2013-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2013

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Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com

Hill Physicians’ 3,800 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.

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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.

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MEDICINE 3

PRESIDENT’S MESSAGE How SSVMS Improves Our Practices and Communities

Massage Parlors – An Investigative Report

David Herbert, MD

Jack Ostrich, MD

EXECUTIVE DIRECTOR’S MESSAGE Sequestration FAQ

First Frost

John Loofbourow, MD

Aileen Wetzel, Executive Director

Careless Narcotic Prescribing Kills Patients

EDITOR’S MESSAGE Take the “No Robot” Pledge

Bruce Barnett, MD, JD

Nathan Hitzeman, MD

SSVMS Supports Sac County History Day

Getting Serious About Cost Containment

Bob LaPerriere, MD

Adam Dougherty, MPH, MS III

2013 Education Series

Profile: Driven to Connect

Elizabeth Zima, CMA Staff Writer

BOOK REVIEW “None But The Brave”

Why I go to Patients’ Funerals

Reviewed by Jack Ostrich, MD

Ann Gerhardt, MD

Sign Language

A Posit on Availability of Doctors’ Notes to Patients

George Meyer, MD

Board Briefs

Sacramento Pioneer Surgeon Dr. Junius Harris

Meet the Applicants

F. James Rybka, MD

Classified Ads

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx Our members often enjoy the luxury of foreign travel, and they sometimes share photos of places and landmarks that are of medical interest. Dr. Bob LaPerriere recently sent this cover photo from Cozumel, Mexico, a small island off the Yucatan coast, which was the first of six stops on an 11-day Western Caribbean cruise, he says. “This store was at the end of the pier in the port area among other shops where we assembled for our day’s excursion. Unfortunately, I did not have a chance to go into the store.” The shop’s wares do inspire imagination! Dr. George Meyer has also been amassing travel photos of a medical nature, which he proudly shares on page 12.

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

May/June 2013

Volume 64/Number 3 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2013 Officers & Board of Directors David Herbert, MD President Jose Arevalo, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Lorenzo Rossaro, MD Christian Serdahl, MD District 3 Bhaskara Reddy, MD District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristen Robinson, MD District 6 Tom Ormiston, MD

2013 CMA Delegation Delegates District 1 Robert Kahle, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Earl Washburn, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Jose Arevalo, MD Richard Gray, MD David Herbert, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Anthony Russell, MD Kuldip Sandhu, MD Boone Seto, MD

District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD District 5 Robert Madrigal, MD District 6 Karen Hopp, MD At-Large Jason Bynum, MD John Belko, MD Jeffrey Cragun, MD Maynard Johnston, MD Olivia Kasirye, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Douglas Brosnan, MD Solo/Small Group Practice Forum Lee Snook, MD CMA President Paul Phinney, MD CMA President-Elect Richard Thorp, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate

Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair John Belko, MD George Meyer, MD Sean Deane, MD John Ostrich, MD Sandra Hand, MD Gerald Rogan, MD Albert Kahane, MD Chris Swanson, MD Robert LaPerriere, MD Lee Welter, MD John Loofbourow, MD Gilbert Wright, MD John McCarthy, MD Adam Dougherty, MS III Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Our Hours Are Changing, But Not Our Commitment. For over 30 years, the physicians at The Doctors Center have always been available to assist you throughout the year. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 12 hours a day, 7 days a week. When your schedule becomes impossible to meet, send those patients requiring basic medical attention to us. We treat acute minor illness and injury cases including flu, eye injuries, lacerations, fractures, sore throats and pneumonia. We take care of your patients’ immediate needs and refer them back to you for on-going care. Prior to November 1, The Doctors Center is open from 8 a.m. to 10 p.m. Lab tests, x-rays and ECG’s are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for multiple HMO’s and PPO’s.

Starting November 1, The Doctors Center new hours will change to 8 a.m. to 8 p.m.

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine ANITA H. BORROWDALE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

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

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2013 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 Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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PRESIDENT’S MESSAGE

How SSVMS Improves Our Practices and Communities By David Herbert, MD AS WE SURVEY THE MANY things that SSVMS has accomplished and continues to accomplish, it is clear that much of our success is due to the work of our committees. Many of our members are not familiar with this work, so I will spend a few paragraphs in this and my next column to highlight our committees’ many accomplishments. They should be recognized for all they do, and we hope that members who would like to contribute to these areas will recognize an opportunity and contact me or the committee chairs. Our Editorial Committee is chaired by Drs. Nate Hitzeman and Ann Gerhardt. This group spends literally dozens of hours every month putting together our terrific journal. Lively (but respectful) discussions are always welcome, along with poetry, reflection, photography, and more. Let your creative side loose, and send something! The Emergency Care Committee is chaired by Dr. Doug Kirk and has been amazingly productive, making a real difference in the emergency care in our community. Among their best known work is the elimination of emergency department closures. Newer members of our community may not be aware that for many years emergency departments around the area temporarily “closed” when they became very busy, a practice called “diversion.” The solution required considerable trust on the part of all of our hospitals as they pledged not to close – and it worked! Our museum is operated by our Historical Committee, chaired by Dr. Bob LaPerriere. They have maintained an outstanding collection of historical medical instruments and treatments, displayed in an engaging format that is utilized by schools and our community at large. If

you have not had the opportunity to tour the museum at SSVMS, I would encourage you to bring your family for a look! And, if you have some spare room in your garage, I understand that Dr. Bob is looking for more places to store our ever-increasing collection. Perhaps most popular is the Medical Review and Advisory Committee, chaired by Dr. Howard Slyter. Working with NORCAL Mutual, SSVMS’ sponsored medical malpractice carrier, this group reviews cases of possible malpractice and advises NORCAL about their merits. This not only guides the efforts of NORCAL, but offers the committee opportunities to identify areas of practice in need of improvement in their own institutions. NORCAL supports this committee’s work with significant funding for SSVMS. The SPIRIT Management Committee, chaired by Dr. Jack Rozance, coordinates our volunteer efforts, both those directly overseen by SSVMS and those we coordinate with community clinics. I’ve mentioned the important work of this group in prior columns, and I’m pleased to note that our SPIRIT surgeons who provide hernia repairs to those without insurance have been selected as Health Care Heros by the Sacramento Business Journal. The Child and Adolescent Health Services Committee is chaired by Dr. Mary Jess Wilson. They have reviewed important scientific, practice, and policy issues affecting children. Next time: Public and Environmental Health, Scholarship and Awards, Professional Conduct and Ethics, Judicial, and Wellness Committees. Through these committees and more, SSVMS truly makes a difference. Join us! davidherbert166@gmail.com May/June 2013

