2011-Sep/Oct - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

September/October 2011

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Medicine 3

PRESIDENT’S MESSAGE Let’s Work Toward Increased Collegiality

The Future of Our Past: A New Venue for the Medical History Museum

Alicia Abels, MD

F. James Rybka, MD

SSVMS Alliance Holiday Sharing Card

The Envelope Sign

Gerald Rogan, MD

New SSVMS Member Directory Solutions

What is the RUC, and Why Does it Matter?

Bill Sandberg, Executive Director

George Meyer, MD

EDITOR’S MESSAGE Apollo, God of Medicine and Poetry

Gross National Happiness and Medicine

John Loofbourow, MD

Scott Sattler, MD

CONVERSATIONS Gerald Lazarus, MD: Bleak Outlook for Primary Care

New Applicants

Board Briefs

A Posit on Full-Time Medical Practice

Classified ads

David Gunn, MD

A Morning in the ER: Observations of a First-Time Visitor

Camille Getz

Request for Annual Award Nominations

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, devans@sacent.com. “The State Fair is a good place for night photography because of the moving lights which create repetitive shapes. The Zipper creates a pattern which looks like the ‘Spirograph’ toy. The trick here was getting the correct exposure to create the full pattern without overexposing too much. For this ride the exposure was about 5 seconds at f/16 (ISO 200) which was a bit too much exposure for the stationary parts of the ride in the lower half of the photo, so this was adjusted with a second shorter exposure of 3.5 seconds and manual blending of the two images with layer masks in Photoshop.”

September/October 2011

Volume 62/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

Position Available: Urgent care, full-time, partnership

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

mmended By re Doctors. 2011 CMA Delegation Delegates District 1 Jon Finkler, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Ron Foltz, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Satya Chatterjee, MD Richard Gray, MD David Herbert, MD Richard Jones, 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 Ruenell Adams, MD District 4 Demetrios Simopoulos, MD District 5 Anthony Russell, MD District 6 Karen Hopp, MD At-Large Robert Forster, MD Russell Jacoby, MD Maynard Johnston, MD Robert Kahle, MD Robert Madrigal, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Gerald Upcraft, MD 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 Ann Gerhardt, MD George Meyer, MD David Gunn, MD John Ostrich, MD Nathan Hitzeman, MD Gerald Rogan, MD Albert Kahane, MD F. James Rybka, MD Robert LaPerriere, MD Gilbert Wright, MD John McCarthy, MD Lydia Wytrzes, MD Managing Editor Webmaster Graphic Design

Nan Nichols Crussell Melissa Darling Planet Kelly

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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.

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President’s Message

Let’s Work Toward Increased Collegiality By Alicia Abels, MD GROWING UP IN SACRAMENTO, the daughter of a physician in the 50s and 60s, it was considered to be unprofessional to be boastful, let alone to advertise. Doctors who advertised were assumed to be inferior. There were whispers: “Doctor so and so isn’t busy enough — he has to advertise.” Before the internet and Angie’s List, patients learned about physicians and hospitals mostly through word of mouth. Referrals came from patients or other doctors who knew each other professionally and socially, often through our medical society activities. Doctors in that day helped to keep each other busy, well-educated and well-socialized through medical society activities. The medical society was founded and still exists to promote the highest level of healthcare and community health in our region. SSVMS’ legal name is the “Sacramento Society for Medical Improvement.” Now, almost anything goes in healthcare advertising. The more boastful, the better. We all see advertising for “quality care” and for the ”best” or “ brightest,” most “caring” docs and for that warm fuzziness that many feel is lacking in modern healthcare delivery. How is the public to know who is the best or most fuzzy? Sacramento Magazine has come up with their own imperfect method of determining the “best,” and all of you should know that this has provoked plenty of discussion by our Board of Directors in the past. I’m not sure if all the advertising is to blame, but with increasingly conspicuous ads, all grabbing for dollars in such a high-profile way, it seems to me that our collective medical community psyche is suffering. We are losing

the quiet professionalism of this outstanding medical community. I fear that we are losing some of the collegiality and overall sense of medical community spirit that we have been so blessed with for many years. What do our patients think about this use of resources? In this time of fiscal austerity, shrinking healthcare dollars and physician shortages, perhaps some of the money spent on healthcare advertising could be diverted to benefit patient experience, community health or even for membership in SSVMS. Our members continue to feel a sense of community — engaged with each other regardless of group size, specialty or system affiliation. We work together for improvement of health and the practice of medicine in our region, without a lot of advertising overhead. Let’s work toward increased collegiality — it feels good! Ask a friend to come join us. aabels.ssvms@me.com

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.

SSVMS Alliance Holiday Sharing Card Summer is almost over and the Holidays will be just around the corner. Be on the watch for the SSVMS Alliance Annual Holiday Sharing Card letter. Your dedicated support for the annual SSVMS and Alliance’s Holiday Sharing Card has enhanced Sierra Sacramento Valley health projects and the next generation of medical professionals. The 2010 Holiday Sharing Card raised $16,585 for the Alliance’s Community Endowment Fund, the SSVMS William E. Dochterman Medical Student Scholarship Fund, and the AMA Foundation Medical School Scholarship Fund. Your letter will be arriving in October, so please be generous and give. Thank you. Glenda Morris and Paula Cameto are Co-Chairs. gamorris@pacbell.net

September/October 2011

New SSVMS Member Directory Solutions 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.

WE ARE GOING DIGITAL. The printed pictorial membership directory, so familiar to our members, is being replaced by exciting alternatives. SSVMS members and staff have been engaged in testing, tweaking and implementing three new options to replace the traditional printed directory. Going digital will allow us to routinely update our data so that the portability and usability of the directory will be greatly enhanced. We are going green! NORCAL Mutual Insurance Company, our Society-sponsored professional liability carrier, is sponsoring the implementation of DocBookMD. This iPhone, iPad and Android application was developed by Tom Gueramy, MD, Orthopedic Surgeon, and his wife, Tracey Haas, DO, Family Practice, who reside and practice in Austin, Texas. Only physician members of SSVMS/CMA will be able to download and activate the application after HIPAA agreements and password protection have been established by the user. You can read more about DocBookMD at www. DocBookMD.com. You will need your CMA ID number from us to accomplish registration and downloading. DocBookMD highlights include: • All active members of SSVMS are included in the directory. For the first time, email addresses will be shared and available only to other members. Non-members will be included, but only with minimum contact information. Retired members are also included. • The listing includes photos, addresses, office phone numbers and email addresses. • Secure email communication, which is HIPAA-compliant, allows the sender to establish priority messaging and to attach images directly

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to the message from a smart phone camera. Email exchanges are encrypted and do not remain on the smart phone. The secure email system can be turned off and traditional email can be accomplished in the familiar fashion.1 • Phone numbers can be dialed automatically with a touch of the screen and mapping occurs when a highlighted office address is touched. • There is a complete list of major pharmacies. • Users can build a “favorites list” of frequently-contacted physicians. SSVMS has had an online membership directory since 2001, hosted by Memberclicks. com. It is intended for use by the general public, but anyone can use it. The online directory can be accessed by anyone through the main page of our website or by going to http://www. ssvms.org/disclaimer.asp. Each member profile contains all of the information we have traditionally displayed in our printed directory. Email addresses are not included. Non-members and retired members are not listed. As a final option, we are creating a PDF membership directory that will be available, at no cost, to members who request one. It will be searchable, and for those who prefer paper, a hard copy may be printed. When it is ready for distribution, members will be able to download it or receive it on a CD. bsandberg@ssvms.org 1 If you are a member of a medical group and intend to use DocBookMD for the exchange or sharing of identifiable patient information, you are encouraged to contact your medical group’s IT department for guidance on its policies.

Editor’s Message

Apollo, God of Medicine and Poetry By John Loofbourow, 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.

THIS ISSUE CONTAINS SEVERAL poems written by physicians. Some well-known poets were/are physicians, like John Keats, William Carlos Williams, Rafael Campos, Danielle Ofri, and Jack Coulehan to name a few. I would like to suggest that medicine/science and poetry/art, are two extremes of the same spectrum. Why? Because medicine is art, even when the instruments physicians use are derived from science or technology. In theory we are scientists, but in practice we encounter deep and profound emotions in our patients, and, inevitably, in ourselves, given enough time and the fleshy or spiritual wounds of living. We don’t have to rely only on the current dogmas of neuroscience to believe that emotion and behavior involve neural interactions between the areas like the amygdala and related brain loci including the cortex. Come on! What does that mean? There are other, more poetic, truths; to list a few: Apollo was god of medicine and poetry, as well as the prophetic deity of the Delphic Oracle. His son was Aesculapius, one of our professional forebears. In written Chinese, where words are often graphic metaphors, the word poem is a combination of two characters, word and temple. Physicians who practice the art of medicine as well as its science can find that writing and poetry enriches their lives and that of their patients; they may also discover within themselves the soul of a poet. Anyone can readily learn to drain an abscess. But not all can so easily learn to drain the emotions of a parent who loses a child, or faces any number of the other wounds dealt by life. In this area we are outside the realm of science,

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into the territory of art. The term practice itself implies certain humility, a need to continuously improve, to learn, to seek, but never to completely achieve perfection in either the science or the art of medicine. Art and science in medicine are like knowledge and wisdom; related but at two limitless extremes of a continuous spectrum. Whatever physicians create, or accomplish, is altered by things beyond our control, and often beyond our conception or understanding. It is usually not we, but our patients, their friends or family, or the vagaries of life, that determine the ultimate success, or failure, of our interventions. When our work is done it is often undone. We can try to understand, and to make allowance for loss, pain, anger, grief, misery, guilt, or self-destructive behavior. We can try to learn and to practice our art, like our science, even while we must accept our limitations as “healers.” Yet generally patients find hope in us, believe in us, confide in us, trust and reveal themselves to us, even when strong emotions are concerned. Then we must rely on the art of medicine. Poetry and writing are ways to do so, both for physicians and for our patients. I hope you will enjoy the nearby poems written by local colleagues, and consider exploring your own poetic nature. Because there is much evidence that writing in general, and poetry in particular, can be healthy and healing, you or selected patients may wish to attend a writing/poetry session where patients and professionals get together to write. Locally there is one at 6:30-8:30 pm every Tuesday, 6th floor library of the Sutter Cancer Center. Call John Crandall at (916) 708-9708 or email

john@fireartofsacrmento.com. For electronic inspiration online, punch up some journals that encourage poetry by docs: Ars Medica, is a Canadian publication that explores “the interface between the arts and healing…” Bellevue Literary Review accepts poetry about the “relationships to the human body, illness, and health and healing.” Anthologies are available by several contemporary docs: • Jack Coulehan, http://www.uiowapress.org/ people/jack-coulehan, (See “I’m Gonna Slap Those

