2012-Jan/Feb - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

January/February 2012

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Medicine 3

PRESIDENT’S MESSAGE The Future of SSVMS

David Herbert, MD

EDITOR’S MESSAGE Tribute to Outgoing Chief Editor John Loofbourow

TIAs – Too much Intervention Attacks?

Nathan Hitzeman, MD

2011 CMA Resolutions

Richard N. Gray, Jr., MD

Safeguarding Data — Tips on Managing Professional Risk

Nathan Hitzeman, MD

e.Letter to SSV Medicine

A View from Over the Hill — Sisyphus Revisited

Cannabis’ Regulatory Void

Gilbert Wright, MD

Donald Lyman, MD

SSVMS 2012 Committees

It’s Illegal to Die of Old Age

Scott Sattler, MD

SSVMS Election Results

How Can Membership in SSVMS/CMA Help You?

Meet the Applicants

Aileen Wetzel, Executive Director

IN MEMORIAM Byron H. Demorest, MD

Improving Peer Review

Gerald N. Rogan, MD

A Posit on Cannabis

Annual Meeting

Board Briefs

Touched by “Untouchables”

Classified Ads

Tyler Andre, MS II, and Eric Morley, MS II

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 Are you looking for a sure-fire cure for a cough? How about some of Upjohn Company’s “Heroin Compound — Green Cough Syrup” consisting of heroin, chloroform, cannabis, tarter emetic, lobelia and 7% alcohol. If you suffered from a bad cough in the early 1900s, this might well have been your pharmaceutical of choice. Lobelia, also called Indian tobacco, was touted as an herbal remedy for respiratory conditions. Tartar emetic is a poisonous efflorescent crystalline salt of sweetish metallic taste used in dyeing and in medicine as an expectorant. Chloroform was widely used in cough medicine, but has not been for this purpose since the late 1970s. Heroin narcotics are known cough suppressants. Tolu Soluble (Tolu balsam) is a resinous plant or tree secretion used more often today in perfume. And cannabis: see articles on cannabis in this issue and the Nov./Dec. 2011 issue of SSV Medicine. The bottle pictured on the cover is from the early 1900s and is one of many interesting artifacts on display at the SSV Medical History Museum. Photograph by Dr. Bob LaPerriere, xtbob@surewest.net

January/February 2012

Volume 63/Number 1 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

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

Position Available:

2012 Officers & Board of Directors David Herbert, MD President Demetrios Simopoulos, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD, Secretary District 2 Jose Arevalo, MD Ann Gerhardt, MD Lorenzo Rossaro, MD District 3 Bhaskara Reddy, MD, Treasurer District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristin Robinson, MD District 6 J. Dale Smith, MD

mmended By re Doctors.

2012 CMA Delegation Delegates Alternate-Delegates District 1 District 1 Robert Kahle, MD Reinhart Hilzinger, MD District 2 District 2 Lydia Wytrzes, MD Margaret Parsons, MD District 3 District 3 Katherine Gillogley, MD Ruenell Adams, MD District 4 District 4 Earl Washburn, MD Russell Jacoby, MD District 5 District 5 Elisabeth Mathew, MD Anthony Russell, MD District 6 District 6 Marcia Gollober, MD Karen Hopp, MD At-Large At-Large Alicia Abels, MD Robert Forster, MD Richard Gray, MD Maynard Johnston, MD David Herbert, MD Alexis Lieser, MD Richard Jones, MD Robert Madrigal, MD Norman Label, MD Rajan Merchant, MD Charles McDonnell, MD Richard Pan, MD, Stephen Melcher, MD Assemblyman Janet O’Brien, MD Vacant Kuldip Sandhu, MD Vacant Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

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CMA President-Elect Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair George Meyer, MD Sandra Hand, MD John Ostrich, MD Albert Kahane, MD Robert LaPerriere, MD Gerald Rogan, MD John Loofbourow, MD Gilbert Wright, MD Adam Dougherty, MS II John McCarthy, MD Managing Editor Webmaster Graphic Design

Nan Nichols Crussell Melissa Darling Planet Kelly

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2012 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

The Future of SSVMS By David Herbert, MD ONE OF THE CHALLENGES OF WRITING a column like this is that one is never certain of who, if anyone, will read it. And with the increasing demands on our time as physicians, we have less to spend perusing the Journal. So I’ll try to keep my remarks brief, and hopefully of some interest, in case anyone takes a look. I should first say a few words about my background. I specialize in critical care medicine and infectious diseases at Kaiser Permanente, and I do some administration. I’ve been a member of SSVMS for 20 years, but it took me awhile to recognize the importance of more active involvement in organized medicine. I am very appreciative of the opportunity to serve as your president in this time of change for both medicine and SSVMS! So what are these changes, and what do they mean for SSVMS? The most immediately recognizable change is that Bill Sandberg has retired after an exceptionally productive 25 years as our executive director. Bill has been a remarkable resource for our society with his knowledge of almost everything and everybody in local and state medical affairs. His help for individual physicians and guidance of SSVMS have been invaluable, and he is a big part of the reason why SSVMS is one of the most successful medical societies in the state in terms of membership and financial stability. Fortunately, we have an amazingly-talented new executive director in Aileen Wetzel, who we managed to lure away from CMA. Along with the change in executive director, we, of course, have the yearly change in president. Dr. Alicia Abels has been especially energetic and capable, and we are fortunate that she will continue to be involved in SSVMS as past president. But our internal changes are nothing compared to what is happening around us! Health care reform is upon us, regardless of

how much we may like or dislike its various components. It brings big changes in who will pay for the care of many of our patients, how they will pay, and the requirements that we all will need to meet to stay in business. At the same time, our slow economic recovery plus local and national political dysfunction puts us at risk for declining reimbursement. Businesses and consumers are beginning to balk at paying about twice as much for health care as the rest of the developed world while getting mediocre results. This has brought high deductible plans and self insurance, and some companies are dropping health insurance altogether. Some are exploring in-house networks, and others are paying patients to get their care overseas. Business as usual is fading fast. As the world around us changes, so must SSVMS. But to chart a new course, we need to decide where it is we wish to go. How do we help physicians adapt to health care reform, recognizing that this is a very different question for solo practitioners and small groups than it is for large groups? How can we better coordinate volunteer care for the underserved members of our community who will soon be largely composed of undocumented aliens? How should we engage with local governments as they dismantle much of our public health departments? How can we facilitate the professional and social interactions of physicians in the increasingly isolated large and small groups in town? How do we make SSVMS membership sufficiently visibly valuable so that non-participating groups and members join us? Our responses to issues such as these will substantially determine what SSVMS will look like in the coming years. Your input is essential, so let your board members and me know what you think. dherbert@pol.net January/February 2012

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. 3

Editor’s Message

Tribute to Outgoing Chief Editor John Loofbourow By Nathan Hitzeman, 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.

RETIRING SSV MEDICINE EDITOR John Loofbourow has packed a lot of living into one life, and he is still going strong. He’s a family physician with a background in tropical medicine, surgery, and emergency medicine. A pilot and physician who served as a U.S. Navy flight surgeon. An advocate for the health and rights of local migrant farm workers. A world traveler. A gringo with a lifelong fluency in Spanish and an MA in Spanish Literature. An expert on all things Chilean. A regular volunteer with local medical students’ clinics. And above all else – a writer and an editor! I’ve known John for two years, and I feel like I am just starting to get to know him. It seems with each personal encounter or email exchange, a new nuance in John comes through. What is clear to me is John’s love of language and his deep-seated belief that every physician should have a voice. During his past eight years as chief editor of this magazine, John has nurtured the germination and ultimate fruition of so many physician articles that otherwise would not have seen the light of day. It is impossible to convey how many email exchanges go on behind the scenes to get an article ready for publication. Among all his communications with an author, John steered clear of directing or molding the final product. Rather, he gave an interesting counterpoint,

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a helpful web reference, a reflection on how things are done in other countries, or a personal anecdote. His reflections not only showed that he cares, but also inspired writers to push themselves to new limits. In short, John made writing fun! How refreshing it is to open a magazine and have the privilege of reading the unadulterated viewpoints of local physicians or to hear first-hand accounts about their personal and professional lives. To see that they put their pants on one leg at a time like we do, and that they hate being sued, love to travel, often volunteer, have an interesting hobby, know something unique about the history of the community in which they practice, and sometimes miss the yesteryears of autonomy and look ahead with trepidation at a managed health care system that is too often mismanaged. I hope to continue this tradition. We are very fortunate to have John stay on the editorial committee, and we look forward to his continuing contributions. His soft-spoken nature and kind smile, matched at times with the ability to call out cow manure as cow manure, will continue to be a guiding force. Perhaps there is no greater honor than the accolades of one’s peers, so below are a few comments on John:

Editorial committee members are, by involved in the debate of ideas. He really made nature, an opinionated lot. In modulating our publication interesting and relevant. I hope these, John has been a patrician — a fair, he keeps his “presence” felt for many years to intelligent, steadfast advocate of preserving come! — Jack McCarthy, MD the intent of the author against an While a third-year medical student, I took omnipresent few grumblers. He embraced a chance in submitting something I’d written controversy, yet kept our standards so high to the local “medical journal.” John (and that he rarely had to bang the gavel against then managing editor Ted Fourkas) were the any clearly-offensive proposed article, antithesis of what I had feared: attending-like or one unsupported with facts. Beyond criticism on my written word. To the contrary, the practice-of-medicine issues, John has they were warm, welcoming, appreciative and embellished our journal with poetry, art, altogether wonderful people. The more I got to photography, history, community health know John over editorial committee meetings issues and book reviews, so that it became the and at extracurricular events, the more I came top-notch medical society journal in California. to see the young man at heart who was full of — James Rybka, MD curiosity and thought. Never afraid to tackle John makes a great editor because he a delicate issue openly, he brought a breath of welcomes widely disparate views, in spite of his fresh air to any discussion by saying aloud what own strong and insightful opinions. He wears everyone had been thinking. Thank you for his kindness openly and makes everyone feel setting a great example for each of us, John. — welcome. It is refreshing to read his editorial David Gunn, MD pieces because they pull my rather concrete brain into clouds of previously-unexplored, hitzemn@sutterhealth.org subtly-nuanced ideas. — Ann Gerhardt, MD John is the fifth editor I have worked with and certainly the most ANNE E. FERGUSON dedicated. I always look A P R O F E S SIONAL LAW CORPORATION forward to the limited time either before or after the meetings where we shared  Physician IPA & health plan contracts our ideas. His posit idea is Providing legal  Medical group organizations, operations & s e r v i c e s to a huge success and part of other business matters p h y s i c i a n s & the reason our readership medical groups for  Practice management, governance & buyis so high. I will miss more than 20 years sell agreements working with him. — Bill  Physician employment agreements Sandberg Anne E. Ferguson  Practice sales, acquisitions & mergers John always encour655 University Avenue Suite 110  Medical director, hospital-physician, aged the more radical side Sacramento, CA 95825 recruitment, call-coverage & other of my writing, in fact, the Telephone: (916) 488‐5388 contracts more radical the better as Facsimile: (916) 488‐5387  Medical Records, HIPAA & EHRs far as he was concerned. website:  Regulatory compliance, compliance He didn’t always agree with www.fergusonlawcorp.com programs, Stark and Anti-Kickback my ideas about the failures  Medical office leases, ASC investments & of capitalism, nationalism, This is attorney advertising. other business matters or the drug war (but sometimes he did), and he loved the controversy

