2011-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2011

Get More Support

Andrew Jacobson, M.D. Hill Physicians provider since 2005. Uses Hill inSite, Hill EHR, RelayHealth and Ascender for eligibility, eClaims processing, electronic health records, practice management, secure online communications, ePrescribing, eReferrals and preventive care reminders.

Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,700 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group.

Get more information at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com

Hill Physicians’ 3,700 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

Sierra Sacramento Valley

Medicine 3

EDITOR’S MESSAGE Physicians and Tectonic Shifts in Health Care

John Loofbourow, MD

When a Heart Attack Walks in the Door

Richard N. Gray, Jr., MD

How Noisy Our Lives Have Become

Nathan Hitzeman, MD

CONVERSATIONS Earl Wolfman, MD: Founding of UCD School of Medicine

David Gunn, MD

Why Volunteer?

Ann Gerhardt, MD

New Care Options for MDs Without Diversion Program

James T. Hay, MD

A Posit on Circumcision

The Drug Expiration Date: A Costly Illusion, Part II

Scott Sattler, MD

Managing Hand-off Risk: Which Mnemonic is Right for You?

Mary-Lynn Ryan, NORCAL Group

New Applicants

IN MEMORIAM John B. Reardan, MD

Board Briefs

The Night the Old Tavern Lights Went Out

Ted Fourkas Retires as Managing Editor

Bill Sandberg, Executive Director

David F. Dozier, Jr., MD

Things I Knew and Know

Classified ads

Ted Fourkas, Erstwhile Managing Editor

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s web site. Contact the medical society for permission to reprint.

SSV Medicine is online at www.ssvms.org/magazine.asp This is another in a series of covers by Sacramento otolaryngologist Dr. David A. Evans. “This is an image of the American River taken with a digital SLR converted to infrared. Digital sensors are sensitive to infrared and generally have a hot mirror filter to remove the infrared. The camera is converted by removing this filter and replacing it with a filter which transmits wavelengths of light longer than about 650 nm. Foliage appears white in these images as the leaves reflect the infrared in a similar fashion to visible light reflection from snow. This is known as the ‘Wood Effect’ after infrared pioneer Robert W. Wood.”

July/August 2011

Volume 62/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2011 Officers & Board of Directors Alicia Abels, MD President David Herbert, MD, President-Elect Stephen Melcher, MD, Immediate Past President District 1 District 5 Robert Kahle, MD, John Belko, MD Secretary Louise Glaser, MD District 2 Robert Madrigal, MD Jose Arevalo, MD David Naliboff, MD Ann Gerhardt, MD Anthony Russell, MD Vacant District 6 District 3 J. Dale Smith, MD Bhaskara Reddy, MD, Treasurer District 4 Demetrios Simopoulos, MD 2011 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Vacant 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 David Herbert, MD Richard Jones, MD Robert Kahle, MD Norman Label, MD Charles McDonnell, MD Janet O’Brien, MD Kuldip Sandhu, MD Boone Seto, MD Earl Washburn, MD

Alternate-Delegates District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Katherine Gillogley, MD District 4 Demetrios Simopoulos, MD District 5 Anthony Russell, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Ulrich Hacker, MD Russell Jacoby, MD Maynard Johnston, MD Robert Madrigal, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Gerald Upcraft, MD Vacant Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD Very Large Group Forum Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate

Editorial Committee John Loofbourow, MD, Chair Robert Forster, MD George Meyer, MD Ann Gerhardt, MD John Ostrich, MD David Gunn, MD Gerald Rogan, MD Nathan Hitzeman, MD F. James Rybka, MD Albert Kahane, MD Gilbert Wright, MD Robert LaPerriere, MD Lydia Wytrzes, MD John McCarthy, MD Managing Editor Webmaster Graphic Design

Nan Nichols Crussell Melissa Darling Planet Kelly

Give Us A Break. The physicians at The Doctors Center are available to assist you with minor fractures. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 14 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. The Doctors Center is open from 8:00 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for most HMO’s and PPO’s.

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine DAWN M. HAYES, M.D. 20 Years of Urgent Care and Primary Care Experience KIMETTE M. MARTA, M.D. Board certified in Family Medicine

We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287

The Doctors Center Medical Group Inc.

The Doctors Center new hours are 8 a.m. to 10 p.m.

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2011 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

Sierra Sacramento Valley Medicine

Editor’s Message

Physicians and Tectonic Shifts in Health Care By John Loofbourow, MD I HAVE BEEN IN CALIFORNIA actively practicing medicine since 1959. Never have people in our state been so involved, engaged and sometimes enraged about health and medicine. The drug pandemic addressed in a recent posit is only a small part of the upheaval in health care, yet it is instructive. It affects us all in one way or another, whether as practicing physicians, or as residents in a world where drug abuse and all its ramifications precipitate deep, personal tragedy and international drug-related violence. As in other areas, legislation and regulation about drugs affects the practice of medicine as well as the well-being of our loved ones, our neighbors, and the nations of the Americas. Regardless of legality, the drug situation is complex, even when only considering prescribing. Consider this CMA physician information on prescribing for pain medication: “...In 2006, the California Legislature re-wrote Business & Professions Code §2241.5 with A.B. 2198, previously referred to as the Intractable Pain Treatment Act. When adopting the legislation, the Legislature commented that investigation and prosecution of pain management cases have evolved over the (sic) pass fifteen (15) years. …“ (GASP! I omit a few hundred words here!) “For information on the penalties which may apply for inappropriate prescription of controlled substances, see CMA ON-CALL document #0515, ‘Drug Prescribing: Unauthorized.’ “For information on prescribing and dispensing controlled substances, see CMA ON-CALL document #0509, ‘Controlled Substances: Prescribing,’ and CMA ON-CALL document #0508,

‘Controlled Substances: Dispensing.’” STOP! Despite the fact it is only a summary or guide to information, it contains more than 8,600 words, including two suggested legalistic CYA forms; don’t even consider reading it all. Read the Decline and Fall of the Roman Empire by Edward Gibbon instead, or ten boring volumes of Mao; Gibbon can at least make sense. While CMA usually provides information useful to members, we are unable to make sense of millions of words of sometimes conflicting or nonsensical State and Federal legislation and regulation. In political-industrial-medical warfare, individual physicians are outgunned, whether we are in solo, small group, large group, or academic medicine. Too many of us are missing in action. To be effective in matters of national health, or in addressing the drug pandemic, organized medicine must involve most physicians. Members of our three-county society are guerillas, acting independently though we are interconnected, through voluntary association, rather than a top-down obligatory and hierarchical union closed shop. The prescription drug problem is only a small part of the national and world health debate today. Addressing it in our recent little posit, or this little essay in this little magazine, SSVMS members are speaking mainly with one another. Yet physicians remain a privileged and respected part of society; our opinions carry weight especially when we express them clearly and with some degree of unity. Our shared thinking is best established, like all politics, at the local level. This is where we exchange views.

July/August 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

ANNE E. FERGUSON A PROFESSIONAL LAW CORPORATION

Providing legal s e r v i c e s to physicians & medical groups for more than 20 years

• Physician IPA & health plan contracts • Medical group organizations, operations & other business matters • Practice management, governance & buysell agreements • Employment agreements

Anne E. Ferguson 655 University Avenue Suite 110 Sacramento, CA 95825 Telephone: (916) 488-5388 Facsimile: (916) 488-5387 website: www.fergusonlawcorp.com This is attorney advertising.

• Practice sales, acquisitions & mergers • Medical director, hospital-physician, recruitment, call-coverage & other contracts • Medical Records, HIPAA & EHRs • Regulatory compliance, compliance programs, Stark and Anti-Kickback • Medical office leases, ASC investments & other business matters

Non-member physicians can benefit from the work of SSVMS or CMA without paying dues or taking part. But we are less informed without hearing their voice, and therefore, less able to help improve the health of our nation or our hemisphere. Communication among and between us, including that provided by this magazine, our medical society, and the worldwide electronic “net’’ is vital. We will not always agree — why should we! While it’s not free to be a member, being an active member promotes a practice of medicine that is more free. Membership in a local medical society is the best investment of money and time a physician can make. Next time you are at the SSVMS building, pick up some extra copies of the current issue of this magazine to pass on to non-member colleagues; speak with them about membership. Let them know the magazine is online, open access. Point out that, as clearly demonstrated in posit commentary, our members are sincere, thoughtful, able to disagree without rancor, and often eloquent; our opinions are remarkably diverse, though our shared concerns prevail. Communication and cooperation among us is essential as the earth moves under our feet. john@loofbourow.com

Sierra Sacramento Valley Medicine

When a Heart Attack Walks in the Door By Richard N. Gray Jr., MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

THE SCENARIO: It is 10 a.m. on a rainy morning. Some of your elderly patients didn’t come in because they don’t drive in the rain. So, you aren’t particularly rushed when 45-year-old “Mr. Jones” comes in complaining of chest pressure. A little pale and only slightly diaphoretic (or is it the rain?), he walks in smiling, in no acute distress. You know he smokes, but his blood pressure is controlled, no diabetes, no elevated cholesterol, and negative family history for premature coronary artery disease. He isn’t dyspneic, but is slightly nauseated. While your medical assistant sets up the EKG machine you examine Mr. Jones. No JVD, heart tones normal without gallop, lungs clear, abdomen benign, no edema. The EKG shows classic 4 mm ST elevations across the precordial leads: An acute anterior MI (myocardial infarction)! What should you do? What is the standard of care? The answer to these questions should be quite apparent and straightforward. However, they are not. Why not? Because, as a physician, you need to exercise medical judgment. The Issues: What standards do we have for pre-hospital management of acute MI? There are none, because management depends on the circumstances. What guidelines do we have? The American Heart Association ACLS1 guideline for acute coronary syndrome recommends activating EMS,2 which can initiate or continue MONA (cardiac Monitoring, Oxygen, Nitrates, and Aspirin) while transporting the patient to the nearest hospital capable of providing definitive cardiac care. The American College of Cardiology (ACC)