Doctors,” http://danielleofri.com/?p=788, a poem written from the viewpoint of a chronic drunk, a putative response by the same man Nate Hitzeman writes of in his poem.) • Rafael Campos MD, and • Danielle Ofri, MD. Ofri publishes a great doc blog at: http://danielleofri.com/ Bottom line: Poetry, Doc. Try it, you’ll like it. It promotes the art of medical practice; and you may find, somewhere inside you, a poet. john@loofbourow.com

Incomplete

By Nathan Hitzeman, MD The showerhead drips. I drip. The minutes fall like drops, agonizingly slow and relentless. Perfect balls of water stretched thin to their breaking point. Gravity is strong today. “You have an incomplete abortion. One in five pregnancies miscarries. You will have more bleeding.” An ultrasound that only last week showed a flicker of life. The beginnings of what in Spanish was “dar luz.” Now the bulb is dim. A lifeless bat hanging from the wall of my womb. “We can speed things along,” my doctor says. But I decline. It is my burden to carry. And not some burnt bread in the toaster to be scraped out. The long days pass. The house is too big and quiet. My husband occupies himself fixing things that can be fixed. I am painfully aware of the children shouting in the street. The large holes in the shopping cart. Families bicycling past. My wheels are spinning, but I am going nowhere. How do you grieve something that never was? Time passes all too slow, says my aching womb. But all too fast say the crow’s feet in the mirror. I carry within me a secret, a guilt, a bad report card, a lie, a truth A nothing… But a nothing that was something.

A pebble that sent a ripple over the pond. The breath of God that rustled the leaves ever so slightly. The shooting star that only I saw. I would like to think that a tree falling in the woods still makes a sound Even when there is no one to hear it. Finally, the dripping stops and the colors of the world return. Life goes on for the living. And there is plenty in this world for me to love.

Prefiero la Amistad By Bill Roby

Prefiero la amistad al amor. El arbol es más fuerte que la flor. La cuchara no tiene Los picos del tenedor. Prefiero la amistad al amor. [translation] I Prefer a Friend More than love, I prefer a friend. Unlike a flower, a tree does not bend. Unlike a fork, a spoon has no pointed ends. More than love, I prefer a friend. william.d.roby@kp.org From Sonoma Medicine Vol. 62, Number 4, Spring 2011. Mr. Roby is an LCSW at Kaiser’s La Clinica Santa Rosa

September/October 2011

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Possession of current physician’s license from the state of CA; not under suspension from Medicare, Medicaid, or from practice in California; not previously sanctioned for fraud or abuse.

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By John Loofbourow In The Book of Humanity Chapter Titles are Great Moments When a universal Truth dies And its fearsome Child Is born: Whose name is Language; Agriculture; Writing; Clay tablets, Papyrus, Paper, Printing Gunpowder, and its numberless fierce siblings. What’s written on the pages of the past is clear; Yet we live here in an electromagnetic spectral Now. When truth moves at c-speed of light, Is short lived but fecund, Its progeny disrespectful, rapacious, And unrestrained by reflection, Its face so deceptively foolish, That we name it Twitter, Facebook, Wiki, As it destroys and reinvents meaning. We fear. Yet the pages from the past make clear it has happened before; Many times before; as when Gutenberg’s toy Shattered the Alliance of Gods and Kings. Then as now, the worthy wise knew That cheap, uncontrolled, communication Among the unschooled unlicensed or undocumented Would end all that was; and is; and will be. Seeing only what is near, and dreading An uncertain but certainly ominous future, We fail to see the ageless truth in the Book of HumanityWhat is threatened now is only The Past. john@loofbourow.com

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Conversations

Gerald Lazarus, MD: Bleak Outlook for Primary Care By David Gunn, MD This is one of a series of interviews with Deans of the School of Medicine at the University of California, Davis. Dr. Gerald S. Lazarus was dean from 1993 to 1997. Under his guidance, the School of Medicine initiated a strategic planning process that established a blueprint for the future; completed highly successful recruitments for faculty and chairs; nurtured collaborations with the School of Veterinary Medicine and the Division of Biological Sciences; and supported initiatives in tissue repair and remodeling involving the burn surgery department and the Shriners Hospitals for Children.

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.

Gerald Lazarus: The nature of the institution when it was founded by Dr. [John] Tupper was primarily primary care and diversity. It actually has done a remarkable job. There was a sense of addressing the mission to ensure that the individuals who were graduated would make some contribution to the State of California. I had known him a little bit because I did my internal medicine at the University of Michigan — he was a wonderful human being. I also knew Hibbard Williams before I came, and in fact, he was the chief resident at Mass [Massachusetts] General who took me under his wing while I was applying for internships. Hibbard came out of Cornell as a chairman of medicine, and he began to alter the focus which would then pay attention to specialty health care. Hibbard had done research and was in a laboratory when I came to Davis. When I arrived, there were several issues which were profoundly influencing what transpired. Number one, this was the era of managed care rolling through California generally and Sacramento particularly. Most medical institu-

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tions generated substantial dollars that were then invested in academic issues, such as young faculty members, research initiatives, high-quality peer review research and academic enrichment. What transpired was those clinical revenues were falling. The practice at UC Davis was not as productive as it might have been. David Gunn: So UC Davis wasn’t making as much money to support those academic efforts. GL: Right. And this was the money that was involved in academic enrichment. Secondly, the margin of revenue from the hospital was diminishing because of the competition between Mercy, Kaiser, Sutter and UC Davis. Third, there was a tendency to capitation. In fact, what was occurring was people were being enrolled in health systems. As you may be aware, the hospital and clinics really were referral institutions. So many of these faculty generated these dollars, basically by seeing referral patients. So access [getting patients to UC Davis] was a critical issue. DG: So the cash cow of the UC Davis system was referrals to the specialists. GL: Really, yes. It was the cash cow for the faculty practice. The money that Joe Silva might have spent in medicine to do exciting things, those things were not easily available and were decreasing. Finally, because there was capitation, you had to have primary care practices. If you wanted patients to come to the hospital, you had to have them enrolled in your own health system. There was great pressure to develop a primary care network. The hospital was spending very substantial amounts of money to buy primary care practices and develop primary care sites. These were the financial issues.

The hospital provides substantial support to the academic mission of the medical school and practices. It was spending its money on facilities and primary care networks — we were not unique in that. Stanford lost its shirt in primary care practices, the same at UCSF, Irving and to some extent San Diego. GL: There was a fair amount of pressure, and actually, friction because the medical school felt the hospital should have been investing more in the academic mission. Sometimes things got contentious because the academic mission was being, we felt, underfunded, and the hospital was involved in a “strategic” development of a primary care system. DG: Did you have a position within the hospital administration, as Claire Pomeroy does now? GL: I was the CEO of the University of California, Davis. But the hospital director reported directly to the Chancellor, not to me. So, there were multiple discussions in the Chancellor’s office about how funds should flow. Sometimes that made life a bit unpleasant. However, we did get the hospital to build a research building [Research 3]. We talked vigorously to plan the medical education building. The hospital basically built the outpatient department, which was leveraged by Larry Ellison. He was a patient of Mike Chapman, the head of Orthopedics. Mike Chapman took care of Larry Ellison, and essentially as appreciation for Dr. Chapman’s services, that’s where the three endowed chairs in Orthopedics came from, and why the building was named for Larry Ellison. The hospital basically built the research building, the medical education building and the outpatient center. These were competing priorities to going out and buying practices. In addition during that time, I was able to establish — consonant with the focus of the institution — the research center in primary care. We basically set that program up with Richard Kravitz.1 Rich is terrific. The other thing that had occurred was that research had occasional individuals who were doing very high-quality research. And coming

from my background of the NIH, Cambridge, Duke, Penn, I had been a funded investigator for 25 years. I felt we were lagging behind in this area. DG: Many of the old-timers around here remember your tenure as including a lot of reorganization of departments — clearly for a financial reason. GL: I was a victim of financial change with diminished resources. Second, I felt strongly the departmental leadership should step up to the plate and ensure they were fiscally solvent and they committed resources to academic programs. At the same time I had a department of medicine that was suffering and needed support. Not to speak that the basic science programs had faculty who weren’t making room for bright young folks who were the future of the institution. Challenging times. DG: How did you not lose sight of the academic mission, while also paying close attention to the bottom line? GL: Every medical school does that now. There’s no way you can survive unless you are fiscally sound. In California, we wound up with managed care, reduced dollars to the health system before anybody else. When I was at Penn, our Dermatology Department generated substantial profits, and I invested that money in young faculty, academic pursuits, clinical research and training residents in clinical and basic research. Arguably we were the number one program in the US. We got no money from the University of Pennsylvania, from 1982 to 1993. I had an endowed chair, and that paid a small amount per year, and we were taxed roughly 15 times that endowed chair as a contribution to the medical school. That’s the way it was at Duke, Yale, Harvard and most other institutions. We could be successful because our clinical prices were higher than people in the community. You can’t do that anymore. At UC Davis not every boat was on its own bottom. People expected UC Davis to provide everything. Well, it couldn’t. UC Davis had a limited number of FTE tenured faculty. I said, “Gang, we’re just going to have to generate

September/October 2011

At UC Davis not every boat was on its own bottom. People expected UC Davis to provide everything. Well, it couldn’t.

The issue is that my generation has left your generation a train wreck. The present system is not sustainable.

revenues. And we’re going to invest in academic development.” We began doing it in 1993. This didn’t happen to the country as a whole until the 21st century. But this happened to us early because the competition in the Sacramento area was the fiercest in the United States. DG: Is there anything you would have done differently, looking back now? GL: I, perhaps, could have been more effective in ensuring that there was more commonalty of purpose with the then hospital director. But the point is, he viewed his priority to ensure the viability of the hospital was to develop all of these primary care practices. We were all over California, a huge investment. I did not feel that all of these adventures were prudent, when I believed the future of Davis was to be a prominent academic institution. DG: Did you get any pressure from the Chancellor to increase NIH funding? GL: No, much of the pressure for NIH funding was self-directed. You can think of NIH funding as money; it is far more than that. Peerreviewed funding speaks to the quality of the academic environment, research and intellectual ferment. It says this is a group of thinking individuals who are being creative. In my view, medical school really should involve the development of skills to become problem solvers. DG: So what would you say to individuals who want to spend more time with the family doctors? GL: That’s absolutely the case. Tell me the answer. DG: The Medicare reimbursement rates and the financial demands on the practice are such that the FPs have to move more people through. GL: Absolutely. If you graduate from medical school with $100,000 in debt, you do your residency and you’re going to be an FP doc. You’ll start off being paid as well, or less well, than a specialist. Make it $135,000, pay off your loan, buy a house, educate your kids…does it surprise you that many people choose to go into specialty care? Of course not! The problem is not Davis’, it’s the health care system. What’s the total cost for attendance at Davis now?

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DG: Total cost for attendance for a first year student is about $57,000. GL: Holy cow. Well, think about this. That’s crazy. The fact that people don’t want to be FPs anymore, is dealing with an economic reality. It’s very hard to be able to afford to be an FP. You’re basically going to do procedures on the side to boost your income. And the reimbursement system is crazy. Why should spending two hours in an operating room pay multiples more than two hours in a clinic taking care of patients? DG: There is something I just learned about called the Medicare Relative Value Unit. Apparently the committee that establishes these values is composed primarily of specialists. Do you see changing that committee’s composition as being a fix toward this problem? GL: The issue is that my generation has left your generation a train wreck. The present system is not sustainable. Are we up to 17% of the GDP? American industry can’t tolerate these expenses. Our incentives are based on provision of services, not outcomes. It is a system with competing interests. Richard Kravitz will tell you all about this. The drug companies, the device companies, the hospitals, the doctors. And actually the doctors are a small part of the cost. DG: So how can we politically take more away from the specialists to give to primary care? There is no political will to do that. We’d have to take money away from people like you doing dermatology, and you’re not going to give that money up. GL: You are looking at this just like the budget negotiations in Washington, D.C. Fifteen percent of the budget is discretionary spending; that’s what everyone is screaming about. Eightyfive percent is not discretionary funding. What you have to do is deal with the system. Most goes to hospitals, 15-20 percent goes to drugs. Docs constitute a small amount of the money being spent. It’s like fighting over prenatal care. How can we spend time fighting in Washington over prenatal care when there are so many other areas of waste? DG: So look at other areas of spending, hospitals, drugs, etc… GL: Exactly, this is not a doc problem. It’s continued on page 20

A Morning in the ER Observations of a First-Time Visitor

By Camille Getz Camille Getz wrote this observational essay for an assignment in her junior year high school AP English Language Class. To get material for the writing, she spent two hours taking notes in the corner of the Sutter General ER waiting room. Camille is 17 years old and is now a high school senior at Sacramento Country Day School. IT IS 11:30 IN THE MORNING AND I AM already half an hour late for my “appointment.” Despite having done a dry run the night before, finding the Sutter General Emergency Room proves to be more difficult than I thought possible. After parking in three different lots and circumnavigating the entire hospital twice, I finally arrive in the lobby of the main hospital. I look across the street at the beautiful new modern wing that is being built, and then at the pasty green floral carpeting of the current building. I soon find myself entering through a door labeled “Emergency Department.” I try to walk down the linoleum corridor as quietly as I can, but my flip flops make a slapping noise with each step. Immediately a burnt smell hits me — I had been warned that it is not uncommon to catch a whiff of burning flesh in the ER, as wounds are often cauterized on-site. Upon walking into the actual waiting room, however, I am met with a less ominous atmosphere. Beige and green chairs are lined up against the walls. On one side of the room are a large aquarium, two drinking fountains and two bathrooms. A television in the corner blasts an infomercial for ProActiv acne solution. The air smells of antiseptic and sick people. I take a seat by the television and try to

look as inconspicuous as possible. A security guard, arms folded across his chest, eyes me but does not approach. I survey the room and take note of the people: a woman, draped in a black jacket, asleep in the corner; an exceedingly thin man with wobbly legs and a cane (he later responded to the name “Dwayne”); a man wearing a Giants hat who eventually realizes that he is in the wrong hospital (“I could have sworn this was Sutter Memorial”); a man with a black cap and bloodshot eyes carrying an economy-sized bottle of Arizona Iced Tea; and a clean-cut man with bifocals and an iPhone. A woman sitting across from me carefully arranges her three bags of McDonald’s cuisine. She catches me looking, then winks and smiles. She has approximately four teeth. She begins to unwrap her first hamburger while adjusting her oxygen tank which is sitting on the ground. The infomercial to my right continues to blare. At that moment, the door to the waiting room opens. The squeak it makes is a deadringer for a howling baby. Three people barge through the door: a man, a woman, and a small boy. It quickly becomes apparent that the man is not with the other two people, as he rushes over to the first drinking fountain, drinks as though he has just survived a desert plague, looks around suspiciously as he wipes his mouth, and then silently darts back through the door. The woman drags the little boy by the hand. “Are we going in?” he asks. It’s all he can do to stay upright as the woman yanks him off his feet and cries, “Yes! Come on!” They disappear through another pair of doors and I do not see them again.

September/October 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.

Contrary to what is portrayed in shows such as House or ER, the real emergency room seems to be much less intimidating, and certainly less chaotic.

“When you order ProActiv now, you’ll get the exclusive Refining Mask FREE with your three-piece kit!” An employee walks over in her mint scrubs and turns the TV down. “Man, you can’t hear anything in here!” she says. A line has begun forming behind a sign reading, “NEED TO SEE A DOCTOR, START HERE.” I am hoping to see a patient with some sort of flesh-eating bacteria or chainsaw wound, the likes of which I have seen on various television shows. To my disappointment the people in line are a man wearing two backpacks on top of each other and a woman holding a paper, calmly explaining that she does not actually know where she is. A short, gray-haired man reaches first in line, and the attendant asks him, “Do you need to see a doctor or are you visiting someone?” The man hesitates, then whispers, “Probably a doctor.” He is bouncing up and down. “I’ve already been here an hour and nobody has helped me.” I am watching the toothless woman with the oxygen tank down her third burger and munch on a seemingly endless supply of fragrant fries, when the howling door flies open and a man, dripping wet and wearing nothing but a pair of electric-blue briefs, bursts in screaming that he is on fire. His legs, back, and chest are red and raw and splotchy, and he is holding the fabric of his underwear away from his skin. “I spilled some sort of orange cleaning solution on myself,” he cries. “I’m burning. I jumped in the pool. I’m burning. It was orange cleaning solution.” The medical staff takes him outside, strips him down and hoses him off. The woman in the mint scrubs comes back over to check on me and notices the fiasco with the burning man in the parking lot. “We have to hose him off outside in case he has something on him that can contaminate the whole hospital,” she says casually. He is brought back into the general wing of the hospital wrapped in a black plastic tarp. The toothless woman peers out the window. “Whoo!” she exclaims. “I ain’t never seen nobody burned like that!” Thus ends the most exciting, true-to-TV

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moment of my emergency room visit. One of the security guards saunters over and switches the television to a hockey game. He asks me if I am an aspiring surgeon, and I say no. He shrugs and walks away. As I watch him leave, I realize that my visit is playing out much differently than I thought it would. Contrary to what is portrayed in shows such as House or ER, the real emergency room seems to be much less intimidating, and certainly less chaotic. Instead of watching people being wheeled in with unidentifiable viruses and irreversible head traumas, I am watching the oxygen tank woman unwrap four macadamia nut cookies and blow bubbles in her Pepsi through a bendy straw. I want action, and perhaps I am not getting it simply because I have chosen to visit during a time commonly reserved for having brunch with grandparents or brushing the family dog. I accept the atmosphere for what it is. A very young man in a wheelchair sits in the corner, convulsing. He is hunched over, his fists balled up and pressed into the sides of his arm rests. Suddenly, a nurse comes from behind the office door and calls a name that I cannot hear. The young man leaps out of his chair, his face free of any painful expressions. He walks confidently to the door and disappears. I am left baffled. A few minutes after the young wheelchair man is taken away, a woman in a cream-colored tracksuit stumbles in, weeping. She walks to the front of the waiting line, cutting off the man with two backpacks. He says, “That’s okay,” even though she never actually apologized. She checks in to see her son. The security guard puffs out his belly and growls, “The doctor’s working on him,” to which she responds, “You’re telling me that I have to wait here?” The guard nods. The woman takes half a step closer and whispers, “You do realize that’s my child.” The security guard eyes her for a moment, then simply sighs and in his gruff monotone responds, “It’ll be at least 10-20 minutes, ma’am.” The woman carefully places herself in a chair and cries. “I only got to see him being put

into the ambulance. His bike was completely apart.” She makes that ugly hiccupping noise that people make only when they are sobbing hysterically. The woman with the oxygen tank smiles with her gums and says, “He’s going to be all right.” When the crying woman does not respond, the oxygen tank woman takes a bite of a cookie and turns her attention to the clean-cut man with the iPhone who has not moved the entire time. “Are you here for someone?” she asks. “My son. We’re here for a wedding,” he responds shortly. “And he’s in the hospital?” “Yep. The wedding starts at 6:30.” The woman laughs. “Ah,” she says, waving her hand in the air. “You got time!” The man tears up and looks away. Having made two people uncomfortable, the woman with the oxygen tank gets up and begins to walk out. The security guard calls out to her just as the door begins shrieking. “Ma’am, we’re going to have to throw away your food if you don’t want to take it with you.” The woman turns around, exclaims, “I was not done with that!” and swivels her oxygen tank in order to make her maneuver back through the door a little easier. She picks up her take-out bags and leaves with a flourish. “Hey,” a young woman snaps at me from a few seats down. She has multiple facial piercings and an illegible tattoo. “Can I borrow your phone to call my boyfriend?” I figure that with everyone else in the waiting room she will not try to steal my phone, so I allow her to use it. Upon inspection of my “Recent Calls” list a few days later, I discovered that she had used my phone to make a long-distance call to New York for ten minutes. As my visit nears the two-hour mark, a man rolls in with a wheelchair. He has a handlebar mustache and is wearing a flannel jacket, hiking boots, and a Jack Daniels baseball cap. He approaches the attendant at the front and stops in front of the information window. “My left leg is swollen and there’s a blister on the bottom of my foot,” he says. “My thigh

muscle keeps seizing up and it hurts like a sonof-a-gun. I was sick all day yesterday.” After he checks in, he parks himself right across from me. “You look way too young to be in the emergency room,” he says suspiciously. I confide in him that I am really writing a paper for school, which apparently gives him the idea that he needs to compliment the hospital in order to better my research. “This is a great hospital,” he begins. “I went to another hospital for 15 years and they’re the reason I lost my leg. It started out as a little blister, and then they had to remove my tendon and then my leg. That’s why I’ve got this fake one now.” He knocks on his plastic leg, which I had not noticed under his jeans. “Now the same thing’s going on with the other side. At some hospitals you’re just a number. Here, you’re a real human being.” He watches a security guard help an old woman out the door and says, “Even the security guards try to help you if they can. It’s more expensive, but if your life’s on the line, it’s worth it.” He turns away and begins filling out his required form. “Hey.” He stops and turns to me. “How do you spell ‘thigh’?” On the television, the team wearing red has won the hockey game, and a preview of an upcoming football broadcast is being shown. I look around the waiting room. There are more people leaving the room than there are sick people coming in, which I suppose is a good thing in terms of the general health of the community. However, it also means that it is about time for me to go. I gesture to the security guard that I am leaving, and the man with the Jack Daniels cap looks up and nods at me. I hold the door open for a woman who walks up to the counter and explains, “I’m not sure if I really need to be here. I just feel a little dizzy and I thought I might as well see if you guys can check it out.” Without skipping a beat, the attendant pulls out the usual registration forms and begins the process of admitting yet another non-emergency patient.