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

EXECUTIVE DIRECTOR’S MESSAGE

Sequestration FAQ By Aileen Wetzel, Executive Director

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

THE 2011 BUDGET CONTROL ACT ordered the federal government to cut spending by $1.2 trillion beginning in 2013. Medicaid is exempt from the reductions, but Medicare payments to doctors and others for inpatient and outpatient services will be reduced by two percent, or roughly $11 billion for the year. Below are answers to frequently asked questions about the sequestration cuts. Q: When do the cuts take effect? A: Medicare fee-for-service program claims with dates-of-service on or after April 1, 2013, will be reduced by two percent. Q: What Medicare cuts can physicians expect? A: The two percent claims payment adjustment will be applied to all claims after determining coinsurance, any applicable deductible and any applicable Medicare secondary payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims are subject to the two percent reduction. Medicare Advantage health plan payments will also be cut by two percent, although it is unclear if the health plans will pass the cuts through to contracting physicians. Q: What medical specialties/treatments are affected by the sequestration? A: All services and programs within Medicare (all provider services, hospitals, Medicare Advantage plans and graduate medical education) will be hit with a two percent cut. Q: Will Medicare EHR incentive payments be cut? A: While CMS has released no specific information on how it will handle the sequestration cuts, there is a possibility that providers may see a two percent cut to their

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EHR “meaningful use” incentive payments. This money had been set aside under the 2009 federal economic stimulus package for both Medicare and Medicaid, so it is unclear whether it will be impacted by the sequestration cuts. Q: What programs are exempt from the sequestration? A: Medicaid, Social Security and the Veteran’s Administration are exempt from the cuts. Q: How will the cuts impact health care in California? A: The White House issued a report showing that California would be impacted by the following cuts: Medicare, public health, childhood vaccinations, mental health, AIDS and HIV treatment and prevention. For more information, see the White House summary of the impact of the 2013 sequestration on California www.whitehouse.gov/sites/default/files/ docs/sequester-factsheets/California.pdf. Q: What are SSVMS and CMA doing to stop the cuts? A: SSVMS and CMA physician leaders have met with members of Congress to strongly urge them to stop these cuts. We are urging Congress to take a more targeted approach rather than arbitrary across-the-board cuts that will harm public health and negatively impact access to care for children, seniors and military families. CMA is urging Congress to target reforms to allow physicians to meet their commitments to patients. Q: What can I do to help stop these cuts? A: It is not too late for physicians to contact Congress to explain the impact that a two percent Medicare payment cut will have on physicians and their patients. Contact your U.S. Representatives and Senators through AMA’s grassroots hotline at (800) 833-6354. Enter your zip code and you will be automatically connected to your Representative. Your patients can help, too, by contacting Congress through

EDITOR’S MESSAGE

Take the “No Robot” Pledge By Nathan Hitzeman, MD A RECENT ARTICLE IN The Atlantic was titled “The Robot Will See You Now.” In it, the author provocatively describes how IBM’s robot “Watson” – who bested two top Jeopardy champions, mere humans – is gearing up for applications in health care. A hypothetical example is given of an experimental chemotherapy drug and a particularly favorable genotype. An argument is made that Watson can learn and access information, sometimes obscure or very cutting-edge, and not fall into the trap of human error or bias. Reading on, the article delves into smartphone applications and various techy tools that would monitor patient health parameters and relay them to a team of robots and humans who would be on top of it all. Next, reaching for my Sunday paper, I catch an advertisement by a local health system for robotic surgery. Why is technology-driven medicine perceived as more attractive than traditional human therapeutic contact? How far will this current trend go? I respect what technology has done for us. I really like ATM machines and using GPS navigation while driving (with the exception of visits to Death Valley). But I don’t think I would want to see a robot for mental health counseling, getting my prostate exam, or for my daughter’s well child visits. While part of me would like a robot to go to medical staff meetings and see my chronic pain patients, this is a cop out. Good

doctors need to relish the human interaction – whether pleasant or not. It’s easy to objectify, quantify, compartmentalize; but it’s vital that we humanize. No matter how much we know about the human genome, we will never be able to predict how long someone will live or thrive. A sea of variables – innate, environmental, and life-force (chi or qi) factors – make that impossible. I would also like to point out that a robot has never successfully published in our esteemed medical society magazine. Could a robot write about what it is like to attend a patient’s funeral? Could a robot appreciate a good massage? Could a robot write poetry? Could a robot teach our local medical students the art of doctoring? No, no, no. I don’t think that the robot thing will fly, the main reason being that you can’t teach logical beings to understand illogical beings. And humans are very illogical. From substance abuse to bad life decisions to risk taking to not wearing eye protection – the numerous ways we can screw things up will most likely keep the robotic docs at bay. So take the “No Robot” pledge with me. If you see one in your office interviewing for a position – no matter how attractive! – please kindly show it the door. hitzemn@sutterhealth.org

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.

Sequestration FAQ continued from previous page the AMA’s Patients’ Action Network hotline at (888) 434-6200. Keep an eye on SSVMS’ e-bulletin, SSV Medical Society News, for updates on the sequester

or contact SSVMS for more information at info@ssvsm.org or (916) 452-2671. awetzel@ssvms.org May/June 2013

Getting Serious About Cost Containment Understanding the ACA’s Independent Payment Advisory Board (IPAB)

By Adam Dougherty, MPH, MS III

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

THE PATIENT PROTECTION AND Affordable Care Act (ACA) brings unprecedented changes to the American health care system. Through the individual mandate, health insurance exchanges, and the expansion of Medicaid, the nation may finally shed its dubious title as the sole Western nation without universal coverage. A lesser-known piece of the law has the potential to tackle an even greater challenge: the unsustainable growth in health care spending. National health care costs are now an all too familiar problem. In 2009, the U.S. topped $2.5 trillion in health care expenditures, or 17.6 percent of GDP. This equates to $8,086 per person, more than twice the average of the highest spending countries.1,2 The unyielding growth in federal health program costs, most notably Medicare and Medicaid, remains the single greatest threat to our nation’s fiscal health and long-term deficits. Extended life expectancy and an aging baby boomer population means spending will continue to accelerate, and the CBO projects that direct federal health costs will total 9.7 percent of GDP by 2030 and 13.7 percent by 2050, with national health expenditures nearing 50 percent of GDP by 2080.3 The ACA begins to take important steps to combat these trends and improve the value of the health care dollar through accountable care organizations, comparative effectiveness research, and value-based purchasing. Arguably the most significant effort to contain costs, though, can be found in Section 3403 of the ACA and is known as the Independent Payment