January/February 2012

e.Letter to SSV Medicine Medical Waste: To Test or Not to Test Jerry, I enjoyed your article in the Nov./Dec. issue of SSV Medicine. Twenty-five years ago I served on the Laboratory Utilization Committee for Northern California Kaiser. As a pre-paid medical plan, it behooved us to order only those diagnostic studies that would add value to our patients’ care. It wasn’t easy back then. There were relatively few studies available to guide us, and we often had to do our own. Our work was made even more difficult when the automated multi-test panels became available. It became easy for physicians to use this short-cut approach to testing. It seemed “cheaper” and, theoretically, you “wouldn’t miss anything.”

In truth, of course, these panels generated additional costs. Statistically, the more tests performed, the more likely you would encounter false positives. These, in turn, would generate additional testing and greater expense. Ultimately, even though they were popular, we banned the use of lab testing panels at Kaiser. We preferred that our physicians consider, before ordering tests, what would actually confirm or rule out their diagnostic hypotheses. Sadly, many of our colleagues have invested in laboratory or imaging machines for their offices. Though more convenient, these improperly align with the incentives to practice thoughtful, cost-effective medicine. Best wishes, Steven Orkand, MD orkandsac@pol.net

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Cannabis’ Regulatory Void How did we Become “Gatekeepers” Without a Gate?

By Donald Lyman, MD, Chair of SSVMS Public and Environmental Health Committee IN THE LAST ISSUE OF THIS MAGAZINE, Jesse Oehler told about his work in a local marijuana dispensary. He described the workings of an awkward and perverse non-system in which we physicians are named as the authorizing access point for retail purchase of medical cannabis. We stand in an unhappy situation. On one side is the Drug Enforcement Administration which declares there is no medical utility to cannabis, so keep it as a Schedule I prohibited substance (“illegal”). On the other side, California and 15 other states have decriminalized its use. This means the state has declared it will not enforce the federal illegality — the “Feds” will have to do that themselves. We California physicians are authorized to “recommend” (not “prescribe”) it to patients with no state penalties for that action. That stand-alone recommendation is protected under federal constitutional First Amendment free-speech rights and under state statute. If, however, the physician advises the patient to break federal law (reference White Paper, pp. 6-7) or participates in such illegal acts, he is at risk of federal legal action under that law. In reality, most of the cannabis we physicians “recommend” is probably used for non-medical purposes. And in truth, cannabis travels to the buyer from production to consumption on a totally unregulated track. The California Medical Association has now adopted as policy a call for strict regulation of this substance (not prohibition!) in order to protect the public and physicians from the abuses we see in both the Oehler article and the legitimate anxieties of those who favor continued strict prohibition. So, where is all this going? Here are current status descriptions

and future projections on what is likely to come. We physicians seem “parked” in the position as gatekeepers to cannabis for several years as this non-system of access matures.

Current Status What’s missing is a regulatory system (the ”gate”) we can depend on to assure ourselves, our patients and the public that the cannabis itself is safe and effective. Where did the stuff come from? Is it contaminated with pesticides, herbicides, fecal material, or what? What is its strength? How much is toxic? What medical effects are documented and preferential to other drugs or procedures? I found one shop with a lollipop for sale listed as “Two Doses.” So, what is one dose? The CMA policy calls for a regulatory system to protect us all. While the press has referred to this as “legalization,” it is really a call for re-scheduling by the DEA — a regulatory action — with subsequent research upon which to base rational regulatory schemes. We can’t get the research done while cannabis is listed as Schedule I. CMA has produced two documents to help us navigate to some resolution of this conundrum. First, The Council on Scientific and Clinical Affairs earlier this year issued Physician Guidelines on how to deal with cannabis. It is consonant with similar guidelines by the California Medical Board and the California Attorney General. Second, a Technical Advisory Committee (TAC) produced a White Paper (“Cannabis and the Regulatory Void”) which recommends steps to move this agenda forward. The TAC assumes that the cannabis issue is traveling on a trajectory much like alcohol

January/February 2012

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.

What’s missing is a regulatory system (the ”gate”) we can depend on to assure ourselves, our patients and the

prohibition did a century or so ago; that is, it is a pretty freely available substance nationally, despite its federal illegality. Like alcohol near the time of repeal of Prohibition, we have state after state decriminalizing its use. Also like alcohol, we have an “Al Caponelike” crescendo of violence related to gang control of the substance. While most of the visible parts of this crescendo are in Mexico, it is now also happening with more frequency in the U.S. So why is CMA acting so forcefully now? It is a reaction to a distribution non-system which is now floridly out of control in which we play a major role; an unhappiness with more physicians acting as gatekeepers when our knowledge of medical cannabis is inadequate; damages done by the current federal policies; a growing public repudiation of those policies, and violence both domestic and connected to the drug gangs in Mexico.

What is to Happen Next?

public that the cannabis itself is safe and effective.

For medical cannabis, the TAC recommends that the CMA take an active leadership role in joining with the 15 other state medical societies to petition the DEA to reschedule cannabis. For the past half century, the DEA has functionally ignored such petitions. If granted, CMA would also champion federally-funded research into the uses and dangers of cannabis. The likelihood that the DEA would respond to a coalition of state medical societies is probably proportional to: a) the number of states which have decriminalized cannabis (now 16), and b) the public response to any violence

in the drug wars among gangs in the United States and Mexico. As these actions unfold, the TAC recommends that we sustain our physician role as gatekeeper. For non-medical cannabis (aka, recreational), the TAC calls for either: a) a federal regulatory scheme similar to alcohol and tobacco, or b) federal permissive authority for states to regulate cannabis until the Feds get their act together. These are politically unlikely outcomes. The TAC implies that a fallback option, more likely, is for the Feds to simply ignore states with such regulations and passively let them function. Colorado has already taken this step. In the next few years, we are likely to see more propositions on the California ballot regarding cannabis. We are also likely to see state legislative actions, in California and elsewhere, to set up regulatory schemes to get this matter under some control. The TAC’s White Paper is intended to give CMA a policy roadmap to help guide our policy decisions which protect the public and physicians. donald.o.lyman@gmail.com 1 NovVersion H/CMATAConMJ/11OctSSVMSMag(3) Websites: CMA White Paper: http://www.cmanet.org/files/pdf/news/cmacannabis-tac-white-paper-101411.pdf The Physician Guidelines done by the CMA Council on Scientific Affairs: http://www.cmanet.org/resource-library/ detail?item=guidelines-of-the-council-on-scientific The Attorney General Physician Guidelines: http://medicalmarijuana. procon.org/sourcefiles/Brown_Guidelines_Aug08.pdf The Medical Board Guidelines: http://www.mbc.ca.gov/board/media/ releases_2004_05-13_marijuana.html

Clever MD license plates seen out and about:

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Auction & Concert April 29, 2012 Join us at Del Paso Country Club the evening of April 29, 2012, to support the SSVMSA Community Endowment Fund. 100% of the proceeds go toward our annual Community Health Grants and Scholarships for those entering the medical professions. Contributions The Alliance is looking to showcase artists from our own medical community as well as artists and galleries throughout Sacramento. Support the SSVMS Alliance by making a contribution to the wine, art, and jewelry, auction. Sponsorship Opportunities Patron Level $2,500 • Masters Level $1,000 • Artisan Level $500 • Apprentice Level $250 To make a donation or become a sponsor contact Gabriella Neubuerger at gabby@surewest.net or 916-736-1613. All donations are tax deductible.

2012 Toolkit for Flu Season By Carol A. Lee, Esq., President and CEO, CMA Foundation HEALTHCARE PROVIDERS KNOW that antibiotics cure bacterial infections, not viral infections such as colds or flu, most coughs and acute bronchitis, sore throats not caused by strep, and runny noses. But some healthcare providers are still overprescribing antibiotics. To aid in educating the healthcare community, patients and the public about when antibiotics work and when they do not, the California Medical Association Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) project has developed the 2012 AWARE Provider Toolkit for the cold and flu season. AWARE supports physicians’ efforts to promote appropriate antibiotic use, decrease the incidence of antibiotic resistance and meet the Healthcare Effectiveness Data and Information Set (HEDIS) measures for the “Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis” as well as “Appropriate Testing for Children with Pharyngitis.” The 2012 AWARE Provider toolkit contains educational resources specifically for providers as well as resources to educate patients. The toolkit contains: 2012 Acute Respiratory Tract Infection Guideline Summary (Adult and Pediatric) — A synopsis of appropriate diagnosis and antibiotic treatment of the most common respiratory infections. Prescription Pad — This handout offers over-the-

counter treatments that can help alleviate symptoms of colds. CDC Flyers — Careful Antibiotic Use, Cough Illness in the Well-Appearing Child, Acute Cough Illness (Acute Bronchitis); and Careful Antibiotic Use: Pharyngitis in Children Patient Education Materials Health Tips — This handout provides tips to stay healthy, promotes proper antibiotic use and encourages frequent hand washing; Bronchitis and Other Cough Illnesses — These adult and pediatric handouts contain useful home care options and prevention tips; I Choose…To Prevent Influenza! — These handouts contain information on influenza, how to prevent influenza, and what to do should one get sick; Feel Better Soon…Without Antibiotics! —These brochures identify common symptoms and remedies that can provide symptomatic relief. Medical Office Posters — Feel Better Soon…Without Antibiotics! — These posters inform patients that viral infections cannot be treated with antibiotics. For more information about AWARE and for additional materials regarding appropriate antibiotic use, please contact the CMA Foundation by phone at (916) 779-6620, by e-mail at aware@thecmafoundation.org, or by visiting www.aware.md.