Sierra Sacramento Valley Medicine

guideline for acute MI includes a door-tocardiac cath lab time of 90 minutes.3 How do these guidelines help you? Are you “in the community,” or is your office a medical facility? Does the door-to-cath lab time start in your office, or at the hospital? If you activate EMS do you request the ambulance code 2 or code 3? Though we have made significant progress, coronary artery disease remains the number one killer of Americans.4 Evidence suggests that some of the improved survival rate is related to our ACLS and ACC guidelines.5 Therefore, we want to apply them as appropriately as possible. The appropriate application of these guidelines depends on the underlying guiding principles upon which the guidelines were based, and your particular situation. Guidelines and Terms: Why MONA? Blood flow is critical to sustain living tissue, including myocardium. Myocardium becomes irritable when its blood supply is threatened, which can lead to cardiac arrhythmias. Monitoring allows the physician to observe the cardiac rhythm while care is being provided, allowing use of prophylactic antiarrhythmics when indicated,6 or rapid recognition of ventricular fibrillation, with defibrillation should it occur. Oxygen, nitrates, and aspirin are intended to keep coronary arteries maximally dilated, while keeping oxygenated blood flowing to the myocardium and preventing propagation of clot in the affected arteries, thus minimizing damage to the myocardium until definitive therapy can be provided. If the patient develops a serious ventricular arrhythmia (ventricular fibrillation or

non-perfusing ventricular tachycardia), blood flow to the brain stops and irreversible brain damage starts to develop within 4-6 minutes. So, whatever you do, you need to be able to initiate CPR with rapid defibrillation within this time period. “Time is myocardium.” The sooner a blocked coronary artery can be opened by coronary angioplasty (or thrombolysis),7 the less myocardial damage will be done, and the better the quality of life for the patient. Code 3 means “emergency — red lights and siren.” Code 2 means “emergency — no red lights or siren” (we might say urgent). Code 1 means “routine.” This system is used with all EMS personnel: police, fire, and ambulances. An ambulance makes scheduled, code 1 transfers of patients from one place to another. Code 2 would be for an emergency where the patient is stable; e.g. a broken femur, where you want to move the patient as comfortably as possible and not wait too long, but you don’t want to make this call a greater priority than one for an unstable patient. Code 3 would be for any patient who is unstable, or potentially unstable.8 Putting It All Together: The scenario above is real. It happened to me when I was doing solo family practice in rural Paradise, California. My office was directly across the street from the hospital. I called the ICU and found they had a bed available. I put my patient in a wheelchair and pushed him across the street, and nurses descended upon him the moment we walked in the door. That course of action must be compared to: starting IV fluids, getting oxygen with associated tubing, removing EKG equipment and hooking up the patient to a monitor/defibrillator, then giving an aspirin, all of which would likely have taken more time than it took to get those services across the street, where everything is already at the bedside. Certainly there was the risk that my patient could have had a cardiac arrest during this “unattended” transport, in which case this “could be considered below the standard of care from an EMS viewpoint.”9 That risk has

to be weighed against the benefit that I could wheel him across the street to start ACLS in less than two minutes, well within the four-six minute brain damage limit. Our guidelines allow us some flexibility to use medical judgment. I would suggest that if you are seeing patients in a hospital setting (e.g. a hospital clinic), or can wheel a patient from your office to an ER or ICU within a couple minutes, and/or anticipate any delay in an EMS response, you might consider a scoop-and-run approach for your acute MI patient if he is stable at the time.10 However, if such transportation would take longer than four minutes, MONA and a code 3 ambulance would likely be the better choice. rgraymd@comcast.net

The scenario above is

1 American Heart Association, Advanced Cardiac Life Support, Professional Provider Manual; 2006, pg. 66. 2 American Heart Association, Advanced Cardiac Life Support, Professional Provider Manual; 2006, pg. 70. 3 Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) [published corrections appear in Circulation 2005; 111(15):2013–2014, and Circulation. 2007;115(15):e411]. Circulation. 2004; 110(9):e213– e214. 4 Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, TejadaVera B. Deaths: Final data for 2006. National Vital Statistics Reports. 2009;57(14). Hyattsville, MD: National Center for Health Statistics. 5 Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest. Moretti, et. al., Circulation, 2007 Mar; 72 (3): 458-65. 6 American Heart Association, Advanced Cardiac Life Support, Professional Provider Manual; 2006, pg. 49 7 “There does not appear to be a definite answer in the literature, but most interventional cardiologists would argue that PTCA is better because of the reduced risk of intracranial hemorrhage and potentially shorter times to achieving TIMI-3 flow with PCI.” George Washington University Medical School, Emergency Medicine Student Manual, Edited by Tenagne Haile-Mariam, MD. 2009 8 Patients with acute coronary syndromes if not unstable, are potentially unstable. Therefore, you request the ambulance code 3. The ambulance crew will determine its code status from your office to the hospital based on various factors. (See American Heart Association, Advanced Cardiac Life Support, Professional Provider Manual; 2006, pg. 66.) 9 Steven Tharatt MD, MPVM, former chief of Emergency Medical Services for the State of California. Personal communication. 10 Zi Jian Xu MD, PhD, FACC, representative to the American College of Cardiology from Sacramento with a community-based practice, agreed with this strategy in principle. Personal communication. [Note the difference in perspective of these last two references.]

July/August 2011

real. It happened to me when I was doing solo family practice in rural Paradise, California.

No Pressure, Just Savings!

Spending more than you have to for workers’ compensation insurance doesn’t make sense. Workers’ Compensation premiums are on the rise again, right at a time when reducing practice expenses is a priority for every physician.

The Sierra Sacramento Valley Medical Societyendorsed Workers’ Compensation program, with its 5% member discount (15% depending upon where you place your group health insurance), will be even more important to members this year. When you place your coverage with Employers Compensation Insurance Company, the endorsed program insurer, chances are your savings will exceed the 5% program discount. Rather than guess what your savings can be, take a moment to contact Marsh and let us show you how

Endorsed by:

your membership in the Sierra Sacramento Valley Medical Society can deliver a quality insurance program and exceptional savings to you.

Please call a Client Service Representative at 800-842-3761 today. The process is simple and fast.

Let us show you... how your membership in the Sierra Sacramento Valley Medical Society can save you money.

Underwritten by:

Administered by:

51497 (7/11) ©Seabury & Smith Inc. 2011 • AR Ins. Lic. #245544 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAﬃnity.com

d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #0633005

How Noisy Our Lives Have Become By Nathan Hitzeman, MD RECENTLY, I WENT ON A TEN-DAY trip to Nicaragua — a vacation of sorts in the guise of volunteer work. There was the predictable tornado of last-minute details at the office: narcotic refills, covering an OB patient of mine, a fairly intimidating packet of paperwork to justify Mr. Reed’s electric wheelchair. Slowly, I untangled myself from the debris, and nearly ran down the last few stretches of hallway like a running back with the ball, unstoppable, twirling past disability forms, faking out a medical assistant who had a call for me from the pharmacist. I burst forth into the liberating light of the parking garage, and moments later my 1989 Honda Accord sped past the checkered flag. For the next ten days I would be off the grid, pagerless, cell phone free, and the EMR I had been accustomed to finishing at home most nights would be traded for some much needed REM. Over those ten days, I went to a surf camp with UC Davis medical students with whom I would volunteer, partook of the local libations, volunteered in a Nicaraguan hospital and clinic, did minimal paper charting and no computer interfacing, and made acquaintances with many friendly Nicaraguan students and physicians. I finished the trip by deep sea fishing with a local named Antonio who lived off the ocean and had little need to wear shoes or worry about a 401K. During certain moments, when the ocean wind caressed my face, when palm trees rustled, when roosters crowed and warm sand extruded

through my toes, when I danced salsa with reckless abandon, when I found that nonverbal communication with patients goes a long way when Spanish does not come naturally, when I watched the local people hanging out in the street at dusk in front of their houses talking and laughing — I felt alive in a way that being a doctor in the US doesn’t regularly allow. It is only when I leave the noise of my daily life that I can appreciate the moment of being. In the airport, both to and from my destination, the noise of modern-day life was apparent to me in almost circus-like fashion. As I produced a book to read while waiting for my flight, people all around me were pinned to their laptops, headphones, cell phones, and iPods. Recharging stations were everywhere for people to plug in these electronic pests lest they run out of juice and had to be replaced by dreaded pedestrian human interaction. Flatscreens abounded in the airport showing newsclips and sports highlights. Almost every minute, an overhead announcement advised me to watch my belongings, that I didn’t have to give money to solicitors, and that national security was at a code orange. All around me, humanity wallowed in a sea of noise and passively, if not actively, accepted it. On the plane, I would introduce myself to the person sitting next to me only moments later to watch them scramble to put on headphones like diabetics overdue for their insulin shots. Have snippets of inane information and

July/August 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

all-things-electronic become more valued than conversing with another human being? Have I myself not been a victim of this? My grandmother could keep me captive for hours telling me stories of how she grew up in the Great Depression with nothing more high-tech than her voice and memories. Fat chance that I could do the same with my kids. But hand me the TV remote instead and I’ll deliver. Whenever my nephews visit, they are perpetually glued to their Gameboys. Even my parents can’t come over without plugging in their laptop after ten minutes to check their email or the weather update. All this noise makes me worry about a devaluing of language and words. Somehow a texted LOL on an anniversary doesn’t carry the weight of a handwritten poem or letter. And what of anticipation, wonder, suspense, imagination? When knowledge is not immediate, our minds do wonderfully well to imagine and weigh different possibilities and realities. Take away the suspense, and we merely become a passive audience to the never-ending stream of information which unfolds play by play — what would have been wondrous revealed in its entirety now banal in its increments. This cultural noise threatens the very social fabric of our tradition as doctors. Gone is the

Fisherman’s son playing on boat at sunset. Pacific coast, Nicaragua.