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Advisory Board (IPAB).4 Consisting of a 15-member panel of presidential appointees, IPAB’s task is to produce recommendations to hold down Medicare spending, if the program’s per capita growth exceeds established limits. Beginning in 2015, IPAB will make recommendations with the spending target tied to the Consumer Price Index (CPI), better known as inflation. After 2020, the target will be tied to GDP plus one percent, a historically less-restricting trend. Most importantly, the IPAB recommendations offered to Congress are binding, for legislators must either approve the proposals or find equally effective alternatives to offset the costs. As the federal government has an increasing stake in future health care spending through Medicare, Medicaid and the ACA’s low-income subsidies, an effort to address the underlying costs is imperative for public programs, payers, and employers. IPAB is in a unique position to fast-track successful cost-saving models, mobilize the leverage of the nation’s largest purchaser, and truly effect health system change. Yet the IPAB itself is on life support, as both the House and Senate rescind $10 million of the $15 million allocated by the ACA in their proposed fiscal year 2013 budgets. The highly politicized nature of reining in Medicare costs and the failure of Congress to take action in the last several decades justifies new approaches to real cost containment. Nevertheless, the inability to adopt serious cost control measures has created skepticism and has cast IPAB as a controversial body

comprised of unelected bureaucrats who are accountable to few. These concerns are probably overblown, since Congress has the ability to override IPAB recommendations by enacting comparable cost controls. Efforts to repeal IPAB are commonplace in the House, where it is referred to as a “rationing board” and “the real death panel,” yet little is being done to address long term costs containment.5 This picture offers further justification for IPAB’s necessity. The mere presence of the board requires recognition of the need for a Congressional plan to control Medicare costs, something vehemently avoided in the current age of political polarization and special interest influence. Additionally, concerns about restricting access to care are addressed in the ACA itself, as IPAB is unable to make any recommendations that would alter plan benefits or eligibility levels, and has explicit language against the notion of “rationing” care.6 Organizations such as the American Hospital Association (AHA) and the American Medical Association (AMA) fear that IPAB will simply cut provider reimbursements in order to meet spending targets, and are also pushing for its repeal. Their concerns are valid, but too generalized, as IPAB would be able to propose smarter changes than blunt acrossthe-board payment reductions as seen in the Sequester. A more realistic scenario would be to include strategies similar to those offered by organizations like the Medicare Payment Advisory Committee (MedPAC) into IPAB recommendations. At present, Congress routinely ignores MedPAC recommendations. Examples of MedPAC strategies include targeted reductions to areas of overpayment and high-cost procedures, coupled with a greater investment in primary care. Moreover, IPAB would be able to look at bold new strategies to ensure the future stability of Medicare. For example, given the increasing use of pharmaceutical therapies, recommendations could include Medicare Part D amendments like additional drug manufacturer rebates, negotiated rates, or even a Medicare-operated plan to compete with

private drug plans.7 IPAB will indeed have broad-reaching implications, as Medicare arguably sets the bar for health coverage, price, quality measurement, and workforce training and distribution. Not only is IPAB commissioned to make recommendations for Medicare, but is also instructed to produce non-binding advisory recommendations for non-federal programs, national health expenditure, and health policy issues that affect both public and private health care systems.8 Such recommendations could have lasting effects on the health care system, particularly in the federally subsidized statebased health insurance exchanges. Future challenges will include how best to parallel IPAB’s work with the efforts of the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). Maximizing collaboration and information flow through public-private partnerships will be vital, as well. Concurrent investigations through ACA-established bodies like the Patient-Centered Outcomes Research Institute (PCORI) and Center for Medicare and Medicaid Innovation (CMMI) will glean novel models of evidence-based health care delivery and financing that IPAB could accelerate. Pending its survival in the political arena, IPAB will not only be an effective backstop to impose Congressional discipline, but more importantly will be a vehicle to efficiently translate this research into practice. apdougherty@gmail.com

The unyielding growth in federal health program costs, most notably Medicare and Medicaid, remains the single greatest threat to our nation’s fiscal health and long-

1 Squires D.A., The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations, The Commonwealth Fund, July 2011. 2 California Health Care Foundation, Health Care Costs 101: US Health Care Spending, 2011 Edition. 3 The Long Term Outlook on Health Care Spending, CBO, November 2007. 4 Public Law 111-148, Section 3403: Independent Payment Advisory Board. 5 HR 452, The “Medicare Decisions Accountability Act of 2011,” House Energy and Commerce Health Subcommittee, Feb. 29, 2012. 6 Aaron H, The Independent Payment Advisory Board — Congress’s “Good Deed,” N England Journal of Medicine, June 2011. 7,8 Ebeler J, Neuman T, Cubanski J. The Independent Payment Advisory Board: a new approach to controlling Medicare spending. Kaiser Family Foundation Program on Medicare Policy, April 2011.

May/June 2013

term deficits.

Profile: Driven to Connect By Elizabeth Zima, CMA Staff Writer

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.

OLIVIA CAMPA, A THIRD-YEAR medical student at UC Davis School of Medicine, has distinguished herself as a leader working to reduce inequities in health care and to create educational opportunities for minorities interested in health care careers. Although her career path has sometimes been a winding one, and a degree in medicine wasn’t always her intended destination, she has found a passion in caring for and connecting with others that is a shining example of our future generation of physicians. Campa was an undergraduate science student at Loyola Marymount University in Southern California when she first started working in health care. “I needed to support myself, so I got a job as a file clerk at the UCLA Medical Center working with the National Lung Screening Trial,” one of the largest nationwide clinical research studies funded by the National Institutes of Health. After that experience, she found she had a passion for clinical trials and had learned enough to apply for a job at the Los Angeles Veterans Hospital, where she ran a research program overseeing eight clinical trials on Alzheimer’s disease. This study correlated clinical aspects of Alzheimer’s disease with neuroimaging study results. She found she enjoyed working with the study subjects and their families. “I loved my patients. I loved this population of people,” she says. “Through this work I decided to pursue an MD [degree].” If she had not had a very supportive family and community, Campa may have not taken the path to become a physician. She is the first person in her family to graduate from college. “My father was second generation [immigrant from Mexico]. My mother moved from Mexico to L.A. with her family.” Growing

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up in Santa Barbara, she says, she was able to get “a phenomenal education in high school.” And while her family did not have a lot of money, they encouraged her to go on with her studies. “My parents were a huge source of inspiration for me,” she says. They also inculcated their values of “community and family.” Relying on the moral support of her community to see her through school, she discovered she wanted to help others to achieve their dreams as well. As soon as she arrived on the UC Davis campus, she began volunteering with Clínica Tepati, a nonprofit, student-run clinic that provides primary care for poor and medically-underserved Latinos in the greater Sacramento area. She quickly became the clinic’s co-director, overseeing staffing and determining the flow of the clinic, including triaging patients. A part of her role at the clinic includes serving as a mentor for young, undergraduate Latinos who want to work in health care. This past February, Campa won an AMA Excellence in Medicine award for her work with Clínica Tepati. “I want to share what I’ve learned with students who might come from communities that don’t have a lot of role models in careers like medicine,” says Campa. “I was given some wonderful opportunities and now I want to give back. I hope to encourage these students to pursue academic and career paths in health.” And, while she has taken on all these things, including getting her degree, she still continues to participate in clinical research. She is currently working on two studies. One project, in conjunction with the UC Davis Department of Psychiatry, studies Latino men with depression and the possibility that their depression takes on a different perspective compared to depressed Caucasian men. The study is trying to determine if differing perspectives determine variability in