January/February 2012

It’s Illegal to Die of Old Age 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.

ONE OF THE BIGGEST SURPRISES of my medical career came when I submitted a death certificate on one of my patients back in the early 1970s. That’s when I found out that it was illegal to die of old age in California. (Actually it has been illegal to die of old age anywhere in the USA for the past 56 years, but I didn’t know it back then.) I was working on the Hoopa Valley Indian Reservation in Humboldt County, California, and one of the elders in the community had died peacefully at home. He was in his late 80s. He had acquired a medley of medical conditions common to his age, but none of them was lethal. It was his and my impression, and the family’s, that his body had simply worn out and that he was ready to move on and leave it behind. He didn’t make much fuss over it. He just gradually lost interest in eating and drinking. Finding a quiet place to rest in peace, protected by his family, he had died in welldocumented perfect biochemical balance. I dutifully tendered the required Certificate of Death to the county recorder and was quite taken aback when it was returned with a note that “Old Age” was not a medically acceptable cause of death. I was told that I had to come up with some other diagnosis, something more pathologic, to justify my patient’s demise. And, no, “The Dwindles” wouldn’t work either. Nor would “Inanition.” In all honesty, I couldn’t do so, thus the cause of death had become by definition “Unknown,” and the case was turned over to the county coroner. He called me, and we spent some time reviewing the patient’s office notes together. It contained an entry that mentioned treatment for mild to moderate high blood pressure in the distant past. His more recent office vitals had been within normal limits. As I recall,

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we agreed that “probable hypertensive heart disease” might be used as the cause of death to solve this administrative dilemma. And so it was. But something about this process has bothered me ever since. It turns out that as a country we eliminated dying of old age back in 1951 when a federal Public Health Conference on Records and Statistics standardized causes of death throughout the nation and defined 130 acceptable diagnostic causative conditions. Old age was specifically omitted. Some of you may remember 1951, the year that nuclear power was first used to generate electricity. Penicillin and streptomycin were successfully produced in adequate supply to serve all mankind. “I Love Lucy” and “Captain Video” were tops, and CBS broadcast the first color TV program. My wife had her very first birthday party. It was a great year. Dying from potentially curable diseases was “in.” Dying from old age was “out.” Gathering important scientific data was “in.” Gathering imprecise immeasurable impressions of the various aspects of inevitable mortality was “out.” The World Health Organization, impressed by our nation’s success in conquering old age as a cause of death, soon adopted this same policy, thus making it essentially impossible to die of old age anywhere in the civilized world.

Cell Death is Well Documented As you can see, this presents the medical profession with some significant problems. First of all, it just isn’t true. People do die of old age. No one has lived past the age of 122.5 in recorded history. The biologic phenomenon of apoptosis, i.e. genetically-programmed cell death, is well documented. In 1965, Dr. Leonard Hayflick discovered that human cells stop dividing after a set

number of mitoses. The length of the telomere, which shortens with each division, determines the number of remaining cell divisions. Normal human fetal cells in cell culture will divide between 40 and 60 times, after which they become senescent and are unable to reproduce. The number of times a given cell population can divide before senescence is called the Hayflick limit. Human cells are not capable of immortality. Supercentenarians die as their bodies wear out. A second problem is that this artificial exclusion of the aging process from our causeof-death statistical database leads to significant distortion of the data. Since all deaths have to be secondary to a pathologically-defined condition present on a state-supported diagnostic shortlist, there’s a natural tendency to squeeze all deaths into these categories. Thus we find a 107-yearold man from Eureka dying of “heart disease” in 2006. I discussed this issue with Frank Jäger, Humboldt County Coroner, and confirmed that this phenomenon of assigning a “heart disease” etiology to an otherwise “undetermined” cause of death in the elderly is a recurrent and predictable consequence of the current national policy. This tends both to inflate the statistics for heart disease, which not surprisingly is the leading cause of death in the United States, and to minimize public cognizance and assimilation of another major cause of death, namely the aging process itself.

Since the data generated by death certificates are used “to determine which medical conditions receive research and development funding, to set public health goals, and to measure health status…”,1 this current policy leads to a great deal of the nation’s limited health care research budget being directed toward “diseases on the list,” and fewer resources and attention being directed toward the aging process which may, in fact, be causative to many of those listed conditions. If you find this confusing, consider the totally fictitious and rather silly proposition that HIV, the AIDS virus, doesn’t kill people. It can be argued that HIV is not the cause of death. It is the pneumocystis carinii and the toxoplasmosis which kill. Cryptococcal meningitis kills. Kaposi’s sarcoma kills. HIV doesn’t kill, per se. It seems that this same logic is being applied within the current cause-ofdeath system, namely that Old Age doesn’t kill. Degenerative neurological diseases kill. Degenerative vascular disease kills. Apoptosis kills. But Old Age? Naaah. Thirdly, when we reject dying of old age as the natural end to life, we define death and dying as unnatural pathologic processes. We weave the illusion that given the right vitamins and yoga practices, the right mantras and medications, the right doctors and hospitals and enough money, we can indefinitely avoid this potentially curable condition.

January/February 2012

By not acknowledging the natural course of life, we define death and dying as unnatural pathologic processes.

Propagating a Fear of Dying This sets up the health care system for infinite failure in the eyes of those it serves. It breeds deferral of dealing with end-of-life issues until one’s final breaths. It propagates fear of dying and the subsequent denial and isolation

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attendant upon that world view. It modifies family behavior from that of supporting a natural transition to one of waging war on disease and then dealing with the inevitable sense of defeat and failure when death occurs. It’s time we move on from the currentlyembraced 1951 mentality surrounding death. It’s time to put “Old Age” back on the books and into the research arena as one of the essential causes of the physical body’s demise. Maybe if we gave it a sophisticated title it would be more acceptable, like “Ordinary Legitimate Death — Apoptosis, Genetically Encoded.” Then we could just use the acronym. scott.sattler@gmail.com 1 Physician’s Handbook on Medical Certification of Death, 2003 Revision, DHHS Publication No. (PHS) 2003-1110, pg 1.

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

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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.

Executive Director’s Message

How Can Membership in SSVMS/CMA Help You? By Aileen Wetzel, Executive Director AS A PHYSICIAN ADVOCATE AND A lifelong proponent of organized medicine, I am delighted that the Sierra Sacramento Valley Medical Society Board of Directors has selected me as your new CEO/Executive Director. I fill the very big shoes of Bill Sandberg, who retired December 31, 2011 after 25 years with the medical society. I come to SSVMS from the California Medical Association, where I have spent the past 12 years as Associate Director for CMA’s Center for Economic Services (CES). I was responsible for reviewing and analyzing third-party payor contracts, for educating physicians and office staff on a wide range of reimbursement-related issues, and for intervening with health plans and regulators on behalf of our physician members. The CES team has published multiple toolkits and guides designed to assist physicians with improving practice viability. These resources are available at no cost to members at www.cmanet.org/ces. I am particularly proud that CES is on target to successfully recoup close to $3 million from insurance companies on behalf of physicians and medical groups in 2011. Prior to joining CMA in 2000, I was the National Vice President of Managed Care for Integrated Orthopaedics, Inc., a large physician practice management company. I managed the daily operations of large medical practices in several states, including supervision of business office personnel, accounts receivable, new business development, managed-care contract negotiations and strategic planning. I have also served in management positions for large integrated healthcare systems, including Columbia/HCA and

National Medical Enterprises. As Columbia/ HCA’s Regional Director of Managed Care and Business Development, I was responsible for identifying and implementing strategic initiatives to promote physician and hospital alignment. I founded and managed one of the first physician/hospital organizations in the state of Texas. My background has provided many opportunities to problem-solve with physicians about issues impacting the medical profession. I firmly believe that physicians can and should be at the forefront of any current or contemplated healthcare delivery systems. How can SSVMS/CMA meet your needs? Need help understanding your rights and responsibilities under California law and regulations? Need help analyzing a managedcare contract, completing a fee schedule analysis, or help with dealing with a problem payor? Need information to prepare for 5010, ICD-10, EMRs, ACOs all while remaining HIPAA compliant? Looking for up-to-date information on healthcare reform, the status of proposed cuts to Medi-Cal or Medicare, or key legislation? Interested in volunteering to provide medical services to the uninsured? Whether you practice in a solo/small practice or are affiliated with a large medical group/healthcare system, there is room at the table of organized medicine. I am available to you at any time. Please call, email me, or better yet, let me know if you would like me to come out and meet with you at your practice. I want to know how membership in SSVMS/CMA can bring value to you and your practice. awetzel@ssvms.org or 916-452-2671

January/February 2012

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.

Improving Peer Review CMA House of Delegates Votes for Effective Law Enforcement

By Gerald N. Rogan, MD, CMA Delegate, Administrative Forum

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.