“O would some power the giftie gie us to see ourselves as others see us.” — Robert Burns, Scottish national poet (1759 - 1796)

pie4camille@sbcglobal.net

September/October 2011

Request for Annual Award Nominations Nominations are now being accepted for the following SSVMS Annual Awards: The Golden Stethoscope — Candidate must be a member for at least 15 years and 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. The Medical Honor — Candidate must be a member for five years, currently in practice, or retired, and whose high achievement has allowed a contribution of great significance to El Dorado-Sacramento-Yolo County medicine or community health. The Medical Community Service Award — This award is presented in appreciation to

a non-physician community member or leader of a community organization in the El DoradoSacramento-Yolo Counties area who has made a significant contribution to a medical or public health problem. Please send your letter of nomination to the Sierra Sacramento Valley Medical Society office c/o Margaret Parsons, MD, Chair, Scholarship & Awards Committee, 5380 Elvas Ave. #101, Sacramento, CA 95819, or contact Chris Stincelli at (916) 456-2018, cstincelli@ssvms.org. Deadline: November 1, 2011. We encourage you to discuss your potential nomination with us in advance to be certain that the candidate meets the qualifications.

Kaleidoscopes, Back Scratchers, Various Fruit

I Do Not Like You, Homeless Pete

By Nathan Hitzeman, MD

An ER doc, about to retire, once told me, “Nothing says, you complete me, like a foreign body in the rectum. I’ve seen them all, son, although, I must say, your generation has taken it to a whole new level: kaleidoscopes, back scratchers, various fruit! Why, once I retrieved a gourd, another time an extension cord; still another, an adjustable wrench, and, oh, what a stench! I’ve pondered many a time the reason for these misadventures: to stimulate the bowels? To relieve boredom? To play a trick on a drunk, a passed-out friend?”

I do not like you, Homeless Pete! Your fetid, hole-strewn socks your bloodshot eyes your gnarled yellow nails your toothless grin your foul tongue your lack of hygiene your drunken breath from your cirrhotic belly that makes my stomach twist in knots. But it is 3 a.m. and I must again admit you from the emergency room and again bear witness to your steady but all too slow decay.

Or perhaps, it’s as the old mountaineer once said, when asked, “Why do you climb the mountain?”

hitzemn@sutterhealth.org “Because it is there. Because it is there.”

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Not oNly caN a disability slow your pace…

it could also stop

your income. Studies show that 43% of people age 40 will suffer a long-term disability before they are 65 1 and one in seven workers are disabled for five years.2

If you suffer a disabling injury or illness and can’t continue working, do you have a reliable financial source to replace your income? Sierra Sacramento Valley Medical Society members can turn to the endorsed Group Disability Income Insurance Plan for help. This plan is designed to provide a monthly benefit up to $10,000 if you become Totally Disabled from practicing your medical speciality.

learn more about this valuable plan today!

call marsh for free information, including features, costs, eligibility, renewability, limitations and exclusions at 800-842-3761. Endorsed by:

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1 Statistic attributed to Insurance Information Institute, for Loeb, Marshall. “Excessive or Necessity: Is Disability Insurance Worth the Price?” MarketWatch, Viewed 4/9/11. NationalAssociation of Insurance Commissioners (NAIC). Article found at http://articles.moneycentral.msn.com/Insurance/InsuranceYourHealth/DisabilityInsuranceCanSaveYourLife.aspx. “Disability Insurance Can Save Your Life” Viewed 4/19/11

51498 (9/11) ©Seabury & Smith, Inc. 2011 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • Member.Insurance@marsh.com • www.MarshAffinity.com •

CA InS. LIC. #0633005

The Future of Our Past A New Venue for the Medical History Museum

By F. James Rybka, 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.

ONE OF SACRAMENTO’S GREATEST treasures is its unique and rich history. Our medical society, the oldest in the West, houses the SSVMS Medical History Museum, a legacy that is becoming larger and more valuable each year. In 1999, the venerated Paul Guttman Medical Library was closed, although its most valuable books were retained. Space thereby became available for this museum which opened in 2001. Since opening, the number and size of the artifacts and educational exhibits has grown so fast that we have reached capacity. Even more impressive is the growth of educational services the museum has made available to the community. Features and services of the Medical History Museum, which is located at 5380 Elvas Avenue in Sacramento, include : Virtual Tour — Members who have not yet visited the slick, newly-constructed website should do so at www.ssvms.org/museum. We are proud of it. Historic Books — Review the bibliography. A few go back to the 1700s and many 19th century texts are not available online, or in medical libraries. Tours for School Children — The number of 4th grade students from Sacramento area schools who tour the museum annually has grown from 557 in 2005, to 1248 in 2010. Last year, our docents escorted them on 49 different tours. Kaiser Permanente has kindly donated funds to provide school bus transportation for the children. Educational Lectures — Numbering about three a year, these are given by professors, authors and other advocates of medical history.

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At far right, headband for use with Diathermery machine, a medical instrument for local heating of bodily tissues.

They are free and open to the public. Oral History — Struggles endured by earlier Sacramento physicians have been recorded and videotaped. These are frequently spiked with colorful yarns and are fun to watch or listen to. Artifacts — We are already the largest medical museum in the West, but we are now in a crisis for more exhibition and storage space. Showcasing Medical History to Visitors — We are open to the public almost every weekday. Physician docents are available for pre-arranged tours.

Challenges Ahead One of the Medical Society’s missions is to promote the art and science of medicine. The museum has certainly accomplished this by entertaining and educating thousands of students and members of the general public over the years. But there are challenges: the museum is not located in the best strategic area for visitors; it’s closed on the weekends; its cramped space limits what can be exhibited; and like all museums, it has limited financial resources.

Dr. Robert LaPerriere shows Historical Committee members a newlyacquired artifact. L to R, Dr. LaPerriere, Dr. Irma West, Dr. Margaret Masters (partly hidden) and the late Dr. Otto Neubuerger.

The Historical Committee has asked the Board of Directors to appoint a panel to investigate the future of the museum, its location and operations. Some of the options might include: â&#x20AC;˘ Keep the museum, but find a new location and partners to help fund its operation. â&#x20AC;˘ Create a California Health Science Museum. This idea, initiated by Dr. Robert LaPerriere, has sparked the interest of members on the Historical Committee. Our collection would be folded into an expanded new museum composed of a consortium of other health science professional groups such as nursing, dentistry and pharmacy with an augmented mission to include education in the health sciences as well as medical history. Were the area hospitals to join, they could showcase not only their own history, but some of the latest advances they offer. Some of these associations already have historical collections which, like ours, are too small to thrive independently. The fact that the California Medical Association, the California Nurses Association, California Dental

Association, California Hospital Association and the California Pharmacists Association are all headquartered here, renders Sacramento the most logical location for this new entity. At present, we are fortunate indeed to have as our non-salaried curator, Dr. LaPerriere, who has devoted years to the growth and mission of the museum. A passionate aficionado of local history, he has become well-known in the Sacramento Area History Network, the Sacramento Association of Museums, the Old City Cemetery, and the Sacramento Pioneer Association. Whatever our next move is, we

September/October 2011

Wooden immobilization split circa 1880 used by Dr. Locke of Lockeford, CA

could not have a better person at the helm.

Need for new volunteers and ideas What better time could be found than now for a new generation of volunteers to join in and help SSVMS take on this community project as it develops from scratch? The past isn’t dead. It’s not even past! —William Faulkner jimrybka@hotmail.com

The “iron lung,” shown here, was a medical ventilator used to enable a person to breathe when normal muscle control had been lost, such as with polio.

Gerald Lazarus, MD continued from page 12 a health care problem. That’s where the serious savings are. Does it make sense for every hospital to have three MRIs? DG: If someone wanted to do something productive, what advice would you give to them? GL: I would make sure everyone at UC Davis School of Medicine — student or house officer —spends time with people like Rich Kravitz. There’s a program in health care outcomes, cost effectiveness…how often do we deal with problems of our own making? I spent three years in Beijing, China as an advisor to the Minister of Health after I left Davis, and also at the Peiking Union Medical College. Because of perverse medical incentives, almost 50 percent of all medical costs went for drugs. Why? The government would pay the doctors for it. DG: And that’s what we’re doing over here with the government’s subsidies of Big Pharma, preventing negotiations for drug prices with major pharmaceutical companies.

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GL: There has to be greater thought about this. Now I will speak heresy. I think the Kaiser system really has something to recommend. They don’t send every patient to the specialist. They use e-mail, they ask questions, they find out if it can be done in a better way. You need a good general internist who is in charge to coordinate care. Make the fiscal rewards semi-comparable. I’m not a communist, but it seems to me, three million dollars for a plastic surgeon, and $140,000 for a primary care doc is a disparity that requires some thought. DG: Thank you so much for taking the time to go over these points with me. dgunn11235@gmail.com REFERENCES: http://www.ucdmc.ucdavis.edu/chpr/profiles/kravitz.html 1 A Fellow of the Association for Health Services Research, Dr. Richard Kravitz is also Co-Editor in Chief of the Journal of General Internal Medicine. He was appointed Director of the UC Davis Center for Healthcare Policy and Research in 1996 and served in that capacity for ten years.