accessing mental health care. The other study, with the Department of Mental Health and the Los Angeles County Jail, looks at female inmates with mental illness and how to decrease high recidivism rates. Campa is in the process of evaluating what programs would be helpful for this population, from job placement to psychosocial needs, such as housing and education. The perspective and dedication she brings to her work has also driven her to connect with her counterparts across organized medicine. “I think it is important to connect with people across the profession,” she says. She has found that most physicians who belong to their county, state and national associations bring something special to the table. “I see these members as being more altruistic in their vision” of providing care. “I think we all agree that everyone deserves really excellent health care from clinical research to the health policy standpoint,” says Campa. She sees her membership in organized medicine as a way to work with others to make this vision a reality. “My local association (SierraSacramento Valley Medical Society) has been very welcoming.” She also works closely with the Latino Medical Association where she serves as chair of membership. Finding community with her peers has also been important. “There are some amazing women physician leaders in the [Sacramento Latina] community,” she says. Her close association with these women has allowed her to work out some issues she has encountered in her own life. She says one common issue that Latinas in medicine contend with is maintaining boundaries. “One of my questions has been: how much do you sacrifice for the greater good?” Answering this question is difficult for Campa because she is pulled in so many different ways, from her work as a researcher, a student, a volunteer and the role she plays within her community. “My medical education is a piece of something bigger than just working with individual patients. I hope to have an impact on medicine in a meaningful way.” In keeping with the altruistic vision, Campa

Third-year medical student Olivia Campa.

is looking forward to the implementation of the Affordable Care Act (ACA). “I am excited about it. I do wish that it also included the immigrant population.” And while she acknowledges that no one really knows how the ACA will roll out in California, she says she thinks it will be positive for the nation. “Change is scary, but when the dust settles, I think it will be a good thing,” she says. “This is a very exciting time to be in medicine. I am very hopeful.” ezima@cmanet.org

May/June 2013

Why I go to Patients’ Funerals By Ann Gerhardt, MD

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

I GREW UP IN RURAL PENNSYLVANIA on an acre of land surrounded by farms. It wasn’t exactly a farm, but Dad had most of it planted with roses, lilacs, vegetables and fruit trees, leaving some space for a small softball field. All our neighbors were Caucasian, as was everyone at school. The entire 1200-kid high school was homogeneous middle class, or at least so I thought until I found out later that I unknowingly knew a few homosexuals, even fewer rich kids and more than a few poor ones. At 16, I dated an African American I met at a liberal religious youth church conference, because he was the most fun person I had ever met in my life. That was the extent of diversity for me. Our past forms our frame of reference for interpreting people we meet, so my vanilla background did not prepare me for the patients I encountered in medical school. Within the sleek walls of a clinic, I felt I heard their words, but in retrospect realize that I didn’t truly perceive the paradigm in which they lived and what might underpin their responses and concerns. I made assumptions about the words they used and assigned overly simplistic stereotypes. People don’t spontaneously offer some information that we might never predict. Like the dusty yard, dangerously rickety stairs and drafty windows; the cravings for chocolate, travel or a productive life; the co-dependent husband, adulterous wife, or narcissistic, neglectful children; the geology hobby, history of awards at work, or side job as concertmaster violinist; the personal drug use, prison time or gambling addiction; and certainly the beliefs and biases that determine their approach to

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self-care. These are things we usually don’t ask, because we don’t have time and we make assumptions. Which brings me to funerals. I think I went to my first patient funeral because I felt close to the patient and family who had invited me. The slide show and testimonials about Harold floored me. He had checked the religion box on my intake form, but never once had he told me he was a deacon or how religion underscored his every decision. I didn’t know that his passion for singing in the choir was the reason for his being terribly distraught over some minor postsurgical hoarseness that never resolved. That was an eye-opener. I had given it lip service before, but now I knew that we doctors see only a small part of our patients’ lives and probably understand even less about the hundreds of days that we don’t see them that profoundly impact their health. Would my professional recommendations have been different had I known these things about him? Probably not, but my compassion and focus might have been. I swore that I would do a better job at social history taking. I also swore that I would go to more funerals, to learn what I had missed. I hoped that funerals would keep me humble and better attuned to patients in general − sort of like a social autopsy. So funerals I did, and still do. If I want to attend a funeral, I usually have to suggest it to the family. Most assume doctors don’t go. If there is a scheduling conflict that I can’t change, and I can’t attend the funeral, I send a sympathy card expressing my regret. Each funeral teaches me something,

something I try to do differently with subsequent patients. Attending funerals initiated a shift to conversing with as many family members as a patient allows prior to death. I want to better understand his lifestyle and decision-making before death. I don’t want to learn after her death that she was too proud to use her oxygen. Someone once told me that “90 percent of a job is just showing up.” I would not have thought going to funerals to be part of the job, but being a doctor is a unique and privileged profession. There is a reason we are called “attendings.” If we are not connected with our patients, what’s the joy in doctoring? I go to funerals even if I feel that I had contributed in some way to the deaths, usually in more subtle ways than families know. I’ve never been shunned. Families hug me and cry with me, knowing that death comes at the end of life, and that I did the best I could. The funeral feels like a continuation of care, and not going would feel like abandonment. Going perhaps helps me cope with the loss, while conveying to loved ones, “I still care.” Some funerals are memorable, some not. At some I speak during the “remembrances” part of the funeral; at others I don’t. I only get up to talk if I can think of something that won’t sound trite or make me cry too much. Once I wrote a song about a particularly favorite patient and sang it at the memorial service because I knew I wouldn’t be able to talk. Once, the pastor commented that she had never heard the doctor talk at a funeral before, and now she wished more would do so. The most fun funeral was a small church gathering for a heart transplant patient who had named his dog after me. What a character he was, and how that showed in his friends’ comments. At some point we were all laughing so hard that the whole thing devolved into a circle of us telling story after story. When

I learned that he had resumed smoking but hadn’t told me, I demanded that he come back right then, so I could give him a tongue-lashing. Everyone totally understood and laughed even harder. The most difficult talk I gave was at a tiny funeral with only six mourners. I knew I had to say something, but I couldn’t think of anything nice to say. She was just so frustrating as a patient, so deluded and unable to save herself. So I fumbled a bit, then commented about the wonderful remembrances of the others, because she had never shared that side of herself with me. I sympathized with them, knowing that they were possibly more frustrated with her intransigence than I because they knew what a caring and talented woman she could be. They kindly thanked me, probably understanding my reasons for fumbling. Now, if I’m going to fumble, I keep my mouth shut and just hug. algerhardt@sbcglobal.net

May/June 2013

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Sacramento Pioneer Surgeon Dr. Junius Harris By F. James Rybka, MD