AT THE CALIFORNIA MEDICAL ASSOCIATION House of Delegates (“House” or HOD) meeting in October 2011, the House voted to ask the state of California to enforce current requirements by which hospital medical staffs must perform peer review. The HOD sets the policies and priorities for the California Medical Association. This article explains the significance of the vote, proposes next steps, and seeks your input. Peer review is required under Federal Medicare Condition of Participation 42CFR482.211 and related state law. In 2008, Lumetra, Inc., a Medicarecontracted California Quality Improvement Organization, was tasked by the California Medical Board to analyze hospital peer review activity. Lumetra reported peer review was not being done in many California Hospitals.2 In 2009, the website of the California Department of Public Health, Division of Licensing and Certification3 (L&C) showed no sanctions in the most populated California counties against hospitals or medical staffs for failure to perform peer review. The finding was promptly reported in testimony before the California Business, Professions, and Economic Development Committee,4 but the California Legislature took no action to give L&C greater authority to enforce our law. Moreover, L&C did not request additional statutory authority to impose meaningful sanctions against hospitals for failure of its medical staff to comply with the law, despite urging from interested parties. The peer review laws are designed to protect patients from unconstrained risk of negligent medical care in hospitals. As a result of our collective failure to enforce our laws, physicians

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at Redding Medical Center, California (RMC), were not constrained from harming more than 700 patients over ten years. The hospital’s parent, Tenet Corporation, earned up to $100 million per year by thwarting peer review in order to support Dr. Chae Moon’s unnecessary cardiac services.5 The L&C, Centers for Medicare and Medicaid Services-Region 9, the Joint Commission of Hospital Accreditation, and the California Medical Association Institute of Medical Quality knew peer review was not being done at RMC, but had no power and/or collective will to compel it. As one CMS official in San Francisco explained to me in 2006, “failure to perform peer review is not sufficient to violate the entire Medicare Condition of Participation.” The FBI filled the peer review vacuum in 2002 by hiring outside experts to analyze the case files of RMC physicians Chae Moon and Fidel Realyvasquez. The FBI uncovered the physicians’ negligence.6 Moon’s medical license was revoked.7 Realyvasquez’ license was restricted.8 Tenet Hospital Corporation paid $500 million in uninsured damages. CMS revoked RMC’s Medicare provider status.9 Reportedly, RMC’s administrators had to move to Thailand to find work. The disaster from failure of peer review is not unique to RMC. In 2009 a qui tam lawsuit exposed Dr. Mark Midei, a “star” cardiologist at St. Joseph Hospital, Towson, Maryland. He had inserted 541 intracoronary stents into patients who did not need them. The state of Maryland revoked his medical license in 2011.10 The U.S. Congress investigated the cause of the disaster.11 It found Dr. Midei was in charge of his own peer review.12 As with Moon, no

physician independently verified that Midei’s interpretations of cardiac catheterization images were accurate. Midei routinely overstated the degree of coronary narrowing in order to justify placement of stents for patients who did not need them. Abbott Laboratories, the maker of the stents, rewarded Midei financially. St. Joseph Hospital encouraged Midei’s lucrative behavior with power and money, plus control over his own peer review. The preventable tragedies at RMC and St. Joseph continue to haunt the medical profession. The absence of peer review is like flying in an airplane with a broken gas gauge. Although the CMA’s House now demands our state government shall enforce our peer review law, the state has limited power to do so. Accordingly, we have more to do before these nightmares are behind us. The peer review process is typically triggered to review problem cases or aberrant physician behavior. Most of Moon’s and Midei’s patients were free of complications because they were not sick. RMC and St. Joseph bragged about their high-quality cardiac care measured by low complication rates. Peer review does not routinely examine procedures for medical necessity. However, to fulfill its mission, peer review must not be limited to examination of complications alone. Going forward, peer review must include routine audits for medical necessity, particularly for self-referred profitable cases where a conflict of interest is not mitigated, such as cardiac procedures. For example, each medical staff must routinely audit cardiac image interpretations to verify the subsequent procedures performed are medically necessary. Radiologists or outside experts must perform the audits. An audit for medical necessity would have disclosed that Moon did not know how to interpret intracoronary ultrasound images and that he incorrectly believed some patients who had a normal cardiac cath still needed CABG surgery. Realyvasquez would have learned that a surgeon is expected to verify that his patient actually does require surgery. An audit for medical necessity would have

led to corrective action and probably saved the careers of Moon, Realyvasquez, and Midei. Peer review would have reduced RMC’s bottom line, but Tenet’s stock value may not have collapsed and fewer patients would have been harmed. Clearly, peer review is good for business over the long term to control unnecessary costs and to improve care quality. Each medical staff and hospital, separately and jointly, must assure that peer review is properly performed. A hospital medical staff must appoint a safety and compliance officer. Unbiased external peer review organizations must be hired when the medical staff fails in its responsibility or is hopelessly conflicted. Disciplinary hearings under peer review must be just. Logically, the process of effective peer review is a quality indicator by itself. Moreover, patients should have the right to know whether peer review is performed at their local hospital. Accordingly, the National Quality Forum should adopt a new quality indicator — the performance of peer review. The quality indicator would be posted on the CMS website, Hospital Compare,13 for patient education. When the peer review is of low quality, a measure of its performance may misleadingly assure patients that their hospital is safe. Therefore, we must find a way to measure effective peer review. What shall we do next? Do you have a recommendation for a resolution for next year’s HOD? For example, should model medical staff bylaws require that peer review include routine audits of selected physician services for medical necessity, including review of pertinent medical images when appropriate? Should our government routinely perform an analysis of hospital-based peer review whenever more than three patients are discovered by another process (e.g., a lawsuit) to have been harmed by the work of one physician? Under a federal law enacted in 2009, CMS may review the performance of hospital accrediting organizations and deny them deemed status which CMS uses to validate that

January/February 2012

The absence of peer review is like flying in an airplane with a broken gas gauge.

Medicare Conditions of Participation are met. Are CMS’s standards for hospital accrediting organizations too low to assure effective peer review? Should a physician have a right to obtain an unbiased external peer review hearing when the physician faces an administrative sanction? If you develop a practical resolution proposal for 2012 on this issue, please share it with me. jerryroganmd@sbcglobal.net

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1 2 3 4 5 6

http://edocket.access.gpo.gov/cfr_2009/octqtr/42cfr482.21.htm http://www.mbc.ca.gov/publications/peer_review.pdf http://www.cdph.ca.gov/certlic/facilities/Pages/Counties.aspx http://www.youtube.com/watch?v=5MquLfLJ9BQ http://www.allianceforpatientsafety.org/redding-failure.pdf http://www.amazon.com/Coronary-True-Story-Medicine-Gone/ dp/0743267540 7 http://www2.mbc.ca.gov/LicenseLookupSystem/ PhysicianSurgeon/Lookup.aspx?licenseType=A&licenseNumber= 32120 8 http://www2.mbc.ca.gov/LicenseLookupSystem/ PhysicianSurgeon/Lookup.aspx?licenseType=G&licenseNumber= 33283 9 http://articles.sfgate.com/2003-09-05/business/17508202_1_ redding-medical-center-redding-hospital-steven-campanini 10 https://www.mbp.state.md.us/bpqapp/PProfile3.asp 11 Staff Report on Cardiac Stent Usage at St. Joseph Medical Center, http://www.finance.senate.gov 12 St. Joseph has since revised their peer review practices ‘‘to include independent, blinded review of interventional providers and has ensured that clinical heads are neither selecting nor reviewing their own cases.’’ 13 http://www.hospitalcompare.hhs.gov/

Annual Meeting

Annual Meeting THE 2012 ANNUAL AWARDS AND Installation Dinner was held January 12 at the Hyatt Regency Hotel in Sacramento. Heading the full evening’s agenda was retirement recognition for William Sandberg who served as the Sierra Sacramento Valley Medical Society Executive Director for the past 25 years. Also, introduced as the new Executive Director was Aileen Wetzel, who hails from the California Medical Association. David Herbert, MD, a specialist in Infectious Diseases, was installed as the Medical Society’s 138th President succeeding outgoing President, Physical Medicine and Rehabilitation physician, Alicia Abels, MD. The Society’s highest award, the Golden Stethoscope, went to Ernest Johnson, MD, an otolaryngologist, for his expert, thoughtful and supportive patient care. The Medical Honor Award was presented to John Loofbourow, MD, for his advocacy on behalf of the underserved and as a voice of the medical community as Editor of Sierra Sacramento Valley Medicine. Sister Libby Fernandez, who serves as the Executive Director of Sacramento’s Loaves and Fishes, was presented with the Medical Community Service Award, given to a non-physician making a significant contribution to a medical or public health problem. Gabriella Neubuerger received the Alliance’s highest honor, the Dorothy Dozier Helping Hands Award, as well as the CMA-Alliance

Dedicated County Member Award for devoting her time, energy and talents to the Alliance. A moment of silence was offered in memoriam for the loss in 2011 of SSVMS members Drs. George Batten, Byron Demorest, Patrick Dietler, Jr., Wendy Forrest, Russell Hansen, Shirley Lee, Harvey Perman, John Reardan, Clifford Skinner, Robert Stowell, Daniel Terry, Neville Throckmorton, Alan Travis and Verna Unger. To entertain the guests during the evening, Bosco the Magician delighted viewers with interactive demonstrations of magic. An especially good sport for a surprise on-stage illusion was Bill Sandberg who appeared just as convinced of the enchantment as the baffled crowd!

January/February 2012

Dr. David Herbert, 2012 President presents outgoing President Dr. Alicia Abels with a plaque and gift.

Annual Meeting

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Annual Meeting

Bosco the Magician demonstrating a magic trick to Dr. and Mrs. James Rybka.

Charlotte Sandberg, Lindsey and Matt Sandberg with Dr. Lee Snook, CMA Trustee and wife, Cindy.

Dr. John Loofbourow, recipient of the Medical Honor Award and wife, Liliana.

Part of the UC Davis medical students attending the Annual Meeting.

Alliance President, Celeste Chin (left) with Gabriella Neubuerger, recipient of the Allianceâ&#x20AC;&#x2122;s Dorothy Dozier Helping Hands Award and the CMA-Alliance Dedicated County Member Award.

Members of the SSVMS Board of Directors, L-R, Drs. Russell Jacoby, Demetrious Simopoulos, Alicia Abels, Robert Kahle, Bhaskara Reddy, Dale Smith, Jason Bynum, David Herbert and Jose Arevalo.

Bill Sandberg and Bosco the Magician.

Golden Stethoscope Recipient, left, Dr. Ernest Johnson is presented award by President Dr. David Herbert and Dr. Margaret Parsons, Chair of the Scholarship & Awards Committee.

Dr. Jon Finkler, recipient of the Gold Miner trophy, recognizing his retirement after 21 years of service as a Delegate to the California Medical Association.

10 Gabriel Medina, representative for Assemblymember Roger Dickinson, presents an Assembly Resolution to retiring executive director, William Sandberg. 11 President Dr. David Herbert with Sister Libby Fernandez, Executive Director, Sacramento Loaves and Fishes and Recipient of the Medical Community Service Award.

January/February 2012

Annual Meeting

12 Retiring executive director, Bill Sandberg with Aileen Wetzel, incoming executive director and 2012 President, Dr. David Herbert.

13 Past President, Dr. Charles McDonnell, daughter, Diana, and Past President, Dr. Richard Jones with wife, Dr. Lydia Wytrzes. 14 Dr. John Loofbourow (left), outgoing Editor of SSV Medicine, and Dr. Nathan Hitzeman, incoming Editor. 15 Dr. Ernest Johnson, Golden Stethoscope Recipient, with family, left, wife Muriel, daughters, Jennifer, Kristen and Molly. 16 Steve Lindall, left, with Outgoing President, Dr. Alicia Abels and Lisa Pruitt, wife of Incoming President, Dr. David Herbert. Photo Credit: David Flatter (flickr.com/davidflatter)

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Touched by “Untouchables” Leprosy in 21st Century India

By Tyler Andre, MS II, and Eric Morley, MS II AS WE BOARDED THE 747 BOUND for Chennai, India, we could not have imagined the incredible sights, both beautiful and horrific, that we would encounter just a few hours later. In June of 2011, our contingent of medical students from UC Davis joined with a team to treat people afflicted by leprosy, also known as Hansen’s Disease. We served as volunteers for Rising Star Outreach (RSO), a charity organization co-founded by American Rebecca Douglas, and Padma Venkatraman, daughter of India’s former president Ramaswamy Venkatraman. Hundreds of leprosy colonies still exist in India. These small villages are filled with people living in extreme poverty who have been permanently disfigured by the disease and cast out of the cities. Even after being cured of the active infection, they face a lifelong recurrence of wounds that result from a loss of sensation in the limbs and face. Surrounded by others who lack education about leprosy and who perpetuate the caste system, the victims are shunned by society and deemed “untouchable.” Rising Star Outreach has been working for the past 10 years to help this population in a sustainable way using a three-pronged approach: 1) Placing children from leprosy-affected homes in Rising Star’s Perry Matriculation School, a boarding school for rising stars, where the students learn marketable skills with the goal of enabling them to escape the cycle of begging, dependence, and societal restrictions traditionally placed upon them as “outcasts.” 2) Providing ongoing medical care to those in leprosy colonies already affected by the disease. 3) Rescuing leprosy colony dwellers from a

life of begging by providing micro-loans to start small businesses. Rising Star Outreach is forced to rely on volunteer teams like ours, in part because there is such a stigma surrounding the disease that it is difficult to find local clinicians willing to provide the level of professional care and aid needed. Our UC Davis team stayed in volunteer quarters at the boarding school and focused our efforts in two primary ways. We provided medical treatment and health training to the children living on the RSO campus. We also did outreach by bus to remote leprosy colonies, as far as seven hours away, to set up temporary medical clinics to clean and treat wounds. Perhaps just as therapeutic was for these people to be touched, heard, and acknowledged as human beings. We were amazed to see how little was needed to run an effective mobile clinic in India. Frequently we worked in one-room churches or schools with little or no electricity, brushing aside curious chickens and shooing an occasional water buffalo. Most of the patients came for treatment of enormous foot ulcers, some nearly an inch deep. They were instructed to proceed through a series of stations in our clinics for efficient and effective care. First was a station for documentation and screening. Next, they visited one of three physicians on our team to assess their condition. Lastly, their wounds were soaked, scrubbed, oiled, debrided, and bandaged. When supplies permitted, we offered crutches and a limited amount of medications. What a wonderful and unique experience it was to be medical students able to assist in providing this kind of clinical care for a disease

January/February 2012

Tyler Andre, MS II

Eric Morley, MS II

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.

Tyler Andre and Eric Morley measure and cut off diseased tissue from leprosy victims in India.

that most of the world has never seen. We found it life-changing to interact with leprous patients and to learn firsthand about their plights. Using a translator, we were able to interview a few patients in depth. All were older than 40 and had been living in a leprosy colony for over 30 years. Before moving to a colony, they had lived lives like most other citizens in an Indian society, usually spending their days as farmers, business owners, and homemakers. Then, one day, everything changed. They could each clearly recall the first subtle

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symptom of their disease, such as a discolored area of skin or a tingling in the ears. They didn’t think much of it at first, but then the disease began to progress. Larger areas became numb, and their fingers literally started vanishing. Each patient had a reason for being cast out into a leprosy colony. Some were pressured by their families or communities while others simply felt shameful of their condition. The most striking revelation for us was that, until we educated them, none of the patients understood what caused their sickness or how they acquired leprosy. They all simply assumed, as is the common thinking, that they had been cursed by God for misdeeds performed either in this life or another and had come to accept their fate. Our team members agreed that these humble leprosy patients were some of the most resilient people we had ever met. Rather than pity, they only wanted respect and humane treatment. While they may have given up on being cured of their condition, they certainly hadn’t given up on life itself. One by one they would arrive at our makeshift clinics, patiently waiting for hours in the 110-degree heat. They were grateful for even the smallest amount of help. We felt that, in a way, we did something even more important than to provide medical care; we brought a glimmer of hope into the lives of people who for so long had been discarded by their society. Over the past 20 years, the World Health Organization has made enormous progress in ridding the world of leprosy. Rising Star Outreach continues to be a powerful ally in that effort. But there is still much work to be done. Currently there are over 200,000 patients infected with the disease worldwide, with more than that number of new cases continued on page 24

TIAs – Too much Intervention Attacks? By Nathan Hitzeman, MD ALTHOUGH ONLY IN PRACTICE FOR a decade now, I remember the “good old days” when some work ups were simple, and we were OK with letting time declare a patient’s trajectory. We used to admit and manage patients with transient ischemic attacks (TIA) by ruling out a bleed or mass with a CT scan, by monitoring the patient briefly in the hospital, by starting aspirin and adjusting medication for underlying hypertension and diabetes, and by ruling out carotid stenosis with a Doppler and perhaps cardiac causes with an echocardiogram if a murmur or other risk factors were present… Nowadays, everyone seems to get an MRI/MRA and a neurology consult. Recent years have seen an explosion of medical technology and interventions that are heralded as cutting-edge progress. They are embraced with open arms by physicians and patients alike — and sometimes before any real hard evidence is presented to substantiate their benefits. As UC Davis professor Dr. Michael Wilkes pointed out in his June 5, 2011 Sacramento Bee editorial: “when people are asked if they’d like to try a brand new procedure, the unspoken message is that ‘new’ is better than old.”1 Obviously, there are monetary and prestigious incentives for using high-tech over “high-touch” — and every doctor would like to believe that what they are doing is helping their patients. But are these interventions really improving patient care, are they cost-effective, and are they socially responsible medicine? The latest medical technology “oops” is intracranial stenting. In a September 7, 2011 NEJM study, this intervention was actually shown to be harmful when compared to medical

management alone.2 Intracranial stenting was lined up to be the next interventional cash cow. Medical device manufacturers and eager practitioners no doubt envisioned armies of these little stents populating the heads of our fine countrymen — perhaps only to be rivaled by the army of stents already in existence in lower latitudes of the corpus. It was probably this enthusiasm that prompted the American Stroke Association (ASA) to recommend aggressive imaging of all patients with TIA in their 2009 consensus guidelines.3 These guidelines give MRI with diffuse weight imaging a Class 1B recommendation and noninvasive testing of the intracranial vasculature a Class IA recommendation because it “is reasonable to obtain when knowledge will alter management.” Not surprising, I have seen the MRI/MRA become a standard workup of patients with TIA at our institution. There are up to 500,000 people diagnosed with TIA yearly in this country.4 If you multiply that by the cost of the two to three types of MR scanning used (and the neurology consultation) at perhaps $10,000 a person, we may be spending $5 billion a year in extra work up, which, I would argue, doesn’t alter management. The authors of the 2009 ASA guidelines also contend that MRI sometimes shows infarcts in a number of patients with presumed TIA and that this, in fact, can prognosticate. However, really, shouldn’t we be telling anyone with a TIA to start an antiplatelet and to return immediately if they have recurrent symptoms, in which case, tPA can be entertained? I am not convinced that MR imaging adds much to TIA management.

January/February 2012

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.

Perhaps Dr. Gerald Rogan said it best in his article “Medical Waste” in the Nov./Dec. issue of SSVM: “I believe our professional responsibility includes providing optimal value, which includes knowing when not to order a test, when to postpone it in favor of a less expensive first test, and when to follow the patient for a while without a test.”5 The FDA needs to better regulate new-fangled medical device technology.6 Physicians need to show some restraint in running to perform the newest interventions, especially in sensitive areas like our grey matter! In a recent NEJM commentary, “The Art of Doing Nothing,” cardiology fellow Dr. Lisa Rosenbaum writes of the yester-years in which her grandfather, an esteemed rheumatologist, practiced.7 “In the absence of all the tools

that now forge the bond between patient and physician, words mattered far more. So did touch.” We would do well to embrace the triedand-true methods of the past and be more scrupulous about those interventions that are less proven. hitzemn@sutterhealth.org 1 http://www.sacbee.com/2011/06/05/3673273/new-surgeryoptions-not-subject.html 2 Chimowitz MI et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis.September 15, 2011, NEJM 2011; 365:993-1003 3,4 Easton DJ et al. Definition and evaluation of transient ischemic attack. Stroke 2009;40:2276-2293. 5 Rogan, G. Medical waste: To test or not to test, that is the question. SSVM. Nov/Dev 2011. 6 Curfman GD, Redberg RF. Medical devices – balancing regulation and innovation. September 15, 2011, NEJM 2011; 365:975977 7 Rosenbaum L. The art of doing nothing. NEJM 2011;365:782785.

“Untouchables” continued from page 22

Tyler Andre and Eric Morley interview a leprosy patient.

appearing each year. An additional two to three million people are estimated to be permanently disabled from previous infections.1 The key to curtailing this epidemic is to create sustainable programs such as Rising Star Outreach that can efficiently and systematically provide monitoring and care over an extended period of time.

Wisely choosing an organization for which to volunteer is one way in which students and clinicians alike can truly have a significant impact on this effort. We encourage everyone who is even remotely interested in global health to consider working with people affected by leprosy. To do so is one of the most rewarding experiences in life. We certainly know that we shall never forget both our joy and humility in being able, in a small way, to touch the “untouchables.” If interested in joining next year’s team of volunteers, or for more information about our experience, feel free to contact us or Rising Star Outreach.2 Tyler.Andre@ucdmc.ucdavis.edu Eric.Morley@ucdmc.ucdavis.edu 1 http://www.who.int/mediacentre/factsheets/fs101/en/ 2 http://www.risingstaroutreach.org

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2011 CMA Resolutions By Richard N. Gray, Jr., MD, Vice Chair 11th District Delegation to the California Medical Association EACH YEAR YOUR ELECTED DELEGATES devote a four-day weekend to developing CMA policy at the annual House of Delegates (HOD). This is an amazing process through which approximately 300 physicians with a diversity of backgrounds, specialties, practice sizes and philosophies come together and direct CMA on how to proceed when providing information to the public or working with insurers, hospitals, or legislators. Though we do not actually write laws, we occasionally direct CMA staff to introduce legislation. In October of 2011 we met in Southern California where we dealt with 113 distinct resolutions, in addition to the recommendations from various reports. One ground-breaking item involved asking the CMA to work toward having the liability for providing EMTALA-mandated care transferred to the Federal Tort Claims Act, making the federal government responsible for the liability involved when we see these highrisk, unfunded patients. Examples of other resolutions passed include those in which the HOD directed CMA to: • Develop a Technical Advisory Committee to study coordinating disaster medical relief between the state and its counties. • Encourage the federal government to treat drug addiction medically, rather than punitively. • Oppose any restriction on physicians discussing firearms safety and risk with patients. • Provide an on-call document instructing physicians regarding their legal options in contracting with Medicare beneficiaries. • Oppose financial penalties for physicians who are not using prescribed health information technologies. • Provide relief from regulatory burdens for office laboratories.

• Support a repeal of the SGR (sustained growth rate on Medicare spending which would require a decrease in Medicare payments of 30 percent starting January 2012!) • Increase medical student and resident involvement in CMA. • Assist with decreasing restrictions on obtaining consultations in managed care. • Assist with having managed care organizations provide a list of covered medications or medical devices when a specific one is denied because it is not on the formulary or approved list. • Take action to oppose retroactive demands for the return of monies for services legally rendered. • Prohibit release of physician-specific prescribing data to pharmaceutical companies. • Propose a study to evaluate options to increase the availability of organs for donation. • Permit e-prescribing of Schedule II medications. • Protect against unreasonable demands from hospitals to increase liability limits while indemnifying the hospital. • Develop a “lemon law” regarding electronic health record programs. • Encourage support for medical student debt relief. • Request the Medical Board of California to investigate the illegal interpretation of medical tests by non-physicians. Not all of these examples will affect you the way they affect one of your fellow physicians, but the members of CMA are certainly doing what we can to look after the interests of our member physicians. We’ve got your back! rgraymd@comcast.net

January/February 2012

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.

Safeguarding Data Tips on Managing Professional Risk

By Fran Cain, Information Technology Department, NORCAL Mutual Insurance Company and the NORCAL Group EDITOR’S NOTE: Recently, the theft of a computer from a local area hospital spawned a multi-million dollar lawsuit that charged the hospital was negligent in safeguarding its computers and data. The class-action suit was filed in November in Sacramento Superior Court and seeks $1,000 each for more than four million patients whose information was compromised.

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.

WHAT IS THE WORST COMPUTER PROBLEM you need to prepare for? Is it arriving at the office to find your server doesn’t boot? Is it finding that a friend’s computer was compromised by a virus which your computer now has? Is it the power going out in the middle of the day? Or maybe you just downloaded the latest Microsoft updates and your software stopped working. These are all serious problems, and the threats are seemingly endless. Risks need to be mitigated by backing up your systems, using up-to-date operating system software, antivirus and anti-spyware software, and having reliable batteries in your Uninterruptible Power Supplies. But arguably the worst computer problem you could face would be compromised data. If data containing personally identifiable patient information (also known as Protected Health Information) leaves your possession and you know it — or, in the view of regulators, you should have known it — you will be subject to notification and reporting requirements under state and federal law including, but not limited to, HIPAA. In other words, you must not keep this security breach hidden under the rug. But when you notify patients that confidential information

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about them and their medical conditions has been taken and could be misused, your reputation may suffer considerable damage. There are many ways data can be compromised. One of the simplest is for a staff member to make a copy of data. While it has always been possible for staff to easily photocopy records in paper form, digitized data can be copied in huge quantities. It would be quite conspicuous to copy 1,000 patient files on a photocopier, but it would take only moments using a computer, and it’s possible no one would ever notice. Duplication of data is difficult to control. Mitigation begins with strong written policies that clearly notify staff that data should be copied only for specific, approved purposes, and with proper processes in place to safeguard security and privacy. For example, staff may copy medical records to removable media (e.g., USB flash drives, CDs or DVDs) in response to patient requests. Consequences for failure to follow policy, up to and including termination, must be outlined. Another way data can be compromised is if the computer sends data across an unencrypted (undisguised) Internet connection. Data flowing across a network can be intercepted by eavesdroppers. Always look for indications that Secure Socket Layer (SSL) is being used when connecting to sites on the Internet for business purposes, such as banking. This is indicated by a gold padlock in Internet Explorer, or a grey padlock in other browsers. There are dozens of web browsers, so familiarize yourself with the SSL graphic in the address line of the web browser you use. Mitigation also requires using a good

antivirus software product and keeping the virus signatures updated daily (virus signatures are like fingerprints that can be used to detect and identify specific viruses). You need to keep computer operating systems and software up-todate and patched (problems repaired) on a regular basis, at least monthly. For computers running Windows, each time Microsoft issues security updates for operating systems and/ or programs, all computers in the network or accessing the network should be updated. Avoid using wireless connections to communicate confidential patient information unless you are certain you are using current encryption methods (currently WPA or WPA2), and institute strong written policies about this. Policies regarding use of antivirus software and regular updates must be in place even if Macintosh computers are used instead of Windows computers. While Windows computers are at much higher risk, any computer can become infected with a virus. If you use laptops in your practice, staff members need to be advised to avoid storing patient data on the hard drive, that is, on the C drive or in My Documents, etc. If the laptop is lost or stolen, the password can be easily hacked, and any data on the local hard drive can become accessible. This is one case in which you must contact all of your patients to notify them that their data has been stolen. It is also strongly advised that you seek assistance from your professional liability insurance carrier in the event that protected health information or other patient data is stolen or compromised in any way. One excellent way to mitigate the damage when a laptop is stolen or lost is to use disc encryption on all laptop hard drives. A few years ago, the idea of encrypting hard drives struck fear into the I.T. community. Doing so slowed down the system and made it difficult to recover data if the computer crashed. While it is still true that it is tricky to recover data when the computer crashes, it is not necessarily impossible, and new encryption software does not noticeably slow down the computer. In fact, once your laptop is encrypted,

chances are good that you will never even notice that your data is encrypted. The encryption software runs quietly in the background, and automatically decrypts data for e-mailing, exporting or copying. If the encrypted laptop is stolen, the data cannot be accessed â&#x20AC;&#x201D; and no letters need to be sent to patients or anyone else. The peace of mind that comes from knowing this is worth the tradeoff of any inconvenience. Encryption software can be configured to encrypt not only hard drives, but also removable media, such as USB flash drives. USB flash drives are a headache to IT security personnel. As mentioned earlier, staff can easily steal data by copying to a USB flash drive. Automatic encryption when copying to an external device,

January/February 2012

How not to dispose of medical records.

such as a USB flash drive, makes it more difficult to steal data. If the miniature drive is dropped, lost or stolen, the data on it cannot be read by another computer. (Note: Before attempting to encrypt any hard discs on your own, or even with the help of a consultant, be sure to back up all existing data to reliable media.) When copying a medical record to removable media for a patient, the encryption feature should be disabled. While raising awareness of the many serious threats to data, this article merely scratches the surface of the subject. NORCAL Mutual Insurance Company provides extensive information to assist you in understanding information risks and formulating appropriate policies and procedures. You have online access to this information through your MyNORCAL account (access is at www.norcalmutual.com). You also have full access to a wealth of state-specific information through the DataShield™ Learning Center, also located in MyNORCAL under the

Risk Solutions tab. For example, you will find detailed sample policies which can easily be adapted to your practice, sample newsletters, up-todate information on compliance, and training materials. If you already have a MyNORCAL account, go to the DataShield™ Learning Center and check out the Top Ten Cyber Security Tips under Training/Training Bulletin. Here are some additional free online articles if you would like to learn more about data security: http://www.ama-assn.org/resources/doc/psa/ hipaa-phi-encryption.pdf — A good overview, including helpful graphics and additional resources. http://www.brighthub.com/computing/ smb-security/articles/61722.aspx — More insight into security breaches. http://en.wikipedia.org/wiki/Man-in-themiddle_attack — Discusses eavesdropping or “man-in-the-middle” attacks. jtownson@norcalmutual.com Copyright 2011 NORCAL Mutual Insurance Company. All rights reserved. This material is intended for reproduction in the publications of NORCAL-approved brokers and sponsoring medical societies that have been granted prior written permission. No part of this publication may be otherwise reproduced, edited or modified without the prior written permission of NORCAL. For permission requests, contact: Jo Townson, CME Supervisor, at (800) 652-1051, ext. 2270.

Remember When?

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A View from Over the Hill Sisyphus Revisited

By Gilbert Wright, MD This is the first in a series of occasional articles with a gerontology theme by Dr. Wright, a retired orthopedist. His training at UCSF led him to concentrate on the lower extremity, and then on diabetic complications, and inevitably, on amputations and prosthetics. He worked with amputee skiers and sailors in adaptive sports programs. He also helped develop a locally-run prosthetic program for land mine victims in El Salvador. “I have both an academic and practical interest in the subject of gerontology and would like to learn more about it and share it with you.” SISYPHUS WAS A CHARACTER of Greek mythology who was condemned by Zeus to repeatedly roll a large boulder up a hill where it would stop and roll back down, whereby he would begin again. It has become a classical example of frustrated effort. This metaphor is sometimes applied to experiences in the aging process. Using the current concepts of cognitive therapy, I prefer a positive view of the process. I see Sisyphus cresting the hill with the boulder and standing at the top with a wry smile anticipating its arrival on the bottom of the other side. I would like to apply this positive thinking to the life experiences of two personal heroes of my own age, Arnold Palmer and Dr. Quentin Young. Arnold Palmer is a professional golfer who has been plagued all his life with a hook. A hook describes an unfortunate trajectory of the ball hit by the driver which causes it to veer to the left, sometimes precipitously, and is known as a “snap hook” or “duck hook.” It is likely to end up out of bounds or in the trees. My wish for Arnie is that at the summit, his drives assume

a new trajectory, head straight out for 300 yards, then fall gently to the right on the fairway. Quentin Young is a doctor from Chicago who has struggled all his life to practice compassionate medicine in a for-profit run, insurance-dominated medical care system. He is a founding member of the Physicians for a National Health Program and an important advocate for a single-payor health care system. My wish for him is that at the summit he is able to rest the boulder on top and proceed on down into the Elysian fields of national single-payor health care. According to reliable reports, Arnold has achieved his summit, but the prospects for Quentin Young are bleak. gibwright3@gmail.com

January/February 2012

SSVMS 2012 Committees Below are appointments by the Board of Directors for this year:

Child and Adolescent Health Services Drs. Mary Jess Wilson, Chair, Marcia Britton-Gray, Jason Bynum, Christine Fernando, Lindalee Huston, Maynard Johnston, Robert Meagher, and Patricia Samuelson Editorial Drs. Nathan Hitzeman, Editor/Chair, Ann Gerhardt, Vice Chair, Sandra Hand, Albert Kahane, Robert LaPerriere, John Loofbourow, John McCarthy, George Meyer, John Ostrich, Gerald Rogan, Gilbert Wright, Adam Dougherty, MS II and Nan Crussell, Managing Editor Emergency Care Drs. J. Douglas Kirk, Chair, David Berman, Michael Carl, Troy Falck, Hernando Garzon, Peter Hull, Kendrick Johnson, Robert Kozel, Norman Label, Kelly Nations, Harold Renollet, Lynette Scherer, R. Steve Tharratt, Lee Welter, John Wiesenfarth, David Wisner, and John Wood Historical Drs. Robert LaPerriere, Chair, Donald Brown, Malcolm Ettin, Christine Fernando, Francine Gallawa, Nancy Gilbert, James Hamill, Sandra Hand, Gabor Hertz, Julian Holt, Jack Ostrich, Kent Perryman, F. James Rybka and Irma West Judicial Drs. Joanne Berkowitz, George Chiu, Jose Cueto, Barbara Hays, Paul Phinney and Boone Seto Medical Review and Advisory Drs. Howard Slyter, Chair, Joanne Berkowitz, Vice Chair, Alicia Abels, Denny Anspach, Jose Arevalo, Richard Axelrod, Mark Chang, Satya

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Chatterjee, George Chiu, Jose Cueto, Douglas Enoch, Ronald Foltz, Kenneth Furukawa, Richard Gray, Kern Guppy, Ruth Haskins, Edward Hearn, Reinhardt Hilzinger, Stephen Hiuga, Donald Hopkins, Maynard Johnston, Marvin Kamras, Thomas Kaniff, Abdul Khaleq, Michael Klein, Charles Kuehner, Charles McDonnell, George Meyer, Gail Pirie, Michael Robbins, Kristen Robinson, Linda Schaffer, James Sehr, Boone Seto and Gerald Simon Professional Conduct and Ethics Drs. Joanne Berkowitz, Chair, Ruenell Adams, Frank Apgar, Mark Chang, George Chiu, Douglas Enoch, Malcolm Ettin, Jon Finkler, Richard Gray, James Hamill, Sandra Hand, Barbara Hays, Edward Hearn, Richard Jones, John Kasch, Paul Kelly, Ralph Koldinger, Charles Kuehner, Ivan Rarick, Harold Renollet, Ronald Rogers, Linda Schaffer, and James Sehr Public and Environmental Health Drs. Donald Lyman, Chair, Regan Asher, Donald Brown, Clinton Collins, Anthony DeRiggi, Christine Fernando, Nancy Gilbert, Olivia Kasirye, Albert Kahane, Robert LaPerriere, Stephen McCurdy, Robert Meagher, Boone Seto and Richard Sun Scholarship and Awards Drs. Margaret Parsons, Chair, Ruenell Adams, Ray Fitch, Francine Gallawa, Charles Hammel, Paul Kelly, Mark Levy, Travis Miller, Jack Ostrich, Anthony Russell and Patricia Samuelson Wellness Committee Drs. Michael Parr, Chair, Lee Snook, and Captane Thomson

SSVMS Election Results 2012 Board of Directors President: David Herbert, MD President-Elect: Demetrios Simopoulos, MD Immediate Past President: Alicia Abels, MD District 1, North: Robert Kahle, MD District 2, Central: Jose Arevalo, MD, Ann Gerhardt, MD, Lorenzo Rossaro, MD District 3, South: Bhaskara Reddy, MD District 4, El Dorado County: Russell Jacoby, MD District 5, Permanente Medical Group: Paul Akins, MD, John Belko, MD, Jason Bynum, MD, Steve Kelly-Reif, MD, Kristin Robinson, MD District 6, Yolo County: J. Dale Smith, MD 2012 CMA Delegation District 1, North: Robert Kahle, MD, Delegate; Reinhardt Hilzinger, MD, Alternate District 2, Central: Lydia Wytrzes, MD, Delegate; Margaret Parsons, MD, Alternate District 3, South: Katherine Gillogley, MD, Delegate; Ruenell Adams, MD, Alternate District 4, El Dorado County: Earl Washburn, MD, Delegate; Russell Jacoby, MD, Alternate District 5, Permanente Medical Group: Elisabeth Mathew, MD, Delegate; Anthony Russell, MD, Alternate District 6, Yolo County: Marcia Gollober, MD, Delegate; Karen Hopp, MD, Alternate At-Large Office #7: Demetrios Simopoulos, MD, Delegate; Alternate (Vacant) At-Large Office #8: David Herbert, MD, Delegate; Alexis Leiser, MD, Alternate At-Large Office #9: Norman Label, MD, Delegate; Robert Forster, MD, Alternate At-Large Office #10: Alicia Abels, MD, Delegate; Maynard Johnston, MD, Alternate At-Large Office #11: Boone Seto, MD, Delegate; Richard Pan, MD, Alternate At-Large Office #12: Kuldip Sandhu, MD, Delegate; Rajan Merchant, MD, Alternate At-Large Office #13: Stephen Melcher, MD, Delegate; Alternate (Vacant) At-Large Office #14: Charles McDonnell, MD, Delegate; Robert Madrigal, MD, Alternate At-Large Office #15: Richard Jones, MD, Delegate; Alternate (Vacant) At-Large Office #16: Richard Gray, MD, Delegate; Alternate (Vacant) At-Large Office #17: Janet Oâ&#x20AC;&#x2122;Brien, MD, Delegate; Alternate (Vacant)

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 Babo, Mark E., Family Medicine, Oral Roberts University 1983, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Boone, James D., Anesthesiology, UC San Diego 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Chin, John, Cardiology, UC Davis 1978, Regional Cardiology Associates, 3941 J St #260, Sacramento 95819 (916) 736-2323 Choudhry, Neeharika, Internal Medicine, University of Rajasthan/ SMS Medical College, India 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Cohn, Bruce J., Internal Medicine, The Chicago Medical School 1980, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4040 Golden, Brian K., Urology, UC San Francisco 2000, Radiological Associates of Sacramento, 500 University Ave #200, Sacramento 95825 (916) 961-2514 Hoette, Petra, Family Medicine, Georg-August University, Germany 1998, The Permanente Medical Group, 2155 Iron Point Rd, Folsom 95630 (916) 817-5000 Holz, Andrew L., Nuclear Medicine, Columbia University 2002, Radiological Associates of Sacramento, 1500 Expo Parkway, Sacramento 95815 (916) 646-8300 Khasawinah, Tariq A., Internal Medicine, University of MissouriColumbia 2003, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5877 Lallana, Enrico C., Neurology, Unv. of the East Ramon Magsaysay, Philippines 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Lee, Lenora W., Internal Medicine, Albert Einstein 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Ormsby, Bernard L., DO, Family Medicine, Touro University 2008, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4050 Orlino, Elmo N., Jr, Anesthesiology, UC Davis 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Poirier, Brian F., Transfusion Medicine/Blood Banking Medicine, University of Colorado 2004, BloodSource, 10536 Peter A. McCuen Blvd., Mather 95655 (916) 456-1500 Sonik, Arvind, Radiology/Pediatric Radiology, UC Davis 2004, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5848 Taylor, Sarah E., Emergency Medicine, University of Florida 2007, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5390 Thao, Long E., DO, Internal Medicine, WUHS College of Osteopathic 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

January/February 2012

In Memoriam

Byron H. Demorest, MD 1925–2011

THE MIDWEST BREEDS THUNDERSTORMS and whirlwinds, and molds a territory of strong commitments to family, community, professions and country. It was a land that imparted all those qualities and more to Byron Demorest, MD. October 14, 2011 was the final thunderclap of such a dynamic storm of a man who succumbed abruptly from complications of multiple myeloma. Byron was born in Omaha, NE in 1925, the son of a newspaper editor. His penchant for communication skills was likely imparted from the ink of his father’s newspaper. He put himself through the University of Nebraska by utilizing his resonate voice in radio Byron H. Demorest, MD announcing. Following his residency in ophthalmology at Washington University, he jet-streamed westward to instruct at Stanford University. He also he served as a Lieutenant Commander in the U.S. Navy. In 1955 he settled in Sacramento and commenced a small, solo practice in pediatric ophthalmology. Byron was a leader in his church, a chief in the Northern California Boy Scouts association, and he volunteered his surgical skills to correct eye disorders of needy children. Utilizing his rumbling radio voice, wit and profound knowledge of medicine, he was a daily contributor to the KCRA Channel 3 “Doctor’s Notebook” long before Dr. Dean Edell or Dr. Oz claimed the limelight. Byron was a luminary within his ophthalmic profession, being past president of the 40,000-member American Academy of Ophthalmology and the California Association of Ophthalmology. He was also a national examiner of the American Board of Ophthalmology, and president of the Sacramento County Ophthalmic Society. 32

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Locally he was past president of the SSVMS, and a member and chair to numerous SSVMS committees. For well over a decade, his “golden throat” was the announcer’s voice at all the SSVMS installation dinners. Byron helped to conceive and initiate the University of California, Davis, School of Medicine. He was the co-founder of the Department of Ophthalmology where he served as unpaid chairman until full-time faculty members were hired. For over 30 years as a volunteer clinical faculty member, he trained dozens of ophthalmologists, many of whom still practice within the Sacramento area. He was a devoted father of three successful children. With Phyllis, his wife of 63 years, he shared a deep love and partnership in many activities including music, stamp collecting, bridge, golf, skiing and running. All of these he pursued zestfully until only weeks before his death. Virtually all who knew Byron thought of him as the “conscience of medicine.” In his acceptance address before the national meeting of the American Academy of Ophthalmology, he reminded us that “we choose our profession to take care of patients, not have the patients’ payments take care of us.” Fittingly, Byron was the recipient of the highest award of merit and achievement at SSVMS, the Golden Stethoscope. Despite the brilliant lightening, electricity, resonance, and grandeur of Midwestern thunderstorms, they all ebb. In their wake they leave the land well watered and nurtured. Such is the metaphor for the life of, Byron Demorest MD, a Midwestern super cell of a man, grand in his accomplishments, towering in stature, principled and inspiring and leaving behind a rainbow and a territory fertile for perpetuation of high ethical standards in patient care. — Richard A. Jones, MD

A Posit on Cannabis “In the present circumstances, physicians should advocate for local or state regulation of production, taxation and distribution/sale of cannabis.”

BACKGROUND: See the report on a marijuana clinic in our November/December issue, a recent editorial and an essay by Dr. Paul Phinney, CMA President-Elect, in The Sacramento Bee, and the CMA position paper on regulation of marijuana at these links: http://www.cmanet.org/news/detail/?article =cma-urges-legalization-and-regulation-of http://www.cmanet.org/files/pdf/news/cmacannabis-tac-white-paper-101411.pdf (See also Dr. Don Lyman’s article in this issue.) Results: Agree, 50; Disagree, 27. Some edited comments follow: In the 1930s, my father (a pharmacist and toxicologist) gave a talk at my elementary school’s PTA advocating the legalization, regulation and taxation of illicit drugs in order to cut down on crime (shocking). Here we are, 70+ years later, still struggling over just marijuana, for which there seems to be some medical benefit for certain problems. — James Affleck, MD I agree (only) in part, in that this needs to be a federal matter, not a state matter. Cannabis is significantly less dangerous than alcohol, and it has further been used quite successfully for medical purposes. Continuing to mark this drug as Schedule I is both exacerbating the crime associated with it as well as making it impossible to use in a therapeutic manner. Legalization and regulation make the most sense in preserving our freedoms and serving the public good. Much as we tax tobacco and alcohol and attempt to reduce their ill effects, we do not ban them, and cannabis should be similarly managed. — Srihari Namperumal, MS IV Why advocate for another drug that leads

to multiple accidents, abuse, and exacerbates psychological illness? Working in the ED most trauma, gang-related injuries and psych issues have positive drug screens for THC. It seems to be much more prevalent than alcohol-related problems. You can blame the accepted use for another bad medicine. — Franklin Robinson, III, MD It’s a tough issue. Criminalization is a wasteful and destructive failure. Medicalization is often, but not always, a pretense. The DEA prevents legitimate research. So regulate it like tobacco or alcohol…sister drugs as they are. — John McCarthy, MD If cannabis has medical benefit and it is used as a pharmaceutical, then standardizing dosage forms and dosage for indication would seem logical. Also, distribution through usual pharmaceutical outlets would be most appropriate. We don’t have Vicodin shops or Valium shops — why have we set up an independent distribution system for cannabis? The reason is that it is used more recreationally than it is used medically. Just look at the clients. If it isn’t medically useful, then license and regulate it; you won’t ever stop people from using it. — Thomas Atkins, MD The only patient that I saw who benefitted from taking pot was dying! — Alan Galbreath, MD I am particularly proud of CMA’s effort in this regard. There is a need for leadership on marijuana public policy, and CMA has provided it. There is little argument that the “war on drugs” is a flawed and failed policy. Despite our best efforts, illicit drug use is rampant. Diversion of prescribed medications is epidemic. The good people of California agreed to compassionate use of medicinal marijuana and trust that we

January/February 2012

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.

A large percentage of medical marijuana use is predominantly for recreational use.

in the medical community honor that trust. In order to achieve that, I believe we need a rational policy directed at appropriate treatment, adequate study, and regulation just like we do for any other pharmaceutical. Now that cannabis is prescribed as a medicine, it needs to be further studied and regulated. The CMA looked at this issue carefully and thoughtfully. CMA is [at its] best when we work together for the benefit of our patients. Good job CMA. — Lee Snook, MD Docs can write a recommendation but not a prescription for cannabis. Prescribing [is] illegal. Stating a patient would benefit medically from it is a medical opinion. (I learned this from a doc who is in the cannabis need assessment business. Legalization and regulation of THC should reduce the murder rate in Mexico, indirectly driven by U.S. demand for the product. Selected businesses already screen prospective employees for THC, some using hair analysis. For our people as a whole, the benefit of control through legalization and regulation exceeds the risk. — Jerry Rogan, MD I agree. It would be ideal if the federal government would do the same. — John Rogers, MD I agree but only with stringent oversight and control. The cannabis shops that now exist ad infinitum and that advertise medical acceptance, i.e., medical acceptance with an MD within one-half hour, is absurd and is another example of poor local and state law enforcement — or is the state legislature faulty? Any MD willing to certify any individual within one-half hour after their arrival at a “shop” should be humiliated and disciplined. — Wayne Matthews, MD I was astonished that the CMA adopted a position in support of “medical” marijuana. Recently, The Medical Letter summarized the evidence-based literature on this subject and concluded there was little quality evidence to support “medical marijuana.” Further, given the extensive evidence of adverse effects from marijuana use, the CMA’s position is frankly embarrassing. Please see “Long Term Medical Effects of Cannabis Use” at www.uptodate.com. — Michael A. Patmas, MD

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Given the millions currently using it, regulation to prevent contamination, and taxation to realize revenue, seem obvious. — Patricia Samuelson, MD It is the very height of hypocrisy in this nation to permit advertising of alcohol to millions of young children on national TV during major sporting events… yet to keep marijuana illegal to patients with terminal disease. — James Ruben, MD [The] posit puts physicians in a non-clinical area. We, as physicians and researchers, have no business in taking any political or business position of the use of marijuana. We should continue to research medicinal use of marijuana. — Boone Seto, MD Medical marijuana is a joke in California. I recommend it be limited drastically to terminally-ill patients only; all the other “conditions” can be better treated with traditional and alternative medical care. I would limit the prescribing to the patient’s primary care physician only. — James Margolis, MD I support legalization and regulation of cannabis, but I worry that the regulation will be yet another onerous task put on the primary care doc. Unless the stuff can be injected into the spine at exorbitant costs to the healthcare system, pain management clinics will probably leave the prescribing to me, as is currently being done with opioid medications. Ceiling doses should be better defined in each of these scenarios to make my job a little bit easier. — Nathan Hitzeman, MD It should not be advocated until it is legal on a national level. — Terry Zimmerman, MD While there are some benefits to medical marijuana, for the most part they are over-hyped, and there are better medications for most of the reasons marijuana is “prescribed.” As a medical oncologist, I have written for [recommended] it many times for my patients, but most of the use is for other “indications.” A large percentage of medical marijuana use is predominantly for recreational use. I favor legalizing it for all the reasons listed in the CMA editorial. There is no way for society to completely prohibit use of marijuana. It… would be better for our society

if it were controlled like other similar products such as alcohol and tobacco. Doses can be standardized, and there are obvious benefits to taxation of such products… Legalization would take a large burden off of the police and other authorities… [and] help with congestion in our courts for what are generally minor offenses. — Sidney Scudder, MD As physicians, we should not advocate for distribution/sale of cannabis and should not support its legalization. Already, too many people are using cannabis for the most benign reasons and getting prescriptions from any willing provider. Examples include a teenager who was getting cannabis because his parents knew he used it, but did want to have a legal RX to protect him if he got caught; a patient who just wanted to use it for better sleep; etc. Physicians should oppose any legalization of this drug. And, we should not be swayed by the arguments that its legalization will provide profit to the state of California. — Pankaj Patel, MD The current decriminalization is cost effective for an illegal substance. Legalization will increase use by all age groups, in particularly, the young. Marijuana adversely affects shortterm memory and the ability to multi-task. A

state of dependence by nine percent of the user population would be a large number of people in California draining health care resources and not contributing to society. Tax dollars gained from legalization would be absorbed by increased government bureaucracy and increased need for treatment of dependency. The real winner will be the tobacco industry that is ready to cash in with legalization. — Richard Park, MD American society does not seem able to get a handle on the marijuana problem currently. The “Posit” seems a reasonable change as a start to the situation. I would prefer the state regulate the situation rather than have it done locally. …Physicians should support studies to determine scientifically the efficacy of marijuana and cannabis as therapeutic for the various conditions as claimed. This would require federal and/or state funding as there would seem little profit… for drug companies from such efforts. A simple, inexpensive test for blood levels needs to be developed; and standards for mental and physical impairment… We need a study to show if this could be partially or completely paid for by reductions of expenditures for policing. — Ray F. Fitch, MD

Board Briefs November 14, 2011 The Board: Approved the operating budgets for the Sierra Sacramento Valley Medical Society (SSVMS), the Community Service, Education and Research Fund (CSERF) and the 2011 Third Quarter Financial Statements and Investment Reports. Approved the following recommendations from the Scholarship and Awards Committee for the 2011 SSVMS Awards: Golden Stethoscope Award, Ernest E. Johnson, MD; Medical Honor Award, John C. Loofbourow, MD; Medical Community Service Award, Sister Libby Fernandez, Sacramento Loaves and Fishes. Approved the Membership Report For Active Membership — Mark E. Babo, MD; Neeharika

Choudhry, MD; Bruce J. Cohn, MD; Brian K. Golden, MD; Andrew L. Holz, MD; Enrico C. Lallana, MD; Brian F. Poirier, MD. For Change in Membership Status from Resident to Active Membership — Alexis Lieser, MD For Renewal of Illness Leave of Absence — Douglas Schuch, MD For Retired Membership — Jon G. Finkler, MD; Isaac B. Freeman, MD; Robert B. Gardner, MD; Jack M. Kashtan, MD; Kenneth K. Lee, MD; Richard G. Lockmiller, MD; Harold L. Renollet, MD; Gerald W. Upcraft, MD. For Resignation — Ruth J. Crane, MD; Shuchita Gupta, MD (moved to Pennsylvania); John Hackert, MD; Joseph A. Karam, MD; Jacob Reznik, MD (transferred to LACMA); Maaya A. Wilton, MD (moved to Georgia).

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