteria, whether or not they qualify for a 72 hour evaluation, and for the actions after release of a person who was detained up to 24 hours and who meets specified criteria. For more information, see “Mental Health: §5150 Holds/72-Hour Detention.” (SB 743)

Patient Safety Hospital Security Plans The 2009 amendments to existing law require, after July 1, 2010, that hospitals conduct a security and safety assessment annually and that the security plan be updated annually

based on the assessment. In developing this plan, the hospital must consult with members of the medical staff, as specified. (AB 1083)

Medical Records Management of Medical Records The law was clarified to require licensed clinics, among other licensed institutions (and now also home health agencies) to report instances of unlawful or unauthorized access to a patient’s medical information to the Department of Public Health and to the affected patient within 5 business days of detecting it. For more information, see CMA ON-CALL #1144, “Security Breach of Health Information.” (SB 337)

Board Member Statement and Profile David (Dave) Herbert, MD U Pennsylvania 1976 Internal Medicine/Infectious Disease/Critical Care Representative for District #5, Permanente Please contact me by email at: david.herbert@kp.org

Like most physicians, I feel fortunate to be able to practice medicine and intimately participate in the lives of my patients. Their triumphs, set backs, quiet courage, and even moments of anger and despair provide invaluable lessons in life and living. When not working I am an enthusiastic husband and parent of three kids aged 5 to 20. I manage to ride my mountain bike most days, and am grateful that my various aging body parts still work well enough to allow this. I participate in SSVMS as a way to insure that practicing physicians continue to have a voice at the table concerning legislation and reform relating to health care, regardless of how quickly or slowly the reform progresses. I also view SSVMS as a means for physicians in our different practice environments to get to know and appreciate each other and their organizations. Finally, SSVMS can become an increasingly powerful way for physicians to provide volunteer service to our communities. If I had known as a younger physician what I know now, I would have taken a more active role in organized medicine sooner!

March/April 2010

THE April

Art

25, 2010

Medicine

Auction

& Concert 5-8pm

The SSVMS Alliance is hosting an evening of fine art, fine wines, good food and wonderful music. The proceeds from the auction will go directly towards our Community Endowment Fund which is the sole source of funding for our grant and scholarship programs. Join our efforts to give back to the community.

How can you be a part of the success ? 1. Attend the Event and Bring a Friend 2. Become a Sponsor 3. Donate to the Auction (Wine, Jewelry, Art, Gift Certificates...)

Donations* The Alliance is looking to showcase talented Artists and Musicians from within our own medical community as well as artists and galleries throughout SacramentoTo make a donation or become a sponsor contact Gabriella Neubuerger at gabby@surewest.net or (916) 736-1613

April 25th, 2010 5:00-8:00pm Location: Pacific Design Group Interiors Studios Music: Dan Katz, MD Brass Quartet & TBA Wine: Four Bears Winery & Moniz Family Wines 2009 Grant Recipients YWCA: Breast Cancer Education PBS: Series on Asthma and Diabetes Diogenes Youth Services Mary House Women & Childrens Shelter Loaves and Fishes: Clean and Sober Program *Donations are tax deductible

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2009 Scholarships $2,500 (total): UC Davis, CSUS, American River College, Sacramento City College $2,481 SSVMS William Dochterman Scholarship Fund $5,650 AMA Foundation Medical School Scholarship Fund

Board Briefs December 14, 2009 The Board: Extended appreciation to the following outgoing Directors for their service on the Board: Katherine Gillogley, MD; Urlich Hacker, MD; Elisabeth Mathew, MD; Margaret Parsons, MD; Glennah Trochet, MD. Accepted the Third Quarter 2009 Investment Reports from Morgan Stanley Smith Barney LCC and ratified the actions by the Executive Committee concerning recommendations from the Society’s financial advisor. Approved 2010 Committee Appointments. Approved the Membership Report: For Active Membership — Mark M. Davidian, MD; Crystal O. Masley, MD; Jason B. Wesner, MD. For Illness Leave of Absence — C. Heidi Zhou, MD For Acceptance of Resignation — Douglas P. Brosnan, MD; Seeley D. Chandler, MD (moved to Washington); Brandy A. Hattendorf, MD (moved to Seattle); John S. Humphrey, MD (moved to Missouri); Gregory G. Miller, MD; Boaz Ovadia MD (moved to Florida); Kelly H. Pham, DO (transferred to Solano); Srinath K. Tamirisa, MD (moved to Missouri).