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

JUNIUS1 BRAINERD HARRIS WAS born in Sacramento in 1882 where he lived at 3rd and S Streets. His father, Junius Brutus Harris, was a writer for The Sacramento Bee who later advanced to become the senior editor. Young Junius’ first connection with medicine came when he was chosen to be a houseboy by Dr. George White, a well-known physician. At this time, there were no medical offices; the doctor made all his house calls using a horse and buggy. They needed a boy to live with them who would, among other chores, take care of the horses in the stable at the back of White’s house. While in high school, their mutual trust grew to where Junius would assist Dr. White with some surgical procedures that were done in the home. Dr. White was a scholar who collected many medical books that Junius avidly read. And when it came time for college, Dr. White suggested that, rather than go to college, Junius should just read these books carefully, and then take the California medical test. At this time, if you passed this test, you could go directly to medical school and skip college. Junius did very well, scoring the 16th highest in the state. In 1904, he entered Cooper Medical College, located at Clay and Webster Streets, in San Francisco. To earn some pin money, he taught other students Greek and Latin terms that were required at this time. While there as a student, he became actively recruited to help in the care for the many burn victims from the 1906 earthquake. In 1908, Cooper Medical College became Stanford Medical School, so it was from that university that Junius graduated. He then returned to Sacramento where Dr. White and

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his son, Dr. John White, had established the White Hospital. Dr. John White, who helped Junius to become the Deputy Director of the Sacramento County Hospital, died suddenly in his prime. Junius named a son after him who today is Dr. John White Harris. This county post paid Junius $172 a month that occurred at a time when many doctors were just scraping by. At that time, it was “more than enough money to live on.”

Surgical Training Junius Harris wanted to become a surgeon, but there were no surgical residencies, as such, at the time. So, for his training, he undertook a series of two week “vacations” to go to the Mayo Clinic in Rochester, MN, recognized as the font of modern surgery in the US. He became known to Dr. Charles H. Mayo (“Charlie” 1865-1939) who immediately liked him and made him his first assistant, so he was allowed to participate in whichever operations he wished and the experience was invaluable. Junius was an imposing 6’-4’’ outgoing redhead. In 1915, “June” Harris, as his colleagues called him, was elected President of the Sacramento Society for Medical Improvement, later the Sierra Sacramento Valley Medical Society. Today, his portrait greets visitors entering the SSV Museum of Medical History. In Sacramento, there were no fully trained surgeons then. Some general practitioners did surgery, not only in town, but at outlying hospitals in Chico, Placerville, Auburn and other communities. Once his reputation spread, it was not infrequent that June was called up to these towns where he might have to re-operate

to correct surgical complications. To place these times into perspective, not only were there no antibiotics, but also no intravenous fluids or blood products, and no way of measuring blood electrolytes. The sterile techniques were primitive. Chloroform anesthesia was available, but it forced the surgeon to operate quickly; otherwise, after about 20-30 minutes it could become hepatotoxic. Ether anesthesia, which was being used by some dentists, was just beginning to be brought in. Among the many surgical improvements June Harris brought with him from Mayo were superior suture materials and instruments, an improved method for performing bowel anastomoses, more protective handling of tissues, and the judicious use of surgical drains. As there were no orthopedic surgeons in Sacramento, Dr. Harris had to handle many complex fractures. He also did neurosurgery before Dr. Howard Black arrived.

Sutter General Hospital In 1919, June married Hazel Smith, a scrub nurse who was also from Sacramento. As their young family developed, they had two daughters and four sons, two of whom, Robert and John, are retired doctors in the city today. In 1922-23, he and six other physicians solicited some of their wealthy patients to form a group that was to found Sutter Hospital at 28th and K Streets, where the current Sutter Cancer Center is located. The planners originally considered a landfill site across the street until June warned them to avoid that area because, he recalled when he was a boy, how it was the end of a slough where he used to shoot ducks. Fortunately, they chose the higher, more solid land across the street. Proof of his sharp boyhood observations came a time later, when a Stop and Shop store was being built on this former slough. One weekend, while it was going up, the floor sank two feet down. June was always loyal to Sutter, which had a rivalry with Mercy. At that time, admissions to Sutter were $4 a day versus $3 a day at Mercy. For the Harrises, any animosity between the two

hospitals was smoothed over for June because Mrs. Harris had trained at the same nursing school class at the old Mater Misericordiae Hospital on 23rd and R Streets, as did Sister Mary Peter. The two women became lifetime friends and, years later, Sister Peter became the CEO of the new Mercy Hospital.

A Catalyst for Sacramento Medicine In 1917, Dr. Harris was instrumental in urging Dr. Harold Zimmerman to come to Sacramento with a modern X-ray machine. He was a founder of Radiological Associates of Sacramento. Dr. Harris knew Dr. Paul Guttmann, who was a research pathologist at UC Berkeley, and in 1934, Harris was effective in convincing Dr. Guttmann to come to Sacramento where he organized a modern pathology laboratory at Sutter, and later started the Sacramento Clinical Laboratory. In the 1940s, there was no blood bank in Sacramento, a crucial lifeline for the communityâ&#x20AC;&#x2122;s ability to deal with trauma and major surgery. The closest one was the Irwin Blood Bank in San Francisco. To fill this need, Dr. Harris and a few others visited Irwin and Painted portrait of pioneer surgeon Dr. Junius Harris.

May/June 2013

“He had a lot of drive — he never got tired. He never had any time off.”

were able to convince some of their technicians to leave and come to Sacramento where they would pay them more. The chief technician was furious. But after he was offered a higher salary, he also agreed to come. Hence this raiding of talent was how the Sacramento Blood Bank (aka BloodSource) got its start in 1948. June Harris was so busy at Sutter Hospital that he had his own office there. One architectural mistake that the hospital had made was to have the windows of the operating rooms facing west so they became uncomfortably hot in the powerful afternoon sun. He solved this by paying his nursing staff twice as much from his own pocket to begin operations at 4:30 in the morning — so that many of the cases were finished before the heat arrived. The staff was pleased to make the extra wages. In 1926, Dr. and Mrs. Harris were invited by Dr. Charles Mayo to go on an AMA physicians’ grand tour of Europe together. Dr. Mayo loaned him the money. Among other sights, one night, when dressed formally in “tails” as guests at an exclusive private London club, they witnessed a young man who became obnoxious, inebriated and raucous. They were told, surreptitiously, that he was the young Prince of Wales — the future King Edward VIII who later abdicated.