Sierra Sacramento Valley Medicine

portrait of the austere physician at the bedside of the infirm — two lives intimately intertwined in a glow of candlelight with a body language that bespoke of unrushed time, genuine concern, and transcending human presence. In clinic, I have to address a computer in addition to a patient, and both I and the patient harbor various electronic appendages that threaten to interrupt us at the most inopportune times. Inpatient medicine has become a tedious exercise in collecting noisy data — a pursuit of excessive labs and scans because we no longer trust what we see or hear first-hand from the patient’s body and mouth. I must see the improving pleural effusion on the X-ray, lest the patient’s progress in ambulating today be a red herring. We have little patience in waiting for a diagnosis to present itself anymore. We would rather prematurely pluck it from the womb like yet another unnecessary Caesarean-section, thanks to the often misleading noise of the fetal heart monitor. Now, several days back from vacation, I already feel the noise dial being turned up. I think about the mental exhaustion of being a doctor these days: the constant interruptions, the never-ending data sifting (most of it rote or meaningless), and a perception that more is better, quantity is quality, knowledge is wisdom, and algorithms are logic. Then I think of Nicaragua: a fisherman named Antonio watching the sunset as he pulls in his net, a couple of teenagers silhouetted by a streetlight as they part ways at a doorstep, a lady peeling mangos by the cathedral, a dying man whose hand I held on hospital rounds — the coarse texture of which told his whole life’s story. Those simple moments, real moments, human moments — help me keep the cacophonous noise at bay. I recall the old adage “Physician, heal thyself.” I recall that candles still exist. There is a time to seek out their glow. hitzemn@sutterhealth.org

Conversations

Earl Wolfman, MD: Founding of UCD School of Medicine By David Gunn, MD This is one of a series of interviews with deans of the UC Davis School of Medicine. Earl Wolfman, MD, along with founding Dean John Tupper, MD, laid the groundwork that began the UC Davis School of Medicine. Dr. Wolfman served as founding associate dean for more than seven years, beginning with the school’s formation in 1966. He was also the founding chair of the Department of Surgery and chair of the Division of Surgical Sciences, encompassing 10 academic departments. David Gunn: How did you meet John Tupper? Earl Wolfman: I was a junior medical student and he was a second year resident in internal medicine (he loved geriatrics). We just hit it off. That was about 1948. When he finished his training, he was invited to stay on faculty in internal medicine, and when I finished my training, my chief invited me to stay in the department of surgery. In fact, he almost demanded. When your chief said, ”You ought to do this,” you didn’t hesitate very long. Our clinical relationships were very strong. DG: You were really friends first and colleagues second. EW: We remained colleagues and friends forever. Right up until the time when he went to bed and didn’t wake up. DG: For the people who didn’t have the privilege of knowing John Tupper, maybe you could share a memory that would describe who he was as a friend. EW: You might say we were kind of activists when we were in Ann Arbor [Michigan]. The medical staff there was divided amongst the

faculty. There was a junior medical advisory staff that was made up of instructors and assistant professors. And there was a senior medical advisory staff that was made up of associate professors and professors. We’d get over to the junior staff meetings, and it was just a rinky-dink, a luncheon. Somebody gave a talk about pruritis and ingrown toenails or what have you; that really wasn’t a turn on. Officers (chair, vice-chair and secretary) of the junior staff were invited to attend the senior meetings, and that was a formality. You sat in the back of the room with all of your former teachers there. There were problems in the institution [that should have been solved there] and they weren’t. For example, most were on full-time salaries that were non-negotiable; and other [work related policies], like on-call quarters, etc... John and I discussed this, and decided he would run for an officer position in the junior faculty, and he did. As such, he was invited to attend the senior faculty staff meetings. The first time he came in, he didn’t sit in the back of the room. He went up to the head table with the other officers — and that kind of shocked a few people. But it finally caught on, and when we left Ann Arbor that was the way it was. DG: So he took problems head on, and was unafraid to create a stir for the greater good. EW: Yeah, we had a lot of respect for each other. We were very active in organized medicine. I was chair of the state medical society; John was editor of the journal of the state medical society. And we were members of our county medical society — there weren’t more than two

July/August 2011

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

”Davis has a unique constellation of resources.” That statement should be made more frequently these days, because it really is a special place.

or three other people at those meetings. We believed that academicians should be a part of the profession of medicine, not apart from it. DG: Why do you think it is important for people to belong to their local medical societies? EW: Because they are affected by things going on professionally, and if they don’t belong, then they’re really freeloaders. They say it ”doesn’t increase my income any,” but they fail to see what is done from the medical society. DG: I hear faculty tell me they’re not members of the AMA because they think the AMA is a greedy, self-serving organization. They don’t want to be part of an organization whose sole purpose is to increase their salary. EW: That is a bit of hogwash. The reason UC Davis School of Medicine is here relates to the concept you’re talking about. In the late 1940s, concerns were expressed that we were headed for a shortage of physicians. The AMA wanted a shortage based on the economic principle of supply and demand. We got into a situation where we did get into a shortage, and a number of new medical schools were formed. We admitted our first students in 1968. DG: Let’s talk a little bit more about how this developed. EW: I received a telephone call from a fellow by the name of Emil Mrak, the second Chancellor of UC Davis (1959–1969), the most fascinating, competent...I can’t express enough accolades because he was just...unique. He was looking for candidates for the deanship. I remember Tup and I were attending the Michigan State Medical Society meeting. He came up to me and said, ”Geez, I just had an interesting phone call. The Chancellor at UC Davis called me and wanted to know if I would be interested in the deanship.” At that time Tupper was associate Dean at the University of Michigan. He invited me to come out and bring a senior person with me who might also want to know about Davis. I said, ”What in the heck is Davis? I’ve never heard of it.” He said he’d heard very little of it, but “my mother lives in Sacramento and it will give me a chance to visit.” So I agreed to come out, and another fellow

Sierra Sacramento Valley Medicine

agreed to come out, for a more formal visit. I did it because of John. We met Emil Mrak, and we were here for three or four days DG: Did he explain how Emil Mrak got hold of John Tupper’s name? EW: No, just his reputation at the University of Michigan. I’m sure that was it. We met the Dean of the School of Veterinary Medicine — which is very desirable because one of the goals of UCD SOM was to develop animal models of human disease. So we get back to the motel room, worn out from everything, and we came up with a phrase we would use for recruiting candidates, that ”Davis has a unique constellation of resources.” That statement should be made more frequently these days, because it really is a special place. DG: So then what happened? EW: Well, the wives hadn’t come out yet, so we didn’t agree to anything [laughs]. But we met at the old Voyager Inn and talked about it quite a bit. We got back after the trip of November of 1965, and met at my house. The day after Thanksgiving we met — it wasn’t the week before because that was the Ohio St.-Michigan football game. DG: Who won the game that year? EW: Well, I have no idea because something bad happened that year. John called our third partner’s secretary to set up the meeting with our wives, and was told he was on the phone with the NIH [National Institutes of Health], but she would call back when he was off. When the secretary called back, she said, ”John, I’m sorry, but he’s just died.” You can imagine the shock. So the four of us met instead, and we decided to take them out to see for themselves first hand. After the visit, we indicated to the selection committee that we’d be delighted to come. DG: What did the Chancellor ask you to do? EW: Start a medical school. DG: Did he give you any direction as to the goal? EW: He was an agricultural guy. He just said, ”Start a medical school.” But let me back up. This was in November 1965. In 1963, the

California State Legislature authorized a new medical school on the Davis campus, San Diego and Irvine. So when we got here, there were no buildings, no nothing. They hadn’t started doing anything. John came out in February, and I came out July. I made five or six trips during that time, working on plans. I had a surgical residency approved before I got here! One of the advantages to Davis was its attitude of change. I had visited several schools during this time, and they all had this unsaid attitude that as long as you stay on this straight line of not rocking the boat with intellectual freedom to be an activist, you’ll be fine. And that was always reason enough for me not to go to any of these other places. But we did have ideas, like a department of family practice — UCSF didn’t have one, and what about geriatrics? DG: These other schools gave you the feeling of keeping the status quo, and that wasn’t what you were interested in doing. EW: Yes, yes, yes. DG: What do you mean when you say activism? EW: We wanted to bring things up to date. DG: You were relatively young at the time, 39. John Tupper a few years older, in his early forties? EW: Yeah, we were young. But we were able to be activists because there was an administration that welcomed it. As far as Chancellor Mrak was concerned, he said ”Tell me what you need.” And by gosh, we did. It started as a farm for Berkeley, and it continued in that vein, and didn’t become a general campus until 1959. That was only six years before we came to visit. So Chancellor Mrak was quite a leader. DG: What were some of the first challenges you faced in starting the school of medicine? EW: We never called them challenges, we called them opportunities. It’s an attitude. We knew there would be things that had to be done. The school had two reputations. First, we were a general practice medical school, and second, it was referred to as Michigan West (because of the faculty we brought over). As far as one of our opportunities, we were the subject of a landmark Supreme Court decision forcing

us to accept a medical student. [Regents of the University of California v. Allan Bakke, 1978]. DG: What was that like from an administrative point of view? Did most people agree or disagree with the decision? EW: That’s a hard question to answer because I’m not familiar with the details — we just got the decision. But from a gut feeling, I think it was a reasonable decision. But it could have been reasonable the other way, too. DG: Did you have any sense the faculty wanted more esteem and respect while you were there? EW: Well, in my department, they wanted autonomy. When the departmental system was removed just a few years after we started, we lost our accreditation within two years. DG: And why do you think that was? EW: I think personalities got in the way when we lost the central departmental chief. Departments stopped working well together, like cardiology pointing the finger to cardiothoracic surgery. DG: You’re referring to the controversy Dr. Hibbard Williams oversaw during his early tenure. EW: Yes. The Chancellor really was in charge of overseeing this organizational change, and it happened so quickly, it must have been an issue before Hibbard came on. The departmental sections really wanted more autonomy, and this ultimately led to the lack of accreditation. DG: Interesting. I had heard that Dr. Tupper had worked with the California Legislature to found the school, but it sounds like that’s not the case. The school’s founding was in place before you and Dr. Tupper arrived. EW: We got here in 1966-1967; we had seven faculty members, John Tupper, Earl Wolfman, Robert Bolt, Hamilton Davis, Loren Carlson, Ed Krebs and Bob Hunter. DG: What message would you like to share with the medical community? EW: We couldn’t have done it without the medical community. The local medical society was so very helpful.

One of the advantages to Davis was its attitude of change.

dgunn11235@gmail.com

July/August 2011

Why Volunteer? By Ann Gerhardt, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

PEOPLE SEGREGATE OUT IN ANY number of ways. Omnivores vs. vegetarians. Those who volunteer vs. those who don’t. Those who wear underwear vs. those who don’t. Differences make people interesting and, to me, the motivation behind volunteerism is interesting. Volunteers don’t necessarily have more time. Full-time employment doesn’t keep enthusiasts from helping at charity events, schools, river parkway clean-ups and food banks. Even doctors, usually busy people, find time to build houses in Mexico or help with free clinics, here or abroad. We make time for what we want to do. Most of the doctors precepting at the seven free UC Davis clinics also toil at day jobs, yet they love their time at the clinics. Sort of a feel-good busman’s holiday. Nate Hitzeman is Instructor of Record for Clínica Tepati, which serves Sacramento’s indigent Latino population. He has a full-time practice with Sutter Medical Group and is still raising children. He believes “there is something pure and uplifting about volunteering. The money, bureaucracy, and what is often felt as cumbersome oversight in our daily lives is replaced by that quintessential healer and patient interaction. Sprinkle on that some eager and impressionable learners (1st and 2nd year medical students) and what more could you ask for? Who would have thought working for less gives you more!” Brenden Tu works a day job at a Woodland community clinic five days a week. Almost every Saturday he works as Clinic Director at Clínica Tepati. He does it “to remind me of why I became a doctor.” The time and bureaucratic pressures of his week-day job take the fun out of medicine. On Saturday he reclaims the idealism that took him to medical school. “I thrive on the energy of the place, the enthusiasm of students excited to learn, the patients’ gratitude

Sierra Sacramento Valley Medicine

and a chance to teach.” Doctoring allows you to help people, so why do it for free? Because doing it for free for people who would otherwise go without gives a different feeling. When people know you are doing a paid job, an entitlement/obligation goo oozes into the relationship. You no longer deserve their gratitude, since the legal tender becomes your compensation. Your doctorpatient interaction leaves the realm of personal to enter a commercial domain. How many of you feel fuzzy about your shoe salesman or financial advisor? Certainly some patients in paid medical practices show gratitude. Hence the trinkets at holiday-time and occasional hugs. But often that gratitude results from physician behavior that the patient perceives as above and beyond the call of duty — maybe extra office time to solve a difficult problem or a personal phone call not delegated to a subordinate. Sounds like behavior resembling volunteer work. Many health care professionals go abroad for their volunteer work. Why volunteer in third world countries when we have poverty and 42 million uninsured right here in the good ole U.S.A.? Jim Rybka says, “It may elevate you to talk around town about your recent volunteer trip in a third world country. Less ‘sexy’ is volunteering with the SPIRIT program. This program works within the bowels of Sacramento where indigents abound. They have absolutely no health insurance, yet they need help, sometimes desperately.” He has volunteered “because I was inspired by a few older docs like Fred Pratt and Otto Neubuerger who faithfully volunteered until they died in their mid 80’s” My scandalous opinion, based on having exposure to volunteers in both settings (not necessarily doctors), revolves around the nebulous concept that familiarity breeds contempt.