January 11, 2010 The Board: Welcomed the 2010 President, Stephen Melcher, MD and extended appreciation to outgoing President, Charles McDonnell, MD for his leadership in 2009. Welcomed the following new Directors: Jose Arevalo, MD; Robert Kahle, MD; David Naliboff, MD; Bhaskara Reddy, MD; Demetrious Simopoulos, MD. Continuing as Directors in 2010 are: Alicia Abels, MD, President-Elect; John Belko, MD; Michael Flaningam, MD; David Herbert, MD; Michael Lucien, MD; Robert Madrigal, MD; Anthony Russell, MD; J. Dale

Smith, MD. Elected Michael Lucien, MD, 2010 Secretary and David Herbert, MD, 2010 Treasurer. Reviewed the Membership Survey scheduled to be sent electronically to all Active members January 20, 2010. A similar survey will also be sent to all medical students. Results will be reviewed at the upcoming March Board Retreat. Approved the Membership Report: For Active Membership — Kathryn C. Amirikia, MD; Lesley J. Baladjay-Lindley, DO; Daniel P. Winder, MD; Jeanne Yu, MD. For Reinstatement to Active Membership — Malcolm M. McHenry, MD For Retired Membership — Anthony A. Rayner, MD For Acceptance of Resignation — Lorraine E. Abate, MD; Jason M. Guardino, DO; Denyse A. Nishio, MD; Eric G. Tepper, MD; Marina J. White, MD (transferred to San Francisco); Stephanie A. Yee-Guardino, DO.

February 8, 2010 The Board: Approved providing a donation to the following organizations for Haiti Earthquake Relief: $500 to Relief International and $500 to Doctors Without Borders. Approved the Membership Report: For Active Membership — Richard C. Lynton, MD; Swanpa R. Parikh, MD; Annie C. Yu, MD. For Active-65/20 Membership — John M. Osborn, MD. For Retired Membership — Elviro M. Bernas, MD; Maurice A. Gloster, MD; James A. Lilla, MD; Michael E. Meek, MD; Kuppe Shankar, MD; Earl F. Wolfman, MD. For Acceptance of Resignation — Amy R. Benson, MD (moved to Oregon); Michelle Draznin, MD (moved to Colorado); Michael P. Goodman, MD; Jesse P. Joad, MD (moved to Washington, D.C.); Lawrence J. Laslett, MD; Cong (Christine) Zhang, MD (transferred to

March/April 2010

July Lecture: Mare Island â&#x20AC;&#x2DC;s Naval Hospitals The Sierra Sacramento Valley Museum of Medical Historyâ&#x20AC;&#x2122;s lecture series features Thomas L. Snyder, MD, speaking about the Naval Hospitals on Mare Island, at 7 p.m. on July 14. This is the story of the first Naval Hospital on the west coast and its successors. They served navy and civilian personnel through wars, peace and epidemics for nearly a century. Dr. Snyder served in the Naval Reserve for 24 years, and served as staff urologist and medical administrator with Kaiser Permanente for 20. He is now combining his medical and naval interests to research and write about the navy hospital that once thrived across the Napa River from his home town of Vallejo. The lecture is free and open to the public at the Medical Society, 5380 Elvas Ave. Reservations are requested to ensure adequate seating; please call (916) 452-2671.

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Fresno-Madera). Approved changing from a yearly audit of the SSVMS financial position to a full audit every other year with a substantial cost savings to the Society. Reviewed a letter from SSVMS to Governor Arnold Schwarzenegger expressing concern that the merger of the Bureau of Naturopathic Medicine into the Osteopathic Medical Board of California jeopardizes the safety and welfare of patients in California. It will mislead the public by implying that naturopaths are qualified in the unlimited practice of medicine. Also, the integration of the naturopathic and osteopathy regulating bodies limits the osteopathic professionâ&#x20AC;&#x2122;s ability to regulate its physicians in a way that will best serve the safety, health and welfare of California citizens.

A New Approach to Primary Care Shortages Itâ&#x20AC;&#x2122;s going to take more than just tuition reimbursement to attract students to primary care.

By Janelle Marshall, MS II This article is reprinted from the January 2010 issue of Southern California Physician. AS WE ALL KNOW, the number of U.S. medical students entering primary care is decreasing at an alarming rate. According to the American Academy of Family Physicians, that number has dropped by 51.8 percent since 1997. As a solution, politicians focus on increasing reimbursements and tuition assistance programs. But is this enough to make a significant impact? Students are not going into primary care for a number of reasons, including a perceived lack of prestige, lower pay, and more administrative hassles related to managed care. However, in addition to these oft-cited issues, my classmates and peers seem to share an attitude that students who choose primary care are not as motivated or accomplished as those who choose other specialties. When I ask my classmates why they are not interested in primary care, they often say that they would be bored; they donâ&#x20AC;&#x2122;t want to treat colds and hypertension all day and they donâ&#x20AC;&#x2122;t feel the career would suit them. This attitude seems to be shared by students across the country. The personality type and interests of medical students are shifting, and that phenomenon is in many ways a product of the rigorous admissions criteria. For example, students must meet very high MCAT and GPA thresholds to even interview with a medical school. As a result, the lucky few to be admitted are the highly competitive, type-A personali-

ties who seek fields where they are constantly challenged and pushed to be the best. These exceptional students pursue the competitive, prestigious, and difficult-to-master specialties. Interest in primary care may be declining as a consequence. Students often decide that they want to be a specialist even before entering medical school, and third- and fourth-year hospital work reinforces this position. As students struggle to decide on a specialty, well-intentioned mentors tell them to choose the best fit. Although medical students are certainly influenced by future earning potential due to high debt load, an equally important fact is that many wish to work with physicians who have similar personalities and interests. The primary care physicians they meet are often friendly, but overworked, underpaid and justly frustrated. In contrast, many other specialists are the type-A, confident, ambitious and admired physicians with whom students identify. This pattern is not going to be easy to reverse in our current education system. Many factors must be addressed. First, primary care needs a makeover. Increased reimbursement rates are important, as it lends the specialty more prestige to attract the best and the brightest. But to effectively reverse the current trend, primary care interest groups and professional associations must work to reverse the negative perceptions that are somehow being conveyed to students. Primary care should be a specialty for which students aspire, continued on next page March/April 2010

Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. â&#x20AC;&#x201D; Michael Lucien, MD, Secretary Asaikar, Shailesh M., Pediatric Neurology, University of Bombay, India 1977, 1111 Exposition Blvd., Bldg 700, #102, Sacramento 95815 (916) 649-9800

Huang, Thomas T., Gastroenterology, Rush Medical College 2003, The Permanente Medical Group, 1600 Eureka Rd, MOB2, Roseville 95661 (916) 474-6206

Ruggles, Craig S., Family Medicine, Medical College of Pennsylvania 1996, Sutter Medical Group, 8170 Laguna Blvd., #220, Elk Grove 95758 (916) 691-5900

Behl, Deepti, Hematology/Oncology, Christian Medical College, India 1996, Sutter Medical Group, 1020 â&#x20AC;&#x201C; 29th St #680, Sacramento 95816 (916) 453-3300

Hufford, Laura E., Pediatrics, Oregon Health & Sciences 2003, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4190

Ruiz-Durant, Monica, Internal Medicine, Creighton University 1987, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 480-6507

Casas, Marcia V., Emergency Medicine, Stanford University 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Ciporen, Jeremy N., Neurological Surgery, The George Washington 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5987 Hasyagar, Chhaya P., Gastroenterology, University of Mumbai, India 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5501

Kapinya, Krisztian J., Cardiology, Semmelweis University, Hungary 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 McCart, Ian D., Internal Medicine, UC San Francisco 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6097 Nguyen, Hao T-H., OB-GYN, Eastern Virginia 2005, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-5085 Ramin, Farzad, Emergency Medicine, Medical College of Pennsylvania 1995, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5390

Struthers, Jean M., Pediatrics/Developmental Pediatrics, UC Davis 1985, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 474-2286 Whang, Catherine C., Anesthesiology/Pediatric Anesthesiology, Loma Linda University 2002, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4520 Yegul, Nakiye T., Radiology, Ege University, Turkey 2001, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4736

Shortages continued from previous page rather than a back-up plan. Medical schools must also do their part by closely examining admissions criteria to ensure that quality students are not being overlooked based on MCAT and GPA cutoffs and other cookie-cutter policies. Furthermore, schools need to attract and recruit students who have the desire and qualitative characteristics that are important for a career in primary care. Janelle Marshall is a second-year student at the UC Irvine School of Medicine and serves as American Medical Association Medical Student Section Region 1 chair and as California Medical Association Medical Student Section vice chair of legislative affairs.

Sierra Sacramento Valley Medicine

A Visit to Argentina By George Meyer, MD WE SPENT THE NEW YEAR and half of January in Argentina and had the opportunity to learn about some of its health issues while a guest in the country. The population of Argentina is somewhat less than that of California. The major poverty areas are mostly areas where their indigenous people live â&#x20AC;&#x201D; northeast and northwest parts of the country. Water from the taps is potable and tastes good. Most of the people seem healthy but obesity is becoming a problem in Buenos Aires. Argentina is well known for its beef and, believe me, it is delicious. We were impressed with how difficult it is to get green vegetables, although the salads were very good, especially with the fresh tomatoes. My wife loves avocados, which were easy to get and inexpensive in Chile; but we were told they were too expensive in Argentina. The medical school system resembles the rest of the world other than North America. Students enter the university at age 17 or 18 and go to school for 6 years. There are many public universities with large enrollments and a few private universities with much smaller student bodies. According to one source, the advantage of going to a private school, and paying tuition, is grade inflation. The public schools apparently grade much lower than the privates do. An example is that my friend had an average for 6 years in school of 67 (out of 100) while private school competitorsâ&#x20AC;&#x2122; grades were in the 90s. When they competed in a written exam for a GI residency, my friend blew away the private school competition with higher marks. When students finish medical school, there is no requirement for further training. They may go anywhere, apply to the local state administration, and get a registration number to practice.

There apparently is no licensure examination or annual licensing fee. However, most seek further training, but many are not successful. For instance, in the state of Rosario there are 600 graduates each year from their public medical school for only 100 training positions. Those that do not enter residency may go into a general medicine practice; others may take a special course and serve as EMTs on ambulances. Most residency programs (in individual hospitals) have competitive entrance examinations. Many start with a written exam and then make final selections through oral examination/ interview. Internal medicine residency usually takes 3 years and gastroenterology training 3 years. However, it is not necessary to complete an internal medicine residency in Argentina before entering a GI training program, depending upon the programs. Many training programs will accept a small number of trainees into paid positions while taking several others into unpaid positions (called concurrentes). The obligations are different for the two groups as the concurrentes must work elsewhere to pay for their life activities such as food and shelter. There is no certification examination for any specialty, according to my sources. There is a fair amount of homelessness in Buenos Aires; however, we remarked at how some of the homeless there have managed to set up a place to sleep in a wide covered sidewalk with pretty nice looking mattresses. When you walk the streets, there are frequent signs reminding you about dengue. Apparently last year there was a big dengue outbreak throughout the country. I heard different takes on the issue this year. One senior physician continued on next page

March/April 2010

According to one source, the advantage of going to a private school, and paying tuition, is grade inflation.

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À}i Ì > continued from previous page (founder of the first family practice residency in Argentina in the 80s) says the risk is quite low; another doctor, a veterinarian who works for a large company that makes vaccines for animals distributed worldwide, believes it is still a problem and the country is minimizing the incidence this summer. Apparently lung cancer is the most common cause of death of men in Argentina. This is certainly due to smoking. (Cardiac disease must be next as they are major carnivores and it is difficult to find vegetables other than potatoes on the menu.) A law from 2005 in Buenos Aires, and later in some other states, outlaws smoking in public places. Most people observe the law but from time to time we smelled smoke in a restaurant — it is not a law that is well observed or enforced. There is no governmental effort to encourage the citizens to not smoke. We saw many young people, especially young women, smoking. In addition, there did not seem to be any concerns about parents smoking around their children. We enjoyed our visit. The people were warm and friendly, the cost of living quite reasonable and the meat was spectacular. We look forward to our next visit to the south of Argentina, mostly its Patagonia area. geowmeyer1@earthlink.net

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Sierra Sacramento Valley Medicine

Serotonin Surge Charities presents

Friday, April 16th, 6:30pm to 9 :30pm at the Arden Hills Country Club A food and wine fundraiser for the following clinics and organizations that serve the medically uninsured and underinsured: Bayanihan Clinic, Clinica Tepati, CommuniCare Health Centers, CSERFâ&#x20AC;&#x2122;s SPIRIT Project, The Effort, Folsom Family Clinic, Health & Life Organization (HALO), Imani Clinic, Joan Viteri Memorial Clinic, Mercy Clinic Loaves & Fishes, Mercy Clinic North Highlands, Mercy Clinic Norwood, Paul Hom Asian Clinic, White Rock Family Clinic and Willow Clinic

Join us for an evening of fine wines, delicious food, and a lively fashion show. Learn more about these clinics and help us to honor our special guest, Mr. Pat Fry, President and CEO, Sutter Health.

Sacramento Cal Expo

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For sponsorship and donor information, please contact John Chuck, M.D. at 530-757-4114 or john.chuck @ kp.org. To register to attend, go to www.serotoninsurge.org or contact Tina Bozzini at 530-757-4121 or tina.bozzini@ kp.org. Cost is $100 per person. Early bird registration by March 15th is $75. Serotonin Surge Charities is a 501(c)(3) public benefit non-profit organization (tax ID#68-0411254).

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