CMA’s Unofficial and Unpaid Lobbyist June was a life-long Republican, as well as a Rotarian, a Shriner, a member of the Native Sons of the Golden West, and the Chamber of Commerce. He was the personal physician to many important big wigs in the California legislature, as well as to five governors. As such, he fell into a side position to become the trusted, unendorsed, and unsalaried lobbyist for California medicine when health issues arose, and he did this for nearly 30 years. His sons are especially proud of this important service that their father did pro bono, pointing as comparison what the budget must be for CMA’s cadre of lobbyists today. In 1931, he was elected President of the California Medical Association. In 1937, with

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the support of the Mayo brothers, June was elected Executive Vice President of the AMA. This was normally the first step towards becoming president, but because of his large family in Sacramento, June could not do this, as it would mean having to move to Chicago. Reflecting on his father, John, says: “He had a lot of drive — he never got tired. He never had any time off.” He did have a boat on the Sacramento River, and sometimes he would escape by taking it out for a ride.

Governor Earl Warren Of his five governor patients, June became especially close with Earl Warren (1891-1974) who was elected governor three times (1942, 1946 and 1950.) Their wives were also good friends, and the families gathered socially. Years earlier, when Earl was a high school student in Bakersfield, his father was murdered during a robbery by an unknown killer. This tragedy undoubtedly contributed to Warren’s toughon-crime reputation later when he became district attorney. As Governor, when the issue of clemency came up, this was a particularly agonizing decision for him and, in preparation, he would sometimes ride out to the Harris home where there was a large, beautiful rose garden, and there he would rest to gather his thoughts in solitude. There was an episode in which June saved Warren’s life. One day, the Governor called and confided to him that he noted blood in his stool, but all this had to be kept a secret. June, using his own car, then drove Warren down to UC San Francisco to be under the care of the chief of surgery. He was kept overnight and then released. Two weeks later, however, a lot of blood reappeared, and this time Warren asked June if he would manage his care. He so agreed, and admitted the Governor to Sutter Hospital under an assumed name, and a barium enema revealed a large lesion of the cecum. At surgery, they found it was a cancer that, fortunately, had not spread. It was successfully resected, and Warren went on to be cured. In 1948, when Warren ran for Vice President on the Republican ticket with Governor Dewey of

New York, it was June who proposed his name at the convention. June retired in 1957 and died in 1965. One is left with the feeling that there are many other fascinating, historical episodes left to tell about this energetic, inventive leader, but we are fortunate indeed to have these interesting and fond memories of his sons, Drs. Bob and John, who are our colleagues today. They are probably his most important legacy. I am indebted to Dr. Bob Harris and Dr. John Harris for their help with this article. Much of it was developed from an interview of his son, Dr. John White Harris, conducted on Oct. 23, 2012 by Dr. Jim Hamill, together with Dr. Bob LaPerriere and myself. jimrybka@hotmail.com 1 “Junius” – comes from “gens Junii,” one of the most celebrated families of ancient Rome. Lucius Junius Brutus led the patrician revolution that overthrew the Roman monarchy in 509 BC, and he is considered the founder of the Roman Republic.

Dr. Junius Harris, left, with other physician members of the 1923 staff of Sutter Hospital when it opened. Next to Dr. Harris, from left to right, were G.A. Spencer, Fred Gundrum and Nathan “Jimmie” Hale. The handwritten note on the back of this photo indicates that it was taken in the Capital National Bank Building, 4th floor.

What is it? “Funny how one item can bring back memories from decades ago. When this Micro-Capillary Reader was recently donated to the SSVMS Museum of Medical History, it immediately transported me to those late nights during clerkship and internship when I had to fill a capillary tube with blood, spin it in the centrifuge, then read the red cell volume to determine the hematocrit,” says Museum Curator Dr. Bob LaPerriere. Are you a physician who is near retirement or who has retired? Our museum gladly accepts donations of medical artifacts and equipment. Usable items not appropriate for the museum will be sent overseas to one of several developing hospitals where there is a great need. Contact: xtbob@surewest. net.

May/June 2013

Massage Parlors – An Investigative Report By Jack Ostrich, MD

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

WHEN I WAS WORKING FULL TIME, I commuted back and forth on Arden Way from Eastern Avenue to Exposition Boulevard, occasionally with a sore neck. One day I became aware of a sign in front of a small strip mall on the south side of Arden Way between Morse and Fulton Avenues. At the very top of the sign, in letters larger than any below, it said “BRIDAL” and the word immediately below proclaimed “MASSAGE.” When I first noticed the sign five or six years ago, I wondered what “bridal massage” might be, but as I inspected the little mall itself, I saw that there was a bridal shop with pretty white fluffy dresses in the window and, a few doors away, a massage parlor, denoted by a black-onwhite sign that said simply “MASSAGE.” No pretty white dresses in that window that I could see. Over the last few years, Arden Way certainly has experienced a proliferation of similar establishments. One recent Sunday morning I arose early to drive on Arden Way in order to count how many MASSAGE signs there were from Eastern Avenue to Fulton Avenue, a route that measured 2.6 miles. In addition, having noted at least two MASSAGE signs on El Camino Avenue near Country Club shopping center, I drove from Watt Avenue to Howe Avenue along El Camino, a total of 1.6 miles. There were five MASSAGE signs on Arden Way and six on El Camino. So there were 11 such signs over 4.2 miles. Of course, there may be as many liquor stores along these same routes, but I think that they have been there for a long time, whereas the number of MASSAGE signs has definitely

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increased in the last few years. So what is going on here? I did a brief internet search and confirmed that the observed phenomenon was not unique to Sacramento, but also to my hometown, West Hartford, Connecticut. I also discovered a mix of legitimate vs. shady (“erotic”) establishments. I called the California Massage Therapy Council (CAMTC), which was established by our legislature in 2009, to oversee the education of, and grant licenses to, “certified massage therapists” (CMTs) and practitioners (CMPs). I asked the pleasant lady who answered the phone what I, as a potential client, should expect when I entered a properly-licensed massage parlor or “spa,” other than fairly clean sheets on the table. She replied that the CAMTC depends on voluntary cooperation of the men and women who make a living massaging other men and women. There is no state-mandated exam, and apparently one can hang out a shingle that says MASSAGE without any formal massage education. But the CAMTC is doing its best to educate the citizens of California to be wary of establishments which do not prominently display CAMTC licenses. She said that I would be best advised to beat a hasty retreat should I fail to see CAMTC licenses in whichever parlor I choose to patronize. I told her that I, indeed, would do so, and thanked her for her advice. Therapeutic massage has been around for thousands of years. A wall painting in an Egyptian tomb thought to be the resting place of a physician named Akmanthor, dating from around 2300 BC, depicts two dark-skinned men massaging the hands and feet of two lighterskinned men.