Some have a vague idea that the American poor just don’t try hard enough, there is too much entitlement, those pesky illegals shouldn’t be here anyway and there are plenty of programs for the American poor to access. So they go to some exotic place to help people for whom they believe there is no alternative and where one will be appreciated more. Phooey. Looks of gratitude from patients and students are the same in any country. As I see it, the only reason to help overseas, rather than here, is to learn a new culture and get a cool vacation out of it at the same time. Michael Lawson has volunteered in a number of countries, including the U.S. For him it gives an inside view of a country, is a good way to travel and be immersed in the culture. He’s worked in clinics, but his fondest memory is teaching ERCP [Endoscopic Retrograde Cholangiopancreatography] to surgeons in Nicaragua, feeling that “the more you leave behind in a third world country, the better. We do well in life and get to work at something we enjoy, so it’s a way to give back.” He also enjoys teaching in the student-run clinics and getting to “hang with young people. Of course we do it for ourselves as much as for others — we wouldn’t do it if it were a miserable experience.” Michael’s comments echo the overwhelming sentiment expressed by other volunteer doctors: We get as much or more out of it than we give. David Gunn volunteers “because I believe selfless service to others is the highest calling to which we can aspire. Lofty words, but the principle is true — just try it out. Spending the day helping others is the quickest way to take your mind off of yourself and your ‘problems.’ It cheers you up and brings you a satisfaction that is better than most.” John Loofbourow likes “to volunteer because it expands my little universe. When I volunteer I step for a few hours or weeks out of my normal life into a mini-life, another existence, then return with greater appreciation for my own life. Whether I am admitted to a new world here or in another culture, I connect to new people and places, and often to a new truth. I like to make my presence there meaningful. Even when I

volunteer to build a house, I do it always as a physician to whom doors, hearts, and minds may be opened simply because of my profession. I like to use my years of training and experience in a way that may be meaningful and unselfish. But I do confess that by volunteering, I always receive more than I can possibly give.” George Meyer admits up front that he volunteers “for selfish reasons. I learn much more than I give. I get great love from those I attend to and I get to go to some wonderful places like Saint Lucia, Lima, Phnom Penh through Health Volunteers Overseas. When I work in the student-run clinics I get to be around wonderful, enthusiastic and caring undergraduate and medical students.” Gib Wright felt he “didn’t have anything better to do” after retirement and “wanted to continue being a doctor and find some way to continue my interest in prosthetics.” After some non-prosthetic volunteer efforts with the Rotary, he achieved his wish by helping to set up a prosthesis clinic in El Salvador for treating land mine victims. He developed a system for making BK [Below-Knee] prostheses in the field, and is quite proud that local doctors have continued using the system after his departure. For me it’s a compulsion. I basically charge money for my day jobs to fund my volunteer addiction. I enjoy helping people who would otherwise go without a proper diagnosis and treatment, regardless of the location, but the addiction is to teaching more than treatment. Teaching a patient self-care prevents illness. Teaching medical students and doctors in any country allows many more to be treated. Dispelling myths via my newsletter, DrG’sMediSense, hopefully leads to healthier lifestyles. I’m certainly no Osler, but I treat outof-the-ordinary patients and love to link basic science mechanisms to day-to-day medicine. The thought that un-taught knowledge could be trapped inside my head generates feelings ranging from panic to despair. Why do we volunteer? Gerald Rogan sums it up with a comprehensive list: “I volunteer because I can still practice medicine and help people, find pleasure in service and being a continued on page 28 July/August 2011

“We do well in life and get to work at something we enjoy, so it’s a way to give back.”

Ted Fourkas Retires as Managing Editor By Bill Sandberg, Executive Director

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Ted Fourkas has been the Managing Editor of this journal since 2000 when Yolo County Medical Society joined the Sacramento-El Dorado Medical Society to create a new organization. In that year we started with a new name, the Sierra Sacramento Valley Medical Society, and a newly named and designed journal complete with beautiful color covers. In editing 63 issues of the journal, Mr. Fourkas has distinguished himself as a skilled and highlyrespected editor and a friend to many members of SSVMS. Editing anyone’s work can be a challenging and sometimes frustrating responsibility. In the hundreds of submissions that he edited, I can report in all honesty, that we never received any complaint about his editing. In fact, most authors have been highly appreciative of his skills and thankful for his assistance. I first met Ted when he was with The Sacramento Bee and I was at Roseville Community Hospital during the early 1970s. His beat was medicine and science. He had already served as a reporter for various Northern California newspapers. Our magazine is put together by our physician editor and the managing editor with the aid, assistance and oversight of the Editorial Committee. It’s a journal by physicians and for physicians with a proud heritage of over 60 years of continuous publication. John Loofbourow, MD, is the current Editor and Chair of the Editorial Committee. Nate Hitzeman, MD, is our Vice Chair. With this July/August issue, Nan Crussell assumes the role as Managing Editor. She has worked with Ted in making the transition. Nan

Sierra Sacramento Valley Medicine

has had a fascinating career starting as a reporter and feature writer for The Bee, then owner and editor of a weekly newspaper, The Anderson Valley Advertiser, in Boonville, a toy store owner in Mendocino, and owner of Nan Crussell Computer Services, a bookkeeping and tax preparation company. She has also earned certification as an Enrolled Agent with the Internal Revenue Service, and is a licensed pilot. She is the author/editor of two books: Escape From Folsom Prison–The True Story of William Jennings Bryan Burke; and Nova Scotia Memories–Folklore of the St. Mary’s. She has also written for our Journal. In her spare time, she manages two websites, www.HiddenCalifornia. com, a travel website, and www.Silentwords.com, a poetry website. “Ted is a wonderful friend and teacher,” Nan states. The two of them worked together at The Bee in the editorial department, and are now joining efforts in making a smooth transition for the SSVMS magazine. Please welcome Nan Nichols Crussell. bsandberg@ssvms.org

Ted Fourkas

Nan Crussell

Things I Knew and Know By Ted Fourkas, Erstwhile Managing Editor THERE ARE THINGS YOU KNOW are true. Until they change. In the 1960s, when I was on the staff of the State Assembly, I knew switching to a full-time Legislature could only improve things. California already had what was arguably the best Legislature in the nation. Think of what could be done with more time in the Capitol, with more income so members could avoid some of the distraction of a job back in the district. What happened, of course, was the expansion of career politicians. This certainly did not lead to a better Legislature. In my mind, career politicians are a big reason for the destructive polarization of the two major political parties. Term limits didn’t help matters; they simply led career professionals into a game of political musical chairs. I once knew what made a good writer: An interesting start (in newspaper jargon known as a “lead” or “lede”). A writing style that made reading effortless, so the type seemed to disappear from the page. A dynamite ending that left the reader satiated, and perhaps pensive. So why did I come to think of the late Dr. Eleanor Rodgerson as a good writer? She wrote articles observing the world about her, often in the company of her dog, Michael. She avoided not only dynamite endings, but usually conclusions of any sort. She drifted into her articles, and eased out of them. But she invariably did it in one page. During 10 years of laying out Sierra Sacramento Valley Medicine, I came to treasure one pagers: they can go anywhere in the magazine, solving a lot of problems. Two pagers are more difficult, and multipage articles are a headache. I now know what a good writer is: someone who can tell a story in about 425 words. I once knew what physicians were: compul-

sive, narrow-minded, ambitious, boring premed students (that’s why I abandoned pre-med in college; I couldn’t imagine spending the rest of my life surrounded by people like them) who grew up to be grasping, workaholic, right-wing Republicans. Until I started covering medicine and science for The Bee. I discovered the local physicians’ role in starting the blood bank, a Professional Standards Review Organization and, later, an HMO. I covered the new medical school at UC Davis and realized that, unlike premed, medical school can be interesting and exciting. I once knew that it was a big step forward when local docs lost control over the Sutter Hospitals in the wake of the Miofsky scandal. Now I’m not sure it was a step forward at all. I once knew that trying to edit physicians would be a pain in the butt. How do you tell these arrogant (albeit intelligent) people that their writing could be improved? Very easily, as it turned out. I’m not sure why. Perhaps the docs looked upon my efforts as just another referral. Anyhow, they were very open and receptive to suggestions. I’ve come to the conclusion that doctors are good people. Even the right wingers. I once knew that the best editor, or boss, or executive, was irreplaceable. Without him or her, an enterprise was in deep trouble; it would falter and perhaps collapse. Now I know that if you’re really good, things will go on without skipping a beat. If you’re good, your departure will be invisible. Which is, of course, what I hope happens to this magazine. And last, but not least, I know I will ease out of this piece in one page. Like Eleanor.

I’ve come to the conclusion that doctors are good people. Even the right wingers.

t4kas@comcast.net

July/August 2011

New Care Options for MDs Without Diversion Program By James T. Hay, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

WHEN THE MEDICAL BOARD OF California voted in June of 2007 to end its nearly 25-yearold Diversion Program, the California Medical Association (CMA) responded quickly by convening a work group of interested stakeholders that included, among others, the California Society of Addiction Medicine (CSAM), the California Psychiatric Association (CPA), and the California Hospital Association (CHA). Our purpose was to establish a legislativelyauthorized, independent, non-profit entity to assume leadership for the State in matters related to physician health. Looking back and realizing that we have been working on this for over three years, we are reminded that nothing is easy in a state with the size and diversity of California. [NOTE: the Diversion Program was a monitoring plan that allowed physicians, impaired due to substance or alcohol abuse who were violating the Medical Practice Act, a pathway to “divert away from” disciplinary action and also for physicians with substance use concerns who were not subject to discipline to participate in the program. The program provided public protection by including monitoring controls on impaired physicians to prevent them from working while under the influence. It required participants to sign contracts mandating their adherence to certain treatment conditions. Physicians had to remain in the Diversion Program for at least five years and participation in the program was confidential.] In 2009, the workgroup succeeded in the creation of a new, independent non-profit 501(c)(3) organization called the California Public Protection and Physician Health, Inc. (CPPPH). It has a small board, with a newly-

Sierra Sacramento Valley Medicine

appointed Executive Director, Sandra Bressler, who while at CMA, was known for her many efforts to preserve the Diversion Program. It also works with a top-notch clinical advisory committee and has been the recipient of over $100,000 thus far, to underwrite some of the costs of starting the new organization. The funds are donations from all sections of the medical community, including the Sierra Sacramento Valley Medical Society, many specialty societies, the CMA and other county societies (and their foundations), the California Hospital Association, and some of California’s liability carriers. Individual donors have contributed as well. In both 2008 and 2009, bills were introduced into the Legislature to create a physician health program and to secure funding from physician licensing fees. The first one passed both houses, but the Governor vetoed it. The second was introduced, but was not advanced due to a likely second veto. Now, CPPPH’s funding partners are pursuing a new legislative effort. SB742 (Lee) has been introduced as a placeholder for our renewed efforts to secure the authority to receive funds from licensure fees from all California licensed physicians and to get the legislative recognition for establishment of a statewide program. The new program being phased in by CPPPH will serve as the central entity that can provide physicians and other consumers (hospitals, well-being committees and treatment providers) with a comprehensive resource for evaluation tools and service referrals, as well as individual case consultations, information about education and treatment, monitoring

programs and testing services. Once permanent funding is in place, an expanded, full-spectrum physician health program standardized to evidence-based data on treatment outcomes will become possible. Private organizations and programs emerged when the Diversion Program closed, and they provide some of the needed services. But there is yet a broader need. The programs are not coordinated or widely accessible, and there is significant concern that some physicians who need ongoing support and monitoring are continuing to practice without such aid and supervision. CPPPH is designing its physician health program to include both a wellness component and all the elements necessary to assist those who are responsible for assuring safe and quality patient care. Our efforts will proceed in stages. Parallel with the immediate legislative effort, we are also working to expand our regional well-being committee network with consultation services for all who request them.

We plan to identify standards and guidelines for all elements of the program including for the providers of physician health services. With permanent funding from licensure fees, we expect to create a stable, solid organizational structure capable of assuming responsibility for a robust, statewide physician health program. We anticipate coordinating the provision of monitoring services, where needed, and to offer a wide range of options to preserve and restore physician health over any physician’s lifetime. With the new administration in Sacramento, with hard work, and with the continued support from the medical community and our state agencies, we will get there by 2013. You can learn more about our organization’s plans and progress at our new website, http://www.cppph.org. Dr. Hay is Chair of the Board, California Public Protection and Physician Health. CPPPHInc@gmail.com

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

www.bloodsource.org

not-for-profit since 1948

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

July/August 2011

A Posit on Circumcision BACKGROUND: An upcoming San Francisco ballot initiative states it would be “unlawful to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years.” Violators could be charged with a misdemeanor. If found guilty, they could face a year in jail and a $1,000 fine. An exception is made for circumcisions that are “necessary to the physical health of the person on whom it is performed because of a clear, compelling, and immediate medical need with no less-destructive alternative treatment available.” POSIT: “Circumcision of male infants is child abuse, and, with rare exceptions, medically unjustifiable.”

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Among those who responded, the results were: Disagree,141 (91 percent); Agree, 14 (9 percent). While it was predictable that a majority of our members would disagree with the posit statement, this is a case where it is arguably of value to consider a matter where the medical community has a predominant viewpoint, and is willing and able to express that clearly. Edited commentary below is consistent with the numbers. As our use of posits continues over the years, it is notable that members are less likely to become outraged by posits, even when we are at gut level disagreement. We are unlikely to take posits personally, or to be offended by politically incorrect posit statements. It seems clear that strongly stated and frank dialogue is appreciated by SSVMS members. – Ed. In James Joyce’s Ulysses, God is called the Collector of Prepuces. David got to marry King Saul’s daughter by collecting a couple of hundred “foreskins of Philistines.” Obviously the foreskin was a major currency with God, with one’s enemies, and with one’s culture. But perhaps a dead Philistine warrior is differ-

Sierra Sacramento Valley Medicine

ent than a child. Many tribal religions subjugate women, and require boys to be initiated cruelly into the male-dominant sexual order. The ancient Romans commented on that. In our culture the tendency to circumcise may reflect the historic sacrifice of the prepuce. Well, it could be worse. We must be thankful that our gods did not become similarly enamored of the clitoris. On the other hand, there is no evidence that the bloody rites of male initiation in patriarchal societies has really protected women. Probably the opposite. One wonders what the neonatal brain experiences during a circumcision. An FMRI during the procedure would be interesting. I did one “circ” as an intern many years ago. That baby’s response convinced me that I was inflicting pain for no medical reason, a violation of our Hippocratic oath. That was the last one I ever did. — Jack McCarthy, MD As an internist who has treated many men with phimosis, balanitis and squamous cell carcinoma of the penis, I oppose the effort to restrict circumcision. Carcinoma of the penis ONLY occurs in uncircumcised males. The effort to restrict circumcision is based upon ignorance of the medical consequences of having a prepuce. — Michael Patmas, MD Seventy-five to eighty percent of the female patients under the age of 18, whom I see in my Pediatric Fracture Clinic, have their ears pierced. Is this mutilation? The majority of the girls under the age of five whose parents are Hispanic, Hmong, Vietnamese and AfricanAmerican have small stud earrings. Is this mutilation? These children were not asked their opinion regarding having their ears pierced. There are cultural and religious reasons behind these decisions, as well as with circumcision. Threatening these parents with fines and incarceration simply makes no sense. Ear piercing and circumcision do not fall into the

category of mutilation. The individuals proposing such legislation are being insensitive and ignoring cultural traditions which have been in place for centuries. — Michael Klein, MD When performed in a hospital, it is performed with the same standards required for other minor surgical procedures. Studies suggest benefits in protection from certain STIs, and I am not aware of any major side effects of the procedure. All this ballot initiative will do is increase costs of the procedure because now doctors will have to write a justification for doing it. — Olivia Kasirye, MD, Health Officer, El Dorado County Circumcision is not only an important cultural practice for many in San Francisco, but also has been shown to be protective against STIs, making it a potential tool for public health. — Katherine Crabtree, MSII My strongly-positive position on infant circumcision began in my Air Force tour when, once a week, a group of young men were lined up, given a general anesthetic (with attendant risks), and had an adult circumcision performed using incisions and sutures. Their post-op pain was intense. These men had phimosis or chronic/recurrent balanitis (about three percent of uncircumcised males have the latter). Particularly since the introduction of the PlastiBell, a careful, judiciously-performed circumcision the day after birth is a quick, minimally painful procedure to prevent the more dangerous and painful adult circumcision. In addition, there are the public health hazards of transmission of STDs, including HIV. Questions of decreased sensitivity are very debatable. — James Affleck, MD I came to the conclusion several years ago that routine circs are inappropriate. Since they are legal, it is hard to call the procedure child abuse. I’ve done over 1,000 circs in the past for which I feel a lot of remorse. About ten years ago I refused to do any more, and I speak aggressively against them if I’m asked. We at Kaiser still provide circs without charge if done within the first 30 days of life. I consider male circumcision, like female circumcision, to be genital mutilation. There is NO justification

for routine circumcision and I support the San Francisco initiative to ban them. — Maynard Johnston, MD What constitutes abuse is some of the actions that the people of San Francisco dream up from time to time. This is blatant anti-Semitism and if you weren’t convinced before, go online and view some of the stereotyping of Jews in this group’s advertising that is clearly reminiscent of Germany circa 1936. No exaggeration – view it yourself. — Steven Polansky, MD According to a 2007 report by the World Health Organization, 30 percent of males worldwide are circumcised. Circumcision is perhaps civilization’s oldest known surgery, with Egyptian wall carvings from 6000 years ago (predating Abraham) depicting the procedure. That’s a tough sell to me that a custom this steeped in history and religion can be abuse. And what’s with the double standard? From the amount of body piercings I see (and the ones I don’t see!) on SF folks, obviously they feel it is ok to mutilate the body after 18 years of age! — Nathan Hitzeman, MD Circumcision is a rite that has been practiced for millennia. It is inconceivable that Jews would not be able to circumcise their sons, nor others who do so on behalf of their children. — Richard Gray, MD First of all, it is another attempt to intrude government into medicine – this is a medical issue. I really resent anybody setting up rules for medicine; we need to do this. It reminds me of Berkeley passing an anti-shock treatment measure. Some have approached this as anti-Semitic – this is not a Jewish issue, but a medical one. There is no evidence that (it) is traumatic to young children. From a health standpoint – there is ample evidence that shows that circumcised males have lower HPV and their wives lower cervical Ca; it has also been shown in third-world countries that the incidence of AIDS is much lower in circumcised males. — James Margolis, MD I would want religious and cultural exceptions to this law. The circumcision of male infants is an important part of Jewish and

July/August 2011

According to a 2007 report by the World Health Organization, 30 percent of males worldwide are circumcised.

Legislating medical practice is never a good idea…

Islamic religious practice. — David Katz, MD Circumcision is a controversial procedure with medical justification found on both sides of the argument. Therefore, unlike female genital mutilation, there should be no restrictions placed on this. If you do not agree with circumcising your child, don’t do it. If you do not agree with circumcision as a physician, don’t offer it. But do not go through our outdated ballot initiative process to tell the medical world how to practice. — Jeffery Rabinovitz, MD This is another example of social engineering by a city with a lot worse problems. We are creating a nanny state. I also object to this on religious grounds. — Peter Carruth, MD I agree that it is medically unjustifiable, but cannot go so far as to agree that it is child abuse. — Gregory Joy, MD A ridiculous statement. (Disagreeing) — Charles Kesmodel, MD Circumcision is a surgical procedure performed by a physician, mostly on newborns, at the request of loving parents, not child abuse. — Jose Cueto, MD There is strong evidence that cells within the foreskin can transmit sexually transmitted disease. — Norman Label, MD Even by San Francisco standards, this is lunacy. — Sally Cullen, MD Just plain ridiculous. — Richard Meyers, MD I feel the decision for circumcision should be driven by parental desires/religious beliefs. I disagree that it represents child abuse. —Alexander Chen, MD Only in San Francisco can such absurd statements arise! — Wayne Matthews, MD I do not feel abused at all, and I can medically [justify that] (circumcision). — Reinhardt Hilzinger, MD Insane Government Representatives! — M. Speicher, MD I am offended to even see this question raised. Why not ban all ear piercing of girls under age 18? There is strong evidence to support the health benefits for circumcision. What are the health benefits for pierced ears in a two-year-old or anyone for that matter?

Sierra Sacramento Valley Medicine

Obviously this discussion is being promoted about circumcision and not ear piercing because the organizers have at their heart an agenda that has nothing to do with health or the protection of infants/children. The proposition that circumcision be criminalized is the most disgustingly blatant and hateful anti-Semitic notion I have ever seen promulgated in America. It is an embarrassment as well as a horror to see before us bias and innuendo that invokes memories of Nazi Germany. — Bruce Barnett, MD The posit says it: There is NO compelling medical reason for ritual removal of normal genital anatomy (in EITHER gender) and to do so could certainly be considered abusive. — James Sehr, MD In our rush to appear “politically correct,” are we to deny members of society the ability to follow their religious and cultural traditions? — Jonathan Wardell, MD It is not needed and is mutilation of nature. — Prabhakar Kollipara, MD I personally disagree with circumcision, but I feel it should continue to be allowed. — Charles Maas, MD Leave circumcision as a decision made between parents and medical or religious providers. — Monte Ikemire, MD “Female Circumcision” should be similarly, explicitly prohibited. — Kent W. Jolly, MD As with any medical procedure, the choice should be made by the patient (or in this case in which the patient is a minor, by his parents) after consultation and informed consent. Legislating medical practice is never a good idea, especially in this instance where the proponents of the ballot measure have a social and political agenda which has little or nothing to do with medical care driving their efforts. — Mark Blum, MD I understand that the “civilized” world is horrified at the African tribes who amputate the clitorises of their babies to prevent their babies from ever having orgasms. What’s the difference? — Geoffrey Woo-Ming, MD Circumcision should be allowed for religious reasons. — Phillip Messah, MD The minority again tyrannizing the major-

ity. — Colin Spears, MD Although the benefits may be more social or religious than medical, criminalizing circumcision will lead to back alley procedures – anybody remember all the infections, death and disability that occurred when abortion was illegal? — Katherine Stewart, MD Yet another example of SF going overboard. — Richard Astorino, MD Legislators should not be making medical decisions. Are they banning all Jewish infants from the city? —Terry J. Zimmerman, MD As a “member of the tribe” (albeit a fallen one), I do have some strong feelings on the subject. Firstly, I would suggest a case (either in San Rafael or Vallejo) wherein a TPMG physician was sued by his wife to block the circumcision of their son. I believe that she lost the case…If Bill Petrick is still TPMG’s legal counsel, he would recall same.

This being said, I cannot believe that any court would uphold such a law, or that it would be passed. The first question that this “saviour” of the newborn will have to answer is, “What is his standing in this issue?” It can’t be simply anti-semitism, since the Muslim faith also follows this practice. He should join those who are objecting (through WHO) to the Muslim practice of circumcision of female infants up to their teens. This is a practice that is mutilating at best with no redeeming health benefits, unlike male circumcision. — Al Kahane, MD NOTE: Posits are one-sided statements intended to promote discussion among members. Therefore, comments are particularly relevant. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors.

July/August 2011

The Drug Expiration Date: A Costly Illusion, Part II By Scott Sattler, MD This is the second in a two-part series reporting the author’s investigation of the expiration dates used by the pharmaceutical industry (PhRMA). The article originally appeared as three essays in the Humboldt Del Norte Medical Society Bulletin and has been edited and revised by the author. For references previously cited, please refer to Part I in the May/June issue of SSV Medicine. - Ed.

Background:

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

The U.S. Food and Drug Administration (FDA) requires that drug manufacturers determine the expiration date for all drug products through extensive stability testing, and label each product accordingly. For decades, PhRMA has failed to do so. Instead, drug manufacturers project an arbitrary date one to five years into the future and indicate that the drug will remain safe and potent up to this date. They label this arbitrary quality assurance date as the drug’s expiration date. In 1985, the U.S. Food and Drug Administration (FDA) tested the stability of expiring stockpiled medications at the request of the U.S. military. They discovered that 88 percent of the drugs they tested remained stable for an average of 66 months longer than their labeled expiration dates. Some, like Cipro, were shown to be stable for up to 13 years. The U.S. Department of Defense (DOD) and the FDA subsequently created the Shelf Life Extension Program (SLEP) to provide ongoing drug stability testing for the military and other select federal entities. This program saves certain federal organizations many millions of dollars annually by not destroying perfectly good medicines such as tetracycline, aspirin, atropine,

Sierra Sacramento Valley Medicine

doxycycline, penicillin, Lasix, Tagamet, Dilantin, potassium iodide, cefoxitin and captopril. In 1985, the pharmaceutical industry, via the United States Pharmacopeia (USP), declared that once the manufacturer’s original shipping container was opened and the drug product was transferred to another container for dispensing or repackaging, the expiration date no longer applied. They urged that all secondarilydispensed medications be relabeled with a oneyear maximum “Beyond Use” date stating, “Do not use after ___.” In 1997, the USP made this a requirement for participating pharmacists and by 2000, 17 states had passed laws mandating that their pharmacists comply. According to the AMA, there is little scientific basis for this action. Nonetheless, the FDA has allowed the industry to create these “arbitrary quality assurance dates” and falsely label them “expiration dates” or, even worse, as “beyond use” dates. A former FDA expiration date compliance chief, Joel Davis, once said: “It’s not the job of the FDA to be concerned about a consumer’s economic interest...it would be up to Congress to impose changes.” As the FDA’s SLEP director stated years ago, expiration dates (and by extension, “beyond use” dates) have essentially no bearing on whether or not a drug is usable for a longer period. The stated expiration date does not mean, or even imply, that a given drug will stop being effective or become harmful after that date. That is the simple truth.

Questions that must be asked: 1. Why the secrecy surrounding the SLEP database?

Not only is participation in SLEP restricted to a limited number of federal organizations, but also access to SLEP’s drug stability database is severely restricted by the DOD. My attempts to review this data online were met with pop-up notices threatening confiscation of my computer and storage media as well as criminal prosecution, should I persist. Why are only these few participating federal organizations allowed to share this information or submit drugs for testing? As of 2009, the list of SLEP participants included only the Army, Navy, Air Force, Marines, the U.S. Department of Veterans Affairs (the VA), the CDC’s Strategic National Stockpile (SNS), the U.S. Postal Service and the Defense Supply Center-Philadelphia (DSCP). The U.S. Public Health Service and U.S. Coast Guard are excluded. State and local emergency response centers are not permitted to participate. No similar shelf-life extension program exists for these organizations that are required to stockpile many of these same medications.1 As a consequence, some states have abandoned their emergency medical stockpiles because they cannot afford to replace them when they outdate. Ironically, the federal government has subsidized many of these states to allow them to keep their medicine stockpiles current, authorizing our tax dollars to be used for the destruction and replacement of drugs that the FDA knows are safe and effective. For more information on this bizarre and costly state of affairs, please see this timely article.2 All across the nation, hospitals, clinics and pharmacies waste millions of dollars annually by disposing of nominally-outdated medications known by SLEP to have much longer shelf lives than PhRMA will acknowledge. These facilities also expend a great deal of resources tracking and controlling product outdates with unnecessary frequency. 2. What are the costs of the discarded usable medicines? The CDC reported that in 2008, the USA spent $234.1B on prescription drugs. This figure

had doubled since 1999. This equates to $670 per person, per year. Forty-eight percent of us took at least one prescription drug within the last month. Over a third of Americans 60 years or older take five or more prescription drugs a day. It’s a big market. To express the price of medications in a way one could relate to, I compared the cost of their active ingredients with the price of gold. As of late February 2011, gold sold for $1,356 per troy ounce, or 4.35¢ per milligram of pure gold3. A 100mg tablet of gold would cost $4.35. Are you with me so far? I then checked the current Forbes list of the USA’s ten most-prescribed medications and checked http://www.drugstore.com for their standard doses and costs. The number one drug, hydrocodone prescribed in generic Vicodin, costs 36¢/mg which is eight times the February 2011 price of gold. Then I averaged the cost per milligram of the active ingredient of all ten on the list to include simvastatin, lisinopril, levothyroxin, azithromycin, metformin, atorvastatin (Lipitor), amlodipine, amoxicillin and hydrochlorothiazide. The average price of the active ingredient in these ten drugs was 21 times the February price of gold. And all these drugs except Lipitor were generics. We throw away a lot of money when we discard perfectly good medications. 3. Why were the FDA regulations changed in April of 2010, bypassing the requirement to establish a valid expiration date? In April 2010, FDA regulation 21CFR 211.166 was changed to allow verification of a “tentative expiration date” to suffice for labeling as the expiration date, preempting any requirement to determine drug stability or efficacy after that date. Thus, the previous FDA regulation requiring a scientific determination of a true expiration date after which a drug has been demonstrated to no longer be safe or effective is now history. But the disingenuous label “Expiration Date” lives on. How is this allowed to happen?

All across the nation, hospitals, clinics and pharmacies waste millions of dollars annually by disposing of nominallyoutdated medications…

4. How often is PhRMA using the FDA regulation allowing drug manufacturers to continued on page 27 July/August 2011

Managing Hand-off Risk Which Mnemonic is Right for You?

By Mary-Lynn Ryan, Risk Management, NORCAL Mutual Insurance Company and the NORCAL Group EVERY PATIENT HAND-OFF IS A vulnerable point in the continuum of patient care. Incorrect information can be passed on and crucial information can be lost. In fact, according to the Joint Commission, most of the sentinel events resulting from communication breakdowns occur during hand-offs.1 The primary goal of an effective handoff policy is consistent transfer of accurate patient information to oncoming providers that results in the delivery of appropriate care. Using a mnemonic (pronounced nee-ma-nik) or memory-improvement tool during hand-off provides a systematic approach that sets expectations about what should be communicated. Listed below are summarized versions of a few of the more popular hand-off mnemonics:

SBAR

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Situation, Background, Assessment, Recommendation SBAR is recommended by the Joint Commission. Situation: What’s happening with the patient? Background: What is the clinical or contextual background? Assessment: What is the problem? Recommendations: What can I do to correct the problem? SBAR also has extended versions: I-SBAR. I-SBARQ, and I-SBAR-R. “I” stands for Introduction (or Patient Identifiers), “Q” for Questions, and “R” for Read-back.

I Pass the Baton Introduction, Patient, Assessment, Situation, Safety Concerns, Background,

Sierra Sacramento Valley Medicine

Actions, Timing, Ownership, Next I Pass the Baton can be used at shift change, and at hand-offs between departments and between facilities. Introduction: Tell the patient who you are and what your role is. Patient: What is the patient name, and what are the identifiers, location, etc? Assessment: What is the chief complaint, vitals, symptoms, diagnoses, etc? Situation: What is the patient’s current status, code status, recent changes, response to treatment, etc? Safety Concerns: What are the critical labs, allergies, socioeconomic factors, alerts (e.g., isolation), etc.? Background: What are the co-morbidities, medications, family history, and previous episodes, etc? Actions: What was done and what still needs to be done, including rationale? Timing: What is the level of urgency; what are the priorities? Ownership: Who is responsible for what aspects of care? Next: What’s happening next?

SHARED Situation, History, Assessment, Request, Evaluate, Document The Joint Commission identifies the SHARED checklist as one that is particularly adaptable to hand-offs between departments and services. Situation: What are the names of patient and physician, what is the reason for transfer, etc? History: What are the admitting and current

diagnoses, the medical history, etc? Assessment: What is the status of the patient’s neurological, cardiopulmonary, skin status, etc? Request: What needs to be done, e.g., labs, diagnostic studies, etc? Evaluate: Is there a need to inform other resources? Who? Document: Record communications, including assessments, tests results, progress notes, consultations, etc. Mnemonic use is an important aspect of an effective hand-off protocol. Disorganized handoffs, even if they do not result in patient injury, can add to patient dissatisfaction. As studies have shown, it is not necessarily substandard care that leads patients to file a malpractice lawsuit. In many cases, patients are simply angry about the way they have been treated.2

Sample Mnemonic Forms Sample forms that utilize SBAR, I Pass the Baton and SHARED can be accessed on the Association of PeriOperative Registered Nurses (AORN) website in its Perioperative Patient Hand-off Toolkit at: http://www. aorn.org/docs_assets/55B250E0-9779-5C0D-

1DDC8177C9B4C8EB/44F6B4B2-17A4-49A886F218EDBF23516A/HandOff_SampleTools.pdf (accessed 8/3/2010). These forms can also be found in Improving Hand-Off Communications, Ed. Meghan Pillow, 2007, available for a fee from the Joint Commission on its website at: http:// www.jcrinc.com/Books-and-E-books/IMPROVINGHAND-OFF-COMMUNICATION/1225/. Copyright 2011 NORCAL Mutual Insurance Company. All rights reserved. This material is intended for reproduction in the publications of NORCAL-approved brokers and sponsoring medical societies that have been granted prior written permission. No part of this publication may otherwise be reproduced, edited or modified without the prior written permission of NORCAL. For permission requests, contact: Jo Townson, CME Supervisor, at 800-652-1051, ext. 2270. info@norcalmutual.com 1 Joint Commission. Improving Hand-Off Communications. Ed. Meghan Pillow. 2007. 2 Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims Proc (Bayl Univ Med Cent). 2003 April; 16(2): 157–161. Available on the National Center for Biotechnology Information (NBCI) website at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1201002/ (accessed 3/20/2010).

The Drug Expiration Date continued from page 25 reprocess expired medications? The current FDA regulation 21CFR211.204 allows pharmaceutical manufacturers to retest outdated drugs returned to them and, if they meet quality standards, they may be reprocessed and re-sold. For example this would allow Cipro, given the SLEP findings, to be resold three or four times.

Conclusion: For decades, multinational corporate drug manufacturers have been allowed to label medications sold in the U.S. with expiration dates that do not reflect their true stability. This comes at a considerable cost to patients, to state

and federal budgets and to the environment. Congress has the ability to change this process through its role as regulator of the FDA. I urge that you let your colleagues and your congressmen know of this costly illusion so that this broken, destructive system may be mended. scott.sattler@gmail.com 1,2 Maximizing State and Local Medical Countermeasure Stockpile Investments Through the Shelf-Life Extension Program. Brooke Courtney, Joshua Easton, Thomas V. Inglesby, and Christine SooHoo. Biosecurity and Bioterrorism: Volume 7, Number 1, 2009 © Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2009.001 http://www.upmc-biosecurity.org/website/resources/ publications/2009/2009-03-27-max_st_local_med_cntr.html 3 As of June 27, 2011, the price of gold is $1500/ troy ounce.

July/August 2011

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. — Robert A. Kahle, MD, Secretary

Biren, Helen M., Psychiatry, UC Irvine 1987, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5000 Calkins, Jonica C., Cardiology, Albert Einstein College of Medicine 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5282 Carrasco, William A., Internal Medicine, University of Colorado 2000, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5243 Chun, Grace H., Internal Medicine, Tulane University 1996, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-3040 Duong, Hoa C., Hematology/Oncology, University of Southern California 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5259

Lum, Franklin T., Neurology, University Hawaii/ John A. Burns 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5175 Moon, Kwang J., Anesthesiology, Yonsei University, Korea 1972, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 Patel, Manish T., Internal Medicine, Gujarat University, India 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Phillips, Kenneth O., Plastic Surgery, University of Nebraska 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5515 Reyes, Tina T., Internal Medicine, UC San Diego 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Hartman, Jonathan, Neuroradiology, UC San Francisco 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490

Shapiro, Martin, Internal Medicine, Southwestern University, Philippines 1981, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040

Hwang, Kuo Y., DO, Internal Medicine, Michigan State University, College of Osteopathic Medicine 1990, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5243

Silverthorn, James W., DO, Neurosurgery, University N. Texas Health Science 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490

Skilling, Jeffrey S., Gynecological Oncology, UC Davis 1988, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055 Takakuwa, John N., Internal Medicine, UC Davis 1988, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-7070 Walter, Andrew J., Urogynecology, University of Miami 1991, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4148 Williams, Alan R., Neurosurgery, Albert Einstein 1988, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490 Williams, Eric S., Vascular Surgery, Howard University 1987, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5235 Young, Roger, Internal Medicine, University of Illinois 1985, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Yue, Eric J., Orthopedic Surgery, University of Minnesota 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6697

Jolly, Kent W., Pediatric Hematology/Oncology, UC San Francisco 1985, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4190 Kang, Phil J., Internal Medicine, Hahnemann University 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Karzoun, Nour A., Critical Care Medicine/ Pulmonary Diseases, Damascus University, Syria 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6490 Killam, Shawn B., Anesthesiology, University of Calgary, Canada 1991, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-7705 Krishnan, Lalita, Cytopathology, University of Calcutta Medical College, India 1981, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Lewis, Daniel G., Internal/Addiction Medicine, University of Maryland 1986, The Permanente Medical Group, 2829 Watt Ave #150, Sacramento 95825 (916) 482-1132

Why Volunteer continued from page 15 physician healer, enjoy the opportunity folks give me to share their lives, do not want to lose my physician skills, meet new and interesting people, get out of my house, feel good about myself, do something for others in my community, use the skill, talent and intelligence God gave me to benefit others and do not need to make money with everything I do.” His more practical reasons include the county covering his medical liability insurance and working in a comfortable setting without frustration. Last, but certainly not least, his wife admires his public service. Dr. Gerhardt is a Board Certified Internist and Clinical Nutritionist. She is a medical and nutrition consultant, Medical Director for the Sutter Community Hospital’s heart transplant program, Clinical Professor of Internal Medicine at UC Davis, founder of Healthy Choices for Mind and Body, and part-time hospitalist. Algerhardt@sbcglobal.net

Sierra Sacramento Valley Medicine

In Memoriam

John B. Reardan, MD 1925-2011

To all of us who knew him, he was known as “Jack.” I never knew how that became his nickname, just never thought to ask. He was a local boy who made good by going to Harvard. Yet Jack never made a big point about his education or accomplishments. He was very bright, which spoke for itself. He was always interested in what was happening in health care in Sacramento or the nation. But his lifelong, clearly-evident passion was the practice of medicine first and last. He shared call for some years with the small group of Internists in my office. In fact Jack was responsible for creating that office. Masa Yamamoto and I were looking for a third to share call. Jack introduced me to Bob Forster. That led to joining together in the same office out on Scripps Drive. We added others over the years and practiced together for over 17 years, remaining lifelong friends. Jack seemed to know everybody, so making an introduction might have been very natural; one could say as a consequence Sutter Medical Group came to pass. He loved medicine. He had faith in each emerging generation of physicians, which was why he loved to teach. He was the only doc I knew who religiously read the British Medical Journal. He did not just skim; he could refer to relevant articles and their main points with ease. Of course as call partners, we had special insight into his superb clinical skills. But he also had a special gentleness in dealing with his patients even under the most trying of circumstances. I do not recall him complaining about getting up in the night to respond to some urgent need. Of course his patients adored him. My most vivid memory of Jack and his demeanor comes from the days of the old doctors’ lounge at Mercy General when it was

located at the other end of the building. The lunch room was at the end of the serving line. Docs would gather after morning rounds or surgery. We would share personal information, gossip, or arrange consults. As we sat, Jack would literally seem to bounce into the room full of upbeat energy with a boyish grin. He would plop down next to someone and begin a conversation. It was off to the races, whether clinical discussion referencing the BMJ or world news. I know Jack’s family will miss him. I want them to know we share that loss. Most of all, I will miss that energetic boyish smile. Eugene Ogrod, MD

John B. Reardan, MD

Editor’s Note: Dr. Reardan practiced internal medicine, cardiology and nephrology at Mercy General Hospital and Sutter Community Hospitals for over 40 years, and at UC Davis Medical School since its inception in 1968. He was presented with the Golden Stethoscope, SSVMS’ highest award, in 1998. Candidates for the Golden Stethoscope Award are judged primarily for their devotion to patient care, and the medical needs of their community. Recipients typically have demonstrated a career that is clearly oriented to their practice and the care of their individual patients in an environment of unselfishness, compassion and empathy. In January 2011, the UC Davis Medical Center dedicated the General Medicine Library and Conference Room to “Dr. Jack Reardan - Teacher, Clinician and Role Model since 1988.” He is survived by his wife, Nancy, five children and nine grandchildren.

July/August 2011

Board Briefs June 13, 2011 The Board: Approved the 2010 Audit Report presented by Auditor, Lindsey Kate Lane, CPA. Approved the First Quarter 2011 Financial Statements and Investment Reports, and ratified recommendations implemented by and on the recommendation of the Society’s investment advisor. Approved the 2011 Nominating Committee. The Nominating Committee is in charge of nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. The 2011 members are: Stephen Melcher, MD, Chair; Ruth Haskins, MD, District 1; Pat Samuelson, MD, District 2; Barbara Arnold, MD, District 3; Earl Washburn, MD, District 4; Paul Phinney, MD, District 5; Marcia Gollober, MD, District 6; Richard Jones, MD, At-Large Member; Katherine Gillogley, MD, At-Large Member. Approved staff’s request to implement a smartphone application of the SSVMS Membership Directory using DocBookMD. DocBookMD was developed by two physicians and is being used by other state and county medical societies. Currently, it is an iPhone application, but an Android version is expected soon. DocBookMD is HIPPA compliant, meets

1-800-901-5830 • • • • • •

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

Sierra Sacramento Valley Medicine

security requirements, and offers tremendous flexibility and opportunities to share information between physicians in a secured environment. It was noted that due to SSVMS association with NORCAL Mutual Insurance Company, NORCAL will fund the rollout and application fees for DocBookMD for the remainder of the year at no cost to SSVMS. Rollout is expected late July or early August. Approved the following nominations to 2012 CMA Councils and Committees: Jose Arevalo, MD, Council on Information Technology, and as a representative from the Administrative Forum, the Council on Legislation; Barbara Arnold, MD, Committee on Medical Services; Richard Gray, MD, Council on Ethical Affairs; Ruth Haskins, MD, Council on Legislation; Mary Jess Wilson, MD, representing the Government Employed Forum, the Council on Legislation. Approved the June 13, 2011 Membership Report For Active Membership — Yasser A. Al-Antably, MD; Syed T. Arshad, MD; Andrea E. Belko, MD; Helen M. Biren, MD; William A. Carrasco, MD; Grace H. Chun, MD; Erno J. Gyetvai, MD; Kuo Y. Hwang, DO; Kent W. Jolly, MD; Phil J. Kang, MD; Nour A. Karzoun, MD; John N. Takakuwa, MD; John B. Thomson, MD; Andrew J. Walter, MD; Alan R. Williams, MD; Eric S. Williams, MD; Peter W. Yip, MD; Eric J. Yue, MD. For Reinstatement to Active Membership — Samuel B. Allison, MD; Jonathan Beck, MD; Charles Brownridge, MD; Michael Flaningam, MD; Delfino Z. Gonzales, MD; Martin Shapiro, MD; Susan L. Shiells, MD. For Reinstatement to Retired Membership — William G. Bush, MD. Terminated the membership of physicians who had not paid their 2011 dues by the April 1 deadline.

The Night the Old Tavern Lights Went Out By David F. Dozier, Jr., MD A bunch of fun-lovers were whooping it up in the Caggiano Saloon; The fellow that handles the music-box was playing a rag-time tune. Back of the house, in the kitchen domain, where she ruled like the Queen of Sheba, Was the owner, proprietress, star of the place, the masterful chef known as Biba. While down at the bar, in his own corner spot, sat a fellow who sometimes taught classes, In a nice suit and tie, an avuncular smile, surrounded by bottles and glasses. He is Biba’s true love; you might guess who he is, I’ve given a couple of hints; Yes, you’re right, every night, on his favorite stool, sits the house’s winemaster, named Vince. When out of the night, which was forty below, and into the din and the glare, There stumbled a stranger, fresh from the hills, dog-dirty and loaded for bear. “It’s been many a mile, and quite a long while, and I’ve just now unsaddled my pony. I could use a stiff drink,” he said with a wink, “and I hope you can make a Negroni. I sleep under the stars, and I dream about bars, most of them dim-lit and smoky; But this one’s so nice, I won’t have to ask twice, just serve me a hot plate of gnocchi.” As he noisily chewed, enjoying the food, and then downing his third Negroni, He said, “Give me a dish, some kind of shellfish, crabs or mussels — perhaps abalone.” Biba said, “What the heck, just give me a sec; I really do have to advise you, That we feature a plate that’s been famous of late, and I think it will nicely surprise you.”

When the Monterey guys finally got wise, made a change, and they’ve never been sorry. They smartly renamed a dish often defamed, by calling their squid “calamari!” When the stranger had fed, he lifted his head, and declared to the crowd that he’s able To imbibe as much wine as would make him feel fine, and drink any man under the table. He looked all around, and his gaze finally found Dr. Vince, who gazed back on the level, And said with a sigh,” I just have to try, though this may be a deal with the Devil.” Well, the contest began, and many a man thought that Vincent could be in no danger; But some of the fellas who may have been jealous, started putting their dough on the stranger. Then the pace, it got quicker — you’ve never seen liquor go down gullets so fast in this way. The stranger might win; he quaffed a tall zin; Vincent reached for a nice cabernet. Then the stranger did shout, “I’ll be beatin’ you out, and winning this thing in a hurry.” His supporters all cheered, but a few of them feared that his speech seemed to sound a bit slurry. Then the lights all went out, with many a shout, amid crashes, and curses, and screaming. Biba clutched at her head; to her wait-staff she said, “Tell me this is not real — I’m just dreaming.” When the lights flickered on; it was just before dawn. It looked like the earthquake in Haiti. And Vince said, “Sorry, son, but you’ve picked the wrong one, because this is the day I turned eighty!” 28 July 2010 ddozier36@comcast.net [AUTHOR’S NOTE: This poem was mainly a riff on Robert Service’s “The Shooting of Dan McGrew.” It was offered with Dr. Caggiano’s permission and read at his 80th Birthday.]

July/August 2011

Classified Advertising

Office Space

Doctor-Mentors Needed

Medical office space for Lease at 3609 Mission Avenue. Located in established neighborhood between Arden Arcade and Carmichael. 7 exam rooms with sinks, injection area, kitchen, and lab. Favorable rent. Allowance available for modifications. Please call 916-492-6971.

Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: eabrezinski@ucdavis.edu.

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

Membership Has Its Benefits!

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

Mercury Insurance Group 1.888.637.2431 or www.mercuryinsurance.com/cma

Car Rental / Avis or Hertz

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Clinical Reference Guides

Epocrates discounted mobile/online products www.cmanet.org/benefits/epocrates_guides.asp

Conference Room Rentals

Medical Society 916.452.2671

Credit Card

CMA rewards credit card, Bank of America 1.866.598.4970

Office Supplies/Equipment – Staples, Inc. Save up to 80%

Members-only discount link www.cmanet.org/benefits

www.cmanet.org/hit Healthcare Information Technology (HIT) Resource Center HIPAA Compliance Toolkit

PrivaPlan Associates, Inc. 1.877.218.707 / www.privaplan.com

Insurance Life, Disability, Long Term Care Medical/Dental, Workers’ Comp, more...

Marsh Affinity Group Services 1.800.842.3761 www.marshaffinity.com/assoc/cma.html

Legal Services & CMA On-Call Documents

800.786.4262 / www.cmanet.org/member

Magazine Subscriptions 50% off subscriptions

Subscription Services, Inc. 1.800.289.6247 / www.buymags.com/cma

Medic Alert

1.800.253.7880 / www.medicalert.org/cma

Merchant Services/Payroll Services/ Check Management

Heartland Payment Systems 1.866.941.1477 www.heartlandpaymentsystems.com

Practice Financing Reduced Loan Administration Fees

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

Reimbursement Helpline Assistance with contracting or reimbursement

CMA 1.888.401.5911

Security Prescriptions Products

RX Security www.rxsecurity.com/cma.php

Travel Accident Insurance/Free

All SSVMS Members $100,000 Automatic Policy www.ssvms.org/about/downloads/ travel-accident-ins.pdf

Sierra Sacramento Valley Medicine

Guaranteed growth, in good times and bad. How many of your investments increased in value last year? The guaranteed cash value of whole life insurance from New York Life did,1 as it has every year for the past 155 years. And in each of those years, New York Life has paid dividends to our policyholders2 in addition to the returns we guarantee.3 All while protecting you from life’s uncertainties, and providing significant tax-deferred savings. It’s a secure way to help meet your financial goals and it’s the most selfless gift you can give your family.

Talk with us. We proudly offer New York Life products. Kaneski Associates Financial & Insurance Services

Kaneski Associates

www.kaneskiassociates.com

Financial & Insurance Services Acme Financial Group* ®, mSFS** Jane Smith, cFP Steven R. Kaneski CA License # 0B36175 Kelly D. Kaneski Insurance License # 123456 Blaine K. Johnson CA LicensecA/AR # 0G27275 CA License # 0C47001 Samuel S. Goodyear CA License 123# 0G29812 Anytown Road River Park Drive # 202 New York, NY1425 10010 2999 Douglas Boulevard # 340 Sacramento CA 95815 P. 555-123-4567 F. 555-123-4567 Roseville CA 95661 P. 916.258.7339 F. 916.923.5752 jsmith@acmefinancial.com P. 877.772.4374 F. 916.783.8674 kkaneski@kaneskiassociates.com * Independently owned and operated from New York Life and its affiliates. ** Agent, licensed to sell insurance through New York Life Insurance Company and may be licensed to sell insurance through various other independent unaffiliated companies.

THE COMPANY YOU KEEP® www.newyorklife.com 1 Cash value of a whole life insurance policy begins accumulating at the end of the first year. Cash value is accessible through policy loans, and generally does not equal premiums paid. Loans accrue interest and reduce the cash value and death benefit. 2 Dividends are not guaranteed. 3 Guarantee refers to the guaranteed cash value feature of a whole life insurance policy. Guarantees are dependent upon the claims paying ability of the issuer. ©2011 New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010. In Oregon, the Whole Life policy form number is 208-50.27. SMRU 00425399 CV (Exp. 12/31/11)

35 $416 m

30 25

$416 million

in declared dividends to our policyholders since 1975.

10 5 Years

Dividends Declared

Trust is something you earn from your patients. For 36 years NORCAL Mutual has earned the trust of our insureds. Industry-leading risk management programs, outstanding claims defense and a total of $416 million a few of our strengths.

To learn more about our products and services, please contact:

We value your trust at NORCAL Mutual.

> Ken Stacey, Senior Account Executive

in declared policyholder dividends are just

License #: 0A00400 Fax: 415-735-2353 NORCAL Mutual is proud to be endorsed by the Sierra Sacramento Valley Medical Society as the preferred medical professional liability insurer for its members.

Phone: 800-652-1051, ext. 2054 E-mail: kstacey@norcalmutual.com

Our passion protects your practice