The Envelope Sign By Gerald Rogan, MD IT IS A BUSY MONDAY MORNING. Several patients had to be squeezed into the schedule to follow-up their ED visits over the weekend. It is 11:45 am and two patients are left before I can eat some of the hot lunch the local drug rep has provided. But wait! As I approach the room of the next patient, Mr. Jones, I see attached to his chart on the bin outside the exam room a large envelope. It is one of those official envelopes inside of which is a multi-page form with big boxes and lots of questions. It must be completed accurately in ink for some non-medical purpose, signed by me, in person, together with my printed name and license number. The hanging envelope outside the door is the “envelope sign.” It guarantees I will be in the exam room an extra 10-15 minutes. The last patient before lunch will have to wait even longer. But I quickly decide that my medical assistant can start filling out the form I know is inside the envelope, so I can see the last patient first. Mr. Jones won’t mind the delay because, after all, he has an “envelope.” Sometimes the envelope is not in the bin, but is clutched in the hands of the patient as I enter the room. Usually the patient is quite pleasant, does not ask for pain medication, and will accept anti-inflammatories with a smile, but holds the envelope until the visit is almost over. “By the way doctor,” says Mr. Jones, “can you complete this form for me?” He asked before I placed my hand on the doorknob — but I anticipated the request because of the telltale “envelope sign.” The lunch was cold when I arrived, but fortunately we have a microwave! To function with compassion and safety, our society requires medical professionals to assist a variety of government-based and/or financed

agencies related to law enforcement, social welfare, traffic safety, non-physician medical benefits, and communicable disease control. Typically, the physician is asked to validate a variety of things related to the patient. Often the physician must spend face-to-face time with a patient which may not be part of evaluation, management or treatment. The governmental agencies require physicians to use medical judgment about a patient’s condition, non-medical judgment about the patient’s effect on society, and to complete forms accordingly. But sometimes, especially when I am overworked at the end of the day, I muse that every program ever invented by government has my name on it as its validator. I become a validator without a CPT code to report. It seems to me the service I provide to the government and my patient should be elevated by the AMA-CPT committee for a code, and the Relative Update Committee for RVU assignment, before the Governor can sign it into law. Dr. Alicia Abels, a Sacramento area Physical Medicine and Rehabilitation physician, observes that, “PM&R physicians have long been the ‘go to’ docs for verification of disability for ‘whatever.’ They must document function via range of motion, ambulatory status, need for assistive devices, etc. “If extra time is needed in the exam room, it is included as part of the patient visit for billing purposes as it extends the needed examination time for various measurements and documentation of history/functional status, medical decision-making, and more time for counseling and coordination of care. So if documented properly, the time is billable. “In the workers’ compensation system, reports are billable, and physicians also routinely charge fees for form completion that are not

September/October 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.

It seems that every time government needs validation of a condition or social benefit that has anything to do with the health status of a patient, the physician is drafted to become the validator…

State or SSDI forms. This is a part of the routine practice of rehabilitation medicine. It is a service provided to patients in need of rehab most of the time, and for those not in need, we explain and document why services are not needed.” Neurologists have their forms for evaluation of patients with disorders characterized by repetitive lapses of consciousness. FPs and internists complete forms for a Class One driver’s license and insurance, disability and life, usually for a fee. It seems that every time government needs validation of a condition or social benefit that has anything to do with the health status of a patient, the physician is drafted to become the validator, or invalidator as the case may be. This medical assessment is not without liability. I reviewed a case where the physician missed a ten-second pause on a holter monitor. The patient was certified for his Class One driver’s license. A few weeks later he had syncope while driving and drove his 18-wheeler into a line of cars, killing two persons. The family of the victims sued the certifying doctor for missing the ten-second pause. How do you all feel about filling out forms? Personally, I am happy to fill out forms accurately, especially for disability for patients with a bona fide condition requiring public assistance of one sort or another. Last week at the Sacramento County Clinic, I approved six months of disability to a middle-aged laborer who had significant lumbar radiculopathy with weakness, reflex loss, and vibratory loss in his foot. The form required an extra ten minutes to fill out. But I work as a volunteer and had a light schedule. For me, it was a small courtesy. For the patient, he could receive assistance for six months. These form-completion physician validation services — “envelope services” if you permit me — must be performed accurately and reliably in order to properly administer government programs, to avoid patient endangerment, to protect others from endangerment, and/or to limit fraud. Accurate validation is assumed, but inaccuracy can create legal and professional liability for the physician. Payments to physicians for validation

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services vary. Sometimes the required information for an accurate evaluation may be unknown and the physician provides an “educated guess.” Some information required, such as range of motion of certain joints, is information not needed to diagnose or treat the patient’s condition, but important to functional ability. On June 26, 2011 Foon Rhee wrote in The Sacramento Bee that Governor Jerry Brown proposes to require physicians to provide a certificate of medical necessity regarding a patient who requests HHS (Health and Human Services) financed in-home support services to live independently (i.e. not in congregate care); the patient can be provided caregiver cooking, bathing, housecleaning, and other assistance designed to keep Californians in their own homes and out of more expensive institutions. Program pay-outs in 2010-2011 were $1.37 billion from the State plus $3.3 Billion from the Feds. Our Governor wants physicians to exorcize fraud from the home-support services program. It isn’t yet clear if physicians will be paid for this service, or who will pay, or if a CPT code will be available. Here is a partial list of “envelope” evaluations or certifications: MEDICAL SERVICES: • For hospice care under the Medicare benefit. • For medical care in the home. • For continuing skilled nursing facility care as a Medicare benefit. MEDICAL EQUIPMENT: • For home oxygen under the Medicare benefit. • For other durable medical equipment, such as a power wheelchair. DISABILITY: • For short-term disability. • For long-term disability. • For handicapped parking. • For return to work or limited work. PUBLIC SAFETY: • Report a patient who is a danger to him/ herself, or a danger to others. • Report suspected child abuse or neglect. • Report suspected elder abuse or neglect.

• • • •

Report suspected spousal abuse. Report suspected assault. Report certain communicable diseases. Report disorders with potential repetitive lapses of consciousness. • Report a patient’s capability to safely drive large trucks, dangerous equipment, airplanes. • Order and review a urine or blood test that measures drugs of abuse (cocaine, heroin, THC, methamphetamine) to validate the patient is not a drug addict and, therefore, may receive narcotics for reported pain. The service may include checking the CURES database (Controlled Substances Review and Evaluation System) to review all prescriptions a patient has received. • Order and review the same test to validate the patient who is allegedly taking prescribed narcotics is actually taking them. QUALIFICATION FOR DISCOUNTS: • PG&E energy-use discount form. • Telephone services for the hearing impaired.

INSURANCE SERVICES: • Validate the medical status of a person for life and disability insurance. • Validate whether a patient smokes. SCHOOL SERVICES: • Validate a patient is healthy enough to go to school. • Validate a patient can play sports. IMMIGRATION SERVICES: • Validate an immigrant is free of communicable diseases. FUNERAL SERVICES: • Certify the patient died of natural causes so the coroner does not have to open an inquest and the body may be buried. I am sure I have overlooked many other “envelope” demands. As a more accurate and complete list would be edifying, please consider emailing me with additions or corrections based on your practice. jerryroganmd@sbcglobal.net

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.

September/October 2011

What is the RUC, and Why Does it Matter? By George Meyer, 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.

THIS YEAR I RECEIVED SEVERAL Medicare statements for my own healthcare. I had a first visit with a new internist (about 30 minutes). His bill was for $160; Medicare allowed $152.93. I had both shoulders injected by an orthopedist (with satisfactory outcome, I must say); the charge for that new office visit (about 10-15 minutes) was $125. Medicare approved $73.33. And the charge for injecting both shoulders (less than five minutes) was $298 for which Medicare approved $118.41. My dermatologist charged $80 for an established visit (about 10 minutes); Medicare approved $71.04. I was also charged an extra $90 (Medicare approved $82.89) for liquid N2 application to several lesions. Recently I received a letter from my internist. After more than 20 years in practice, he was closing his office — not retiring — because he could not afford to practice medicine with the quality he and his patients expected and pay his overhead expenses. This is a pattern we are seeing all over the United States. We are losing experienced clinicians from primary care and we are having great difficulty recruiting young physicians into the primary care field. In 2004 the average primary care physician made $162,000 — an increase of 21 percent since 1995. Dermatology gained 75 percent to $309,000 and orthopedics increased 31 percent to $397,000. [Bodenheimer T et al The Primary Care-Specialty Income gap: Why It Matters. Ann Int Med 2007; 146:301-306]. Where are we going wrong? In the past five years several new schools of medicine or osteopathy have been accredited and more are in the plans. More nurse practitioners and physician assistants have also entered the primary

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care workforce. Will this help the impending primary care problems we are anticipating? Not if the RUC has anything to say about it. The RUC was formed to try to help Medicare control doctors’ fees. So what is the RUC and why does it matter? In late 1985 Harvard Medical School initiated a study to evaluate the relative value of medical work. In 1988 they submitted their Phase 1 results to the Health Care Financing Administration (HCFA). In 1989 the Omnibus Budget Reconciliation Act called for physician payment based on a Resource-Based Relative Value Scale (RBRVS). The American Medical Association (AMA) formed the RVS Update Committee (RUC) in January 1992. The RUC has 29 members, 23 of whom are appointed by various medical societies. Three are rotational with two from internal medicine sub-specialties and the third from other nonrepresented organizations serving on a two-year basis. The remaining six include the Chair and Co-Chair of the RUC Health Care Professionals Advisory Committee Review Board, a representative from the AMA and AOA, Chair of the Practice Expense Review Committee and the Chair of the CPT Editorial Panel. The end result? Primary care physicians comprise only one-sixth to one-thirteenth of the RUC’s 29 members, even though they provide about half of Medicare physician visits. Since the creation of the RUC, the income disparity between primary care versus subspecialists has grown from 61 to 89 percent. According to the AMA the factors used to determine the physician work component include: 1) the time it takes to perform the

service; 2) the technical skill and physical effort; 3) the required mental effort and judgment; 4) and stress due to the potential risk to the patient. These values are updated annually to adjust for changes in medical practice. The practice expense component, 44 percent of the relative value for each service, was based on a formula using Medicare-approved charges from 1991; however, in January 1999 CMS started a transition to relative values for each CPT code which differs based on the site of service. The Resource-based Professional Liability Insurance (PLI) component was implemented on January 1, 2000, and by 2002 all components of the RBRVS were resource-based. In 2003 the RUC suggested changes based on PEAC recommendations which were, in turn, based on direct practice expense inputs. Now work and practice expenses each make up about 50 percent of the RVU value; malpractice plays a small part. By May 1992 the RUC had submitted 253 new and revised CPT 1993 Codes. By May 1994 1,000 recommendations had been made for new or revised CPT Codes including 300 recommendations to HCFA for carrier-priced or noncovered services, including those for preventive medicine. Over this period HCFA accepted 95 percent of the RUC recommendations, including RVU changes to 400 codes. After their first mandatory Five-Year Review (FYR), in 1997 the RUC began to look at directpractice expense inputs, creating the Practice Expense Advisory Committee (PEAC). In January 2000 they implemented Resource-Based Professional Liability Insurance relative values (those who paid higher insurance premiums were able to be reimbursed more per unit). The second FYR showed the RUC had made recommendations for 870 CPT codes, including changes to almost 500 work RVUs in October 2000. In March 2004 the PEAC had its final meeting after reviewing more than 6500 codes. The third FYR showed that the RUC had submitted recommendations for 751 CPT codes including significant improvements to E&M (Evaluation and Management) services. The Centers for Medicare and Medicaid services (CMS) accepted all of the RUC’s recommenda-

tions regarding E&M and 97 percent of all their recommendations. Below are a few examples from various Five-Year Reviews: • The first FYR in 1995 recommended changes in many E&M services (99202—99215; ER services 99281-99285); work RVUs (99291) and office and consultations (99241-99245). Following that, however, CMS implemented an across-the-board increase in work RVUs for global surgical services and applied a 0.7 percent adjustment to the conversion factor to achieve budget neutrality. • The second and third FYRs made increases mostly in surgical RVUs, but also in mammography and dermatology. In 2006 the Relativity Assessment Workgroup was formed to identify misvalued services. According to the Bodenheimer article, “On 21 June 2006, the Centers for Medicare and Medicaid Services proposed a 37 percent increase in the work RVU for intermediate office visits (99213) and substantial increases for some other evaluation and management codes commonly used by primary care physicians in accordance with RUC recommendations. This announcement left the impression that primary care physicians would enjoy major increases in Medicare payments. “In fact, the net increase is far smaller: five percent for 2007. As one payment expert commented, ‘The large print giveth, the small print taketh away.’ A careful reading of the CMS proposal reveals that family physicians and general internists will receive five percent more in allowed Medicare charges in 2007 than in 2006. This increase is far lower than might be expected because work RVUs represent only half of the total RVU and because SGR-related budget neutrality requirements reduce the payment increase.” The fourth FYR Final Rule is due in November 2011. In conclusion, the government and payors need to recognize that primary care physicians hold the key to the success of whatever medical system we develop. Until we pay them what they are worth and get out of the way, we will be hard put to recruit young medical students with large debt into the field. geowmeyer1@earthlink.net

September/October 2011

NOTE: A group of six primary care physicians in Augusta, GA, is now suing to prevent Medicare officials from using advice from the RUC to determine physician payment rates, Family Practice News reports. The litigants maintain that primary care physicians and patients are being harmed because the RUC overvalues procedures and undervalues primary care.

Gross National Happiness and Medicine By Scott Sattler, 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.

TODAY MOST COUNTRIES DEFINE their national success in terms of GDP, Gross Domestic Product, a number representing the total value of goods and services produced within their borders in a given year. Similarly in the field of medicine we define our success in terms of longevity, the average length of life of our population. Both of these criteria for success imply “the more, the better.” The greater our GDP, the greater our national success rating in the world; the longer we live, the better our health care system. But what if this isn’t true? What if we are wrong in making these assumptions? Recent information about the world’s growing Gross National Happiness (GNH) movement has spurred worldwide thought about this possibility, and I would like to share these thoughts with you, especially as they relate to the field of medicine. The GNH movement started in the Buddhist Kingdom of Bhutan which borders on India and Tibet/China and is one of the globe’s most isolated countries. By 1970 travel and technology had opened its doors to the modern world. King Jigme Singye Wangchuk felt a strong commitment to preserve his country’s culture and traditions during this influx of modernization. In 1972 he crystallized this concern around the Buddhist notion that the ultimate purpose of life was inner happiness. He felt the need to define successful development in terms of personal happiness rather than solely in terms of economic measurements such as GDP. Pursuit of this intention led to his establishment of Gross National Happiness as a primary national objective. In essence, individual happi-

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ness was to take precedence over economic prosperity as the nation developed. Quality of life rather than sheer quantity of material production was to be the ultimate social goal. With this guiding principle the government took measures to preserve the nation’s traditional culture and environment, balancing modernization with conservation of Bhutan’s ancient identity and traditions. Rampant destruction of the country’s environment was avoided. By 2002 their government was spending almost 18 percent of its national budget on education and health care as compared with two to three percent for China. In 2006 Business Week rated Bhutan the happiest country in Asia and the eighth happiest country in the world citing a global survey conducted that year by England’s University of Leicester. The U.S. ranked 23rd, largely due to “nagging poverty and spotty health care.” Not surprisingly, this Bhutanese concept has spread, moving rapidly from the Indian subcontinent into much of Southeast Asia. The Fifth International Conference on GNH was held in Brazil in 2009, and 800 participants representing 25 countries attended. How does this relate to the current state of health care in the USA? Let us look once again at our health care system and how we define its success. As a profession we tend to measure our accomplishments in terms of quantity of life as reflected by the vital statistics of life expectancy, infant mortality and maternal mortality. We pride ourselves, as well we should, that our life expectancy at birth hit a national high of 78 years in 2008.

And, appropriately, we chafe at the thought that the current 2008 WHO data shows that our life expectancy ranks number 28 in the world, tied with Slovenia, Costa Rica and Chile. Our maternal mortality puts us at number 50, right in there with Saudi Arabia. Sadly, our infant mortality rate places us at number 39, tied with Croatia and Serbia. Clearly these numbers are meaningful to us as a profession. But unfortunately we also define the success of a given therapeutic measure, be it a chemotherapeutic agent or a surgery, by its gross ability to prolong life, and therein lays the rub. I would suggest to you that in our profession we have taken the length of life as our GDP, as our professed litmus test, and that we have largely neglected to evaluate and maximize the quality of life in our decision-making. I don’t believe that we have done this intentionally; it’s just that post-therapy “quality-adjusted life-years” isn’t often evaluated in current research protocols. Even as the goals of GDP and GNH are not necessarily mutually exclusive, neither are those of longevity and quality of life. But we all know that sometimes they are. Slavery may improve GDP but would rarely be expected to improve Gross National Happiness. Placing chronic feeding tubes in non-interactive catastrophic stroke patients may well prolong life, but few would argue that it significantly improves quality of life. Many people appropriately fear that there are states of health worse than death. Even as Bhutan has given higher priority to GNH than GDP, there is a public calling to our profession to manifest our capacity to give quality of life precedence over longevity. In some areas of medicine we have done well with this. We quit doing yearly screening chest X-rays in smokers when we realized that finding early lung cancer did not improve survival. In fact our well-intentioned efforts to cure this cancer were shown to significantly decrease quality-adjusted longevity compared to those smokers who were not screened. In terms of quality-adjusted life years, our treatment was worse than the disease.

Unfortunately we have yet to apply the same wisdom to the use of PSA screening for prostate cancer. Like lung cancer in smokers, we have yet to find a treatment for prostate cancer that is better than the disease in terms of quality-adjusted life years. Many other countries have stopped doing PSA testing in light of this reality. Ours, sadly, has not. As a profession we face a similar conflict of intention (longevity vs. quality of life) when we attend patients at the end of their lives. There comes a time when disease-directed therapy aimed primarily at prolonging length of life has need to give way to comfort-directed therapy, whose goal is maximizing quality of life. Clearly the public wants, even demands, this option. Many of us in medicine have a hard time making this transition. Thus arose the need for Advanced Directives (ADs) and POLST (Physician Orders for Life-Sustaining Treatment) forms, to help patients communicate their end-of-life requests clearly to their physicians, caregivers and families, so that their wishes for quality-driven health care at the end of life would be implemented. Even as our body politic must not overlook the human consequences of unrestrained pursuit of Gross Domestic Productivity, let us not as a profession discount or ignore our patients’ call to use our medical knowledge to maximize their individual happiness and quality of life. This is not easy given the current pressures of the pharmaceutical industry and its directto-patient advertising. This is not easy given the unrelenting persuasive optimism of many oncologists. This is not easy given the legal vulnerability that permeates the very air we breathe as we practice our calling. Perhaps Gross National Happiness in Medicine comes down to the simple dictum, “First do no harm,” also remembering that we must consider harm in terms of both quantity and quality of life.

Suggested Reading: www.gross national happiness. com and www. thedaily beast.com/ newsweek/ 2010/08/15/ interactiveinfographicof-theworlds-bestcountries. html

scott.sattler@gmail.com

September/October 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. â&#x20AC;&#x201D; Robert A. Kahle, MD, Secretary

Bhatnagar, Ritu, Internal Medicine, Meerut University, India 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Chase, Elizabeth P., Otolaryngology, University of Mississippi 2010, UC Davis Medical Center, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Coleman, John F., Anesthesiology, Albany Medical College 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Dhawan, Kapil, Pulmonary Critical Care/Sleep Medicine, University of West Indies, Tobago 2000, Pulmonary Medicine Associates, 77 Cadillac Dr #210, Sacramento 95825 (916) 482-7623 Doherty, Christine B., Dermatology, Baylor College of Medicine 2006, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-3010

Nguyen, Nhan T.T., Nuclear Medicine, UC San Diego 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720 Reyes, Katrina U., Anesthesiology, UC San Francisco 2006, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000 Stewart, Michael J., Internal Medicine, SUNYBrooklyn 1996, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Swensson, Lisa A., Family Medicine, UC Davis 2001, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-4040 Tiska, Heather L., Internal Medicine, George Washington University 2002, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-4040

Doherty, Sean D., Dermatology, Baylor College of Medicine 2007, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (936) 631-3010 Ho, Mark D., Internal Medicine, East Virginia School of Medicine 1997, The Permanente Medical Group, 1955 Cowell Blvd., Davis 95616 (530) 757-7070 Honeychurch, David B., Pediatrics, The Chicago Medical School 1990, The Permanente Medical Group,1955 Cowell Blvd., Davis 95616 (530) 757-7057 Iverson, Alan J., Urology, University of Vermont 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5355 Khan, Seema M., Child Psychiatry, Fatima Jinnah Medical College, Pakistan 1984, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 Kwon, Paul S., Neurology, University of Wisconsin 2001, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5175 Li, Lei, Family Medicine, First Shanghai Medical University, China 1991, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-4040 Nguyen, Dennis H., Dermatology, UC San Francisco 2004, The Permanente Medical Group, 10725 International Dr., Rancho Cordova 95670 (916) 631-3010

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Tjen-A-Looi, Angelique C., Infectious Diseases, Georgetown University 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Trento, Luca U., Pediatric Cardiology, UC Los Angeles 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Wolfe, Ashby J., Family Medicine, SUNY-Stone Brook 2005, UCDMC, 4860 Y St #1600, Sacramento 95817 (916) 734-2011 (Resident Member) Zhang, Leanne L., Anesthesiology, Albert Einstein 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Board Briefs July 11, 2011 The Board: Received an update regarding DocBooksMD, approved by the Board at its June meeting. NORCAL Mutual Insurance Company, the Society-sponsored professional liability carrier, is sponsoring the implementation of this HIPAAcompliant iPhone, iPad and Android application in early August which will provide a directory of all SSVMS active and retired members. Non-members will also be included, but only with minimum contact information.

Approved the July 11, 2011 Membership Report For Active Membership — Jonica C. Calkins, MD; Hoa C. Duong, MD; Jonathan Hartman, MD; Mark D. Ho, MD; Alan J. Iverson, MD; Shawn B. Killam, MD; Lalita Krishnan, MD; Daniel G. Lewis, MD; Franklin T. Lum, MD; Manish T. Patel, MD; Kenneth O. Phillips, MD; Tina T. Reyes, MD; James W. Silverthorn, DO; Jeffrey S. Skilling, MD; Michael J. Stewart, MD; Roger Young, MD. For Reinstatement to Active Membership — Kwang J. Moon, MD; Carl C. Hsu, MD. For Resignation — Steven L-W Chen, MD (transferred to Los Angeles County Medical Association); Alexander A. Kong, MD (moved to San Diego).

September/October 2011

A Posit on Full-Time Medical Practice BACKGROUND: A New York Times op-ed essay reads in part: “Since 2005 the part-time physician workforce has expanded by 62 percent, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part-time. Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine.” To view the entire essay, go to: http://www. nytimes.com/2011/06/12/opinion/12sibert. html?_r=3

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.

POSIT: “Physicians who choose not to work full-time with full careers are defrauding the nation that subsidized their training.” Among 134 responses including 50 comments, 78 percent disagreed with the New York Times op-ed author. However, among those who wrote comments, more than 93 percent disagreed. Your comments were so many that, with apologies, we edited more than we wanted to for limitations of space. — Ed. __________________________ [Physicians] Charles Krauthammer, Ron Paul and his son don’t practice full-time and neither did I after my first heart attack at about age 36 [until] quitting at 75+. There are also a certain number who conclude that they hate the work and we are better off as patients without their ministrations. — Patrick Clancy, MD

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A patently absurd notion en face. … Minority physicians are under-represented … as are female physicians. …Excessive hours, hard work, self-sacrifice is how I was brought up, and I chose to work like that, trying to … be active in medical societies, advance our knowledge and practices. The cost is profound, in marital discord, family health, behavioral issues and many other things. That is one reason … why we have wellness committees, and why all of our organizations are recognizing physician burnout as a real problem. Those of you who have been here in Sacramento practicing for the last 25 years know what I am talking about. We have seen the most sweeping and profound changes in our practices imaginable, and the changes are only going to keep coming. The way to keep doctors in the practice of medicine is to make it fulfilling again. I want the new doctors to truly embrace the awesome responsibility we have to our patients, and enjoy the rewards of being a physician again. We can do this. Even if [we] work part time. — Lee Snook, MD It is unreasonable to accuse part-time physicians of fraud. To defraud is to deceitfully (that is knowingly) act contrary to expectations, promises or requirements under the law. There has never been either expectation or requirement that all physicians work full-time. Furthermore, no part-time physician I know of made any promises to work full-time. Those payers who demand a return on their investment should make full-time work a clear and enforceable condition of medical training, just as the military makes clear in its allowances for medical school. — Bruce Barnett, MD The notion that because women physicians may work part-time more than men physicians

and therefore their medical education should be withheld because it is expensive is absurd. First, women live about five-seven years longer than men. They can easily extend their career over more years, making up for the few part-time years they took to care for their children. Caring for children is the prime reason for part-time work which is most often temporary. Second there is a shortage of physicians. Removing half the medical talent in the country makes no sense. Third, in a fair, more civilized world women’s civil rights would be respected. Men would be working part-time to the same degree as women to care for their children. Working part-time can slow career development. Yet it is the woman’s career that can take a hit while she works part-time. This disadvantage should be shared equally by parents. — Irma West, MD That NY Times article was written by a female physician, just like me. And I agree with her. Each of us took a medical school slot that could have gone to someone who was equally or more passionate about medicine…None of us paid the full cost of our medical education and post-graduate training. I believe we do owe something to the American people for subsidizing that training, especially those of us who received training grants. It may not be the best for our families to work 80-hour work weeks, but many of us raised fine children on 50-60 hour weeks, and continue to work and influence our grandchildren’s lives. The concept of “balance” doesn’t mean “coddle” or entitlement. Half-time and short careers … short-change the American people. — Ann Gerhardt, MD This is truly a “reductio ad absurdum” and could even be considered discriminatory against women physicians who constitute the bulk of those physicians who return to full-time practice after the children are grown. — Al Kahane, MD Medical Schools and Residency Training Programs may receive taxpayer funding for training. However, the labor provided for hospitals is significantly discounted and has probably kept the rise in health care low in the past. Since residency restriction hours have been put in place … hospitals and residency programs have needed to fill that staffing shortage with higher-

cost licensed staff which has probably led to some of the rise in health care cost. We also train a number of international graduates who … go back to their home country and apply their skills there. I would say that loss is 100 percent in taxpayer dollars. We are also the only country that puts a significant cost of training on medical students. We have the highest rate of debt [on] graduating from medical school. …To state that we are not going to train doctors that don’t spend their careers in full-time practice would lead to further shortages. — Rajan Merchant, MD The physician in training is not defrauding the taxpayer. In fact, the exact opposite is true. When I trained, resident physicians worked 80-100 hours per week at hourly rates below minimum wage. Perhaps before the NYT decides to pen such an absurd opinion again, they should survive a six-year surgical residency (with no work hour restrictions) and then comment. The truth is that the physician in training gives back more to society during their residency alone than most people do in their lifetime. — Demetrios Simopoulos, MD Those female doctors between 35 and 44 are in their child-bearing years. So it is not surprising that a number of them are not working fulltime. While the nation subsidized their training, it certainly did not pay in full. Medical students come out over $100,000 in debt and have sacrificed at least seven of their best income earning years to their education. And residents provide dollars to hospitals with their low-paid labor. They work nights, weekends and overtime while the rest of the country is home with their families. If the nation wants to control how many hours are committed to a career, then it needs to pay in full the cost of a medical education similar to what the military does. — Joanne Berkowitz, MD [Agreeing] 1) going part-time happens frequently right after … residency, not after 20 years in practice; 2) if working for a group 60 percent, they still collect 100 percent of the benefits, e.g., health care, dental care, life insurance, CME stipends, societal dues, some bonuses, increase in stock value, etc.; i.e., it

September/October 2011

The notion that because women physicians may work part-time more than men physicians and therefore their medical education should be withheld because it is expensive is absurd.

A happier and healthier doctor provides better care than a tired, harried, and depressed clinician and is less likely to make a mistake.

certainly is way more expensive to hire two 50 percent doctors than it is to hire one 100 percent doctor; 3) sometimes [docs] quit after only working a few years [even] in a specialty shortage field such as dermatology; 4) if 100 doctors on average only work 70 percent of the time, one would have to graduate 143 doctors to achieve [the same] goal; 5) doctors [may] get scholarships and other aid, but then quit or work only part-time; 6) Dr. X is only working part-time but she takes up a spot in the classroom that a qualified person who would work full-time can’t get because there are only limited slots [there are a lot of qualified applicants that can’t get into medical school because there are only a limited number of slots]; 7) it may be appropriate that a person has to commit to a full-time position for a period of time, say ten years, before they are accepted into medical school or possibly they have to pay back a certain amount of money if they quit practicing or go part-time. I don’t think we can afford to train physicians [who] only practice part-time or quit all together. — Maynard Johnson, MD I believe it is short-sighted to equate working longer with the strength of a part-time physician’s contribution. I do not have access to any data, but here are some thoughts: 1) What is the possibility that female physicians will eventually work longer over time, i.e., retire later; 2) I have had several professors pass away in their 40s, 50s. I think it ludicrous to minimize their impact on community and individual patients based on career longevity; 3) Can we really assume that if fewer women are admitted to medical school, more men will fill the primary care ranks? — Rose Arellanes MD While some feel that physicians that work shorter hours are shortchanging the system, others might argue that working less than fulltime may actually enhance patient care. First, the doctor has more opportunity to think about their patients’ medical condition and ways of helping them achieve healthy goals. This is what drives most clinicians that conduct research (basic, translational, clinical, etc.). Second, as doctors have long recommended to their patients, “Take some time for yourself to get some exercise; [get

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a] good sleep so that you can keep your mind as well as your body healthy.” A happier and healthier doctor provides better care than a tired, harried, and depressed clinician and is less likely to make a mistake. Third, I would point out that most physicians that work part-time or see patients only a few days a week, actually spend most of the rest of the time still providing care to their patients by conducting clinical research trials, conducting bench scientific research, interacting with insurance companies, etc. How much is done may not specifically get seen. So just because someone works less than full-time does not necessarily mean that they are defrauding the nation. — John Belko, MD There is nothing in the agreement between medical students, their medical school, their tuition payments that addresses what the eventual physician will do after their training. If society wants to restrict admission and tuition payments only to those who will work full-time, I would fear that we’d end up potentially losing many great future doctors. I do not know of any other field in which training/education that is provided requires full-time commitment for future employment, though maybe I need to be enlightened! — Pankaj Patel, MD What about PAs, NPs, RNs? Should we not train these individuals who are primarily women and who also work part-time? — Audrey Fu, MD Those who agree should, in fairness, apply this principle to everyone who receives a publicly (taxpayer) supported college or postgraduate education. — Ralph Koldinger, MD Part-time or shared practices can actually enhance the patient experience as well as physician satisfaction by reducing physician burnout. Burned-out doctors are no help to anyone, and no “full-time” doctor is immune. The typical “full-time” physician works far more than 40 hours per week, which is neither productive, nor sane. Instead of rigidly insisting that all doctors work full-time, the physician shortage should be addressed by enhancing pay and job satisfaction for physicians, both of which have seriously deteriorated in

recent years (particularly in primary care). This will ensure that the best and brightest are attracted to medicine, and that they are less likely to seek outside streams of income and avocations. — Jody Gordon, MD This is a biased comment regarding our female colleagues. There currently is … a skewed distribution throughout the US, with underserved rural areas and excess specialists in the urban centers. The insurance companies use this to their advantage, based on the simple concept of supply and demand. Working part-time should not [imply] that the medical education was provided to the wrong person. The majority of our female colleagues return to full-time positions when their children are of high school and college age. — Michael Klein, Jr., MD Physicians are human beings with personal lives outside of medicine. How does anyone mandate to what extent that person works, be it full-time or otherwise? I have a hard time believing that medical education is subsidized that much when tuition is $40-60K a year. People in medicine … have demonstrated an ability to process complex problems in the context of human lives. That doesn’t mean that [they must] commit their entire lives to it. Practicing medicine is only part of being a physician…, they should be allowed to determine how much of a part medicine should play in their lives. — Anand Patel, DO [Disagreeing] With the increased workload and stressors placed on today’s physician, [a high] quality of life for the physician ensures longevity and happiness in practice. We should embrace the fact that there are practice models that make it possible for physicians to spend more time with their families or doing the things they love. I am a full-time doc. — William Teague, MD We need as many doctors providing patient care as we can get; the part-time, often female/ mother physician is an important part of our labor force. Even if they can only work parttime, they have invested much more in time and money than the government makes up for. — James Margolis, MD Part time physicians continue to contribute

to the health of the community. — Norman Label, MD There should be some form of commitment to at least a certain number of years …15 years. — Anitha Ayyalapu, MD The generation X and Y people care more for the balance of life and family. That is more important for them. It is just a change in preference. — For-Shing Lui, MD (I would agree) if indeed the nation or state subsidized their training. — Edward Panacek, MD Everyone should have a choice in how they live their individual lives. No one swears an oath to put medicine before personal well-being or family. Like every investment there are risks to be balanced against great potential rewards. Those risks include, but are not limited to, a complete change in career for the doctor, parttime work, debilitating sickness, imprisonment, loss of license due to illegal activity, death… — Anne Igbokwe, MD (Correcting the op-ed NY Times author) Some “medical education is supported by federal and state tax money both at the university level…” —Travis Miller, MD Defrauding is a “loaded” term. The definition of “defraud” is “…to deprive of some right, interest, or property, by a deceitful device; to withhold from wrongfully.” Certainly, the issues of costs associated with medical education, poor return on societal investment, and personal choice deserve consideration. These deliberations should not be held under the pejorative rubric of “fraud.” (I wonder what would happen if medical students were required to pay into a tax-deferred, interest-earning account. After being in full-time practice for, say, ten years, that account would be given to them. If their practice were less than full-time (How much less? Under what circumstances? Judged by whom?), the account would revert to the agency or agencies that subsidized their education originally. Just a thought.) — Thomas Stevenson, MD In this era of rising health care costs, we need to increase the primary care physician workforce, meaning full-time providers who can be available to see patients, and this will

September/October 2011

Part-time or shared practices can actually enhance the patient experience as well as physician satisfaction by reducing physician burnout.

To expect that all physicians should work full-time without regard to their individual personal needs is to treat them like widgets that can be discarded when they wear out.

alleviate the burden of the EDs throughout the country. Medical education money is a limited resource, and should be channeled to funding for primary-care residencies, less toward specialty care, which is a major cost driver in this country. — Alexander Chen, MD Physicians’ work is physically and emotionally difficult and physicians are human beings who need to have balance in their lives in order to be able to maintain their own health and to be able to maintain a long and productive career. To expect that all physicians should work full-time without regard to their individual personal needs is to treat them like widgets that can be discarded when they wear out. Physicians need some downtime, so that they can come to work fully present and energetically ready to help their patients. It is important to realize that off time not only includes time spent in a part-time practice, but includes time spent at conferences, on vacation, or physician sick time. — Dana MillerBlair, MD This is a ridiculous statement. Since when have physicians become slaves? — Mark Sherman, MD The fact some medical graduates choose to work part-time or not at all should be factored into planning for physician supply. We certainly factor in Illness, disability, career changes, death. If this is the course the physician workforce is taking, then we should plan for it, not criticize it. This NY Times article was written by a specialist … both men and women have similar concerns for lifestyle choices. Part of that decision is made when one chooses to specialize. In primary care, physician assistants and nurse practitioners can go a long way in accommodating part-time physician schedules and lifestyle choices and in my opinion would not compromise care one bit. … These physicians can manage more patients and utilize their time effectively for those diagnostic and treatment decisions where they are really needed. — Stephen L. Mandaro, MD Increasingly, medical doctors are regarded by other members of society as worker bees, providers, trained at great expense by society

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and therefore prisoners to their profession. Should society require that every fully-trained medical doctor have a GPS monitor implanted in her thigh so that if she is caught behaving like a free adult … society can employ sanctions to correct her behavior? Why, heaven forbid, would [a woman] bear children [or] fritter away her valuable time as a stay-at-home mother? … No, the eventual solution to our “health care crisis” is that highly-skilled scientists and technicians will invent devices that will quickly, cheaply and easily diagnose disease and recommend appropriate treatment. — Robert Griffin, MD One-half a doc is better than no doc. If we do not allow people to practice part-time, they will drop out of medicine, or not go into medicine in the first place which intensifies the shortage, then you have really misspent your funding. — Jeffrey Rabinovitz, MD A parent may have to work part-time for a period of time. — Joseph Lash, MD The level of state support for private medical colleges is trivial, and federal support dropped dramatically in the mid-1990s when the Inspector General decided that House Staff couldn’t bill insurance for their work, but instead the Teaching Attendants had to do everything in bedside encounters, thereby destroying their research time. The “Taxpayers” haven’t been included in the discussions; actually, there have been no real public discussions, nor public understanding of the issues. Medical Schools need restructuring to downsize their bloated administrative costs, (typically over 40 percent indirect costs of grants, for example,) and they’ve never done any belt-tightening whatsoever, through all the Reaganomic years, [or] the electronic revolution, and the multiple subsequent recessions. — Colin Spears, MD Tuition usually does not cover the cost of the education in any profession. So, if there is a teacher shortage, or (heaven forbid) a lawyer shortage, should such graduates be forced to work full-time? Ditto for engineers, MBAs, etc. Freedom to choose one’s course of action should not be abrogated. — Julita Fong, MD The government subsidizes many forms of public education where people end up not

working full-time with their degrees. How is this any different? Additionally, the government invests huge sums of money in training our military and most military personnel do not serve for the rest of their professional careers. Should they be required to if doctors are? — Trevor Heneveld, MSII Fraud is a criminal act. Use of a degree is a personal choice. In a true, free enterprise system, the best way to increase productivity is to increase rewards and incentives. … Stop applying anti-trust laws against physician groups; restoring the balance of power between physicians, insurers, hospitals and the government…Stop differential payments where hospitals are paid more for a device than are physicians. …Physician reimbursement is controlled by the government, insurers, and hospitals. …Criminalizing use of a degree will only deter the talented from entering the profession. — Richard Park, MD Defrauding is too strong a statement. If we want female physicians to be mothers then their being part-time is small price to pay — Kuldip Sandhu, MD Especially in this age of very high tuitions and big debts of recent graduates and of the years personally invested in medicine, it would seem to me that there is an equal investment by the government and the individual in a career in medicine. It therefore falls to the individual to make a choice as to what to spend their time doing — J. Thomas Wilkes, MD The USA supposedly ended subservience and dependence long ago. Who wishes to resurrect slavery? Subsidies have undesirable consequences, as do many government policies. — Lee Welter, MD Doctors who work part-time are contributing! They are helping to fill the need. — Katharina Truelove, MD Although an interesting view point, I disagree. Some of the best MDs I work with are part-time women and full-time moms. Two part-time good MDs equal one full-time good MD. After studying hard in medical school and getting through residency, most physicians work full-time for several years. I’m OK with some of

them going part-time if they choose. Also I’ve heard the phrase, ”The cost of tuition doesn’t come close to covering the school’s cost,” ever since my kids have been in grade school and, even though it may be true, I’m still tired of hearing that phrase. — Jose Cueto, MD …Physicians want a work/life balance and they can afford it. If physicians want to work part-time, take time off for childbirth and rearing, then we should salute them for their decision. Medical groups and others who have supported and even encouraged this work/life choice get my kudos too. Requiring physicians to remain in full-time practice to return the public’s investment in them is an impossible proposition. Everyone’s education is supported in one degree or another by public funds. I hope the coming shortage will result in a greater appreciation and compensation for primary care which is where the shortage will reach critical first. If they are not already, medical groups should be developing policies and strategies to bring back those who leave practice for an extended period so they can easily come back when they are ready. — Bill Sandberg I am a female family physician and program director of a 100 percent female residency program with colleagues who job share, get pregnant, leave and re-enter the workforce. I couldn’t disagree more with the writer who presents a one-sided story. …As more women enter medicine we will have the chance to see whether many return to careers that actually extend longer than those who burn fast and burn out early. I am … an example of one who has done just that, working far more than fulltime after children left home. Women see fewer patients that their male counterparts because studies show repeatedly they spend more time with patients … The physician shortage problems are not going to be fixed by some mandatory full-time practice requirement, although I do support the idea of at least one year of public primary care service before moving into specialties. The problems lie more in the irrational methodology for supporting medical education in the U.S., a system that should be torn down. — Marion Leff, MD

September/October 2011

Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors.

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