In AD 581, the Chinese Office of Imperial Physicians established a department of massage therapy. (True.) Not widely known is the fact that the Chinese massage therapists soon unionized and successfully sued the Chinese Imperial Physicians Association (CIPA) in order to form their own organization, called the Chinese Imperial Massage Therapists Association (CIMTA), to establish accreditation and licensing powers. The verdict was at once appealed by CIPA, and it went all the way to the Supreme Court of the Sui Dynasty (AD 581-618) where it was upheld by a 5 to 4 vote. (Not entireley true.) Anyway, in 2010, the AMA reported that there were approximately 209,000 physicians in primary care practice, including adult and pediatric practitioners. More recently, the National Center for Complementary and Alternative Medicine − a branch of the NIH − estimated that there are over 300,000 people in this country making a living as massage therapists. Some of them specialize in providing massage to infants and children. Some just massage the foot, or your ear, or who knows what else. It used to be easy. The client lay prone on a firm table, unclothed from the waist up, head turned to the side, and a fellow who looked like former wrestler/linebacker Bronko Nagurski, or a lady who looked like Mrs. Doubtfire alternately pounded or kneaded the width and breadth of the client’s neck, thorax and lower back. Now the National Center for Complementary and Alternative Medicine recognizes about 80 different modalities of massage, from acupressure to erotic, to prostate, to shiatsu, to

watsu. One of my former medical colleagues has, for years, regularly gone to a “Bowen” massage therapist and claims excellent relief from MRI-proven severe low back disease. If you search the internet or print media for massage therapy venues, most of the postings you will see will be for “erotic” or “Oriental” or “Asian” techniques. Many of those ads are accompanied by pictures of young women, some with a note on the picture saying something like “actual CMT.” The more upscale establishments are represented by more muted promotions, and most of them offer the basic Nagurski-Doubtfire type of massage, just like your dad used to get on Friday afternoon on the way home from work. Always the intrepid reporter, I visited two massage parlors, one at an upscale suburban mall, and the other nestled between a bar and a liquor store across the street from a gas station and backing up to one of those do-it-yourself car washes where you hold a high-pressure hose and try not to drench yourself as you blast the grime off your automobile. The former establishment is cheery, welllit and altogether spiffy, and all the staff and everyone in the waiting room − all female − looked like young Grace Kellys. The latter place is labeled with the usual plain black-on-white “MASSAGE” sign over the door, a small red neon “OPEN” sign in the window, and dark blue velveteen curtains arranged so that the interior could not be seen from the outside at all. The bubbly receptionist at the upscale parlor gave me a well-rehearsed overview of what I could expect as a client and recommended that I opt for a membership that would lower the cost

May/June 2013

It is estimated that there are over 300,000 people in this country making a living as massage therapists.

of individual visits. She gave me a slick brochure describing 10 separate types of massage that were available, all of which sounded delightful. One guaranteed that it would “enliven the body and mind and increase circulation,” while another would “reduce inflammation, calm the mind and promote restful sleep.” I figured that if my mind became too enlivened by the first type of massage, I could get the other one that would calm me down. Sounded good. When I went into the be-curtained MASSAGE parlor, it took a few seconds for my eyes to accommodate to the dim lighting, and I was greeted by a pleasant lady who told me that she and her staff offered two basic “Oriental” massages, and that as a new customer, I would be granted a $10 discount for my first visit. But there were “special requests” available as well, and she gave me her card with a handwritten note on the back indicating the $10 discount, one time only. Both places had their CAMTC licences prominently displayed in the reception areas, by the way. That reassured me. After I got home, I looked at the online reviews of the two parlors. There were several for the upscale place, but they were all bland and, albeit, generally positive. The only one for the dimly-lit establishment was, and I quote, “Great service with a bang!” Hmmm. Maybe bland is best? Or maybe I should go back to the velveteen-curtained, dimly-lit parlor with a “special request” and take advantage of that $10 discount. Aye, there’s the rub! jmost119@aol.com

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First Frost By John Loofbourow, MD Our little white frizzy bitch knows I hear the pitch of her quiet 5 AM squeaking; knows that if I try to sleep the other owner will insist. We step into a quiet world where still water sleeps under a thin blanket of mist. The cold bright eye of Venus scans fleet and fading stars. We pass frost-whited rooftops, lawns, bare trees, persimmons waking to orange ripeness, and the neglected trashy yard of a failing elderly widow. Our movement wakens lights and two scanning cameras, on her electrified fence; it’s clear her troubled son will defend his plot of pot. A car passes. A kitchen lights up. Brazen day begins to climb the back of fearful night. Pepa sniffs up the past from scents of urine and scat. OK. “Enough,” I say. “Sun will chase the frost away. Be done with stinky thrills. They will last until we come again this way.” She body-shakes professionally, head to tail – or the other way, gives up the pungent walk, and bounds back eagerly, sure to catch that squirrel today. john@loofbourow.com

Careless Narcotic Prescribing Kills Patients By Bruce Barnett, MD, JD IN THEIR RECENT CONFERENCE at the South San Francisco Conference Center (February 21 and 22, 2013), the California Medical Board and Pharmacy Board enlisted local and federal authorities to warn nearly 600 physicians and pharmacists that they risk suspension and prison sentences when improperly prescribing narcotics and other drugs. This message has been delivered before. The duties of physicians to perform good faith examinations and of pharmacists to dispense drugs only upon receipt of legitimate/legal prescriptions are the foundations of their respective professional canons. However, on this occasion, new data was presented with particular urgency. There is no mistaking that the patterns of controlled substance prescribing in the United States greatly alarm state and federal enforcement agencies. The first two speakers in this meeting came from Washington, DC, with the latest reports about the impact of prescribed opiates. Michael Boticelli, Deputy Director of the White House Office of National Drug Control Policy, announced that the abuse of prescribed drugs has been classified as an epidemic by the Centers for Disease Control. He referred attendees to the website whitehouse.gov/ondcp for further information. Joseph Rannazzisi, from the Drug Enforcement Agency (DEA), held the audience’s total attention for a remarkable two-hour talk that provided the following information: 1) Deaths in 2010 caused by accidental overdose of prescription opiates exceeded the combined rate from all other drug deaths, including heroin and cocaine

combined. 2) Deaths from accidental drug overdoses exceeded all other causes of accidental deaths, including vehicle accidents. 3) Physicians and pharmacists may not be aware of how illicit users achieve the desired effects from prescriptions. The “Holy Trinity” sought on the street is a combination of opiate such as hydrocodone, muscle relaxant such as carisopodol, and tranquilizer like alprazolam. Physicians will prescribe any of these individually not realizing the intent is to put them together into a cocktail. 4) Methadone is particularly dangerous, accounting for the bulk of opiate deaths, and should not be prescribed by physicians unfamiliar with its use. 5) Fentanyl is a very popular street drug. Fentanyl patches are highly sought after, as they are widely abused. 6) Websites that educate abusers include Erowid and Bluelight. All physicians should access these websites for an education in the real world of drug users. 7) The Controlled Substances Act provides details of the law that should be followed by all physicians and pharmacists, 21 U.SC. 822. An important case and regulation are U.S. v. Moore, 423 U.S. 122 (1975) and 21 C.F.R. 1306.04. They propose that pharmacists should not fill prescriptions for controlled substances presented by customers who do not seem to have a legitimate medical need for the prescription requested. For example, patients who will pay thousands of dollars in cash for large amounts of opiates at each

May/June 2013

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.

Pain in the rest of the world is managed with far fewer opiates than in the U.S.

pharmacy visit are not likely buying them for their own use. Laura Meyers, Assistant District Attorney in San Francisco, and Ruth Moretz, Manager for Special Investigations, are both experts in fraud in the workerâ&#x20AC;&#x2122;s compensation arena. Their observations are relevant among all illicit drug users. They described some of the motives for fraud in prescription procurement: 1) Need to sell drugs or use them as a medium for transactions. 2) Examples of transactions are to use drugs to pay off debts, to exchange for other drugs, or to gain favors. Ms. Meyer and Ms. Moretz recommended physicians adhere to standard best practices for treating patients with opiates to reduce the risk of prescribing to patients who intend to abuse or sell the drugs: 1) Obtain a thorough history, including any history of prior drug abuse. 2) Document a focused examination. 3) Have the patient sign a pain contract that makes clear the expectations for compliance. 4) Regularly review effectiveness of the prescribed medications and reconsider the need for drugs. 5) Report suspected fraud to the local district attorney or California Department of Insurance. On day two of this conference, the attendees heard compelling data and insights from Dr. Cesar A. Aristeiguieta, an emergency physician and longstanding member of the Medical Board. Dr. Aristeiguieta also served as a police officer prior to becoming a physician. Speaking from the perspective of medicine and enforcement, he made the following points: 1) Many patients seeking opiates and other controlled substances are actors playing a role to gain the drugs. 2) United States has 4.6 percent of the worldâ&#x20AC;&#x2122;s population, but consumes 80 percent of the worldâ&#x20AC;&#x2122;s opiates and 99 percent of the entire world production of hydrocodone. 3) For every death by opiate, there are 130 individuals abusing the drug chronically. 4) The person at highest risk for opiate abuse

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is doctor shopping, misuses all drugs (not just opiates), has low income, has a history of substance abuse in the past and has other mental health issues. 5) Pain in the rest of the world is managed with far fewer opiates than in the U.S. Alternatives include NSAIDs, acetaminophen, physical therapy, herbal remedies and supportive care. 6) Except for sickle cell disease, most conditions for which opiates are prescribed do not benefit from opiates, including kidney stones, chronic low back pain, and most causes of chronic pain. 7) Physicians eager to please patients mistakenly administer opiates to satisfy demands despite the lack of efficacy from these drugs and the dangers in their use. Dr. David G. Greenberg, addiction specialist working with the Arizona Medical Board, described how commercial interests in promoting opiate medications have created a huge demand for these drugs, with misleading claims that underestimate the danger in their use and overstate opiate effectiveness. In particular, Dr. Greenberg reported that there is a paucity of evidence to support the following myths: 1) No substantial risks exist for overdose or respiratory suppression. This is not only false, but it is especially misleading because narcotics are often combined with other drugs, such as muscle relaxants, which together, have extremely potent respiratory suppressant effects. 2) There is no maximum opiate dose that will be dangerous; patients can take as much as they need to treat pain and not be at risk of toxic effects. This is incorrect, as the adverse side effects of opiate use increase with increasing doses, just like any other drug. 3) The risk of addiction to opiates is minimal. This has been shown to be false. All package inserts approved by the FDA make the risk of addiction clear. 4) It is safe to drive while taking doses of opiates for which the body has acclimated. This is false. Reaction times, judgment and intellectual functions are significantly impacted by

opiates. only after prescription opiates provided 5) Physicians will be sued for not prescribing the gateway, vehicle accidents while under opiates. This fear is exaggerated. Except for the influence, accidents at work reported the inmate population that files frequent through the workerâ&#x20AC;&#x2122;s compensation system, habeas and civil rights petitions on multiple and deaths in hospitals/SNF/prisons from accounts including reduction in their opiate opiate overdoses. The real number of deaths prescriptions, there are very few suits filed due to prescribed opiates likely exceeds for failure to prescribe an opiate, as little or 30,000 individuals each year. no harm comes from not being prescribed Additional lectures by physicians, pharmaan opiate. On the other hand, there is a cists, attorneys and enforcement agencies during substantial risk of being sued for prescribing the two-day conference emphasized the importoo many opiates, as an opiate overdose can tance of following approved guidelines (most lead to death. recently updated by the California Medical 6) Any licensed physician can prescribe large Board in 2007) to properly prescribe controlled amounts of opiates to control pain without substances and avoid promoting illicit and specialized training. This is not true. The dangerous drug use. The investigative arms of treatment of patients who are seeking the Pharmacy Board and the Medical Board reitunusually large amounts of opiates, or erated that professionals suspected of overpreclaim to need opiates chronically requires scribing will be rigorously reviewed and prosexpertise and experience not necessarily ecuted if wrongdoing is established. However, possessed by physicians without additional investigators and prosecutors have no interest training in these matters. continued on page 25 7) Drug diversion is rare, and thus testing to assure drug use is unnecessary. This has not turned out to be the Walk With A Doc is a case. Drug diversion is, in fact, FREE walking program relatively common. Random for anyone interested in drug testing is appropriate and taking steps to improve necessary for many patients on their health. chronic opiate therapy. 8) Opiate therapy will permit patients Saturday, May 11, 2013 Sponsored by: otherwise severely impaired by pain McKinley Park to resume normal function. This Saturday, May 18, 2013 has not been the case. There are Robbie Waters Pocket-Greenhaven Library no studies to support this notion. In fact, patients who have needed Saturday, June 8, 2013 opiates to treat substantial disease UC Davis Arboretum are not able to resume normal Supported by: Saturday, June 22, 2013 activities merely with the use of Garcia Bend Park opiates. 9) Addiction to opiates and WHO CAN ATTEND: ANYONE. Tell your patients! Bring a friend! Bring your kids! accidental overdose is relatively rare. This is the most false of Check our website for all presumptions promoted by start times and directions. drug manufacturers. Many causes http://www.ssvms.org/Events.aspx of overdose related to opiates www.ssvms.org/Programs/WalkWithADoc.aspx are not reported, such as deaths from illicit drugs like heroin used

May/June 2013

SSVMS Supports Sac County History Day By Bob LaPerriere, MD

The winning poster in the Sacramento County History Day competition was about Florence Nightingale.

NATIONAL HISTORY DAY culminates a yearlong educational program encouraging students to explore local, state, national, and world history. Not only do students learn a new subject in detail, but they also derive the secondary gain of learning how to do historical research using primary and secondary sources, and also how to present their material using various techniques. The theme changes yearly. This year it is “Turning Points in History: People, Ideas, Events.” Sacramento County History Day was March 9th and qualifiers from the county competition went on to the state event. State winners advance to national. This year the California state event was in Sacramento April 26-28. There are six categories of projects. The 2-D (poster) category is limited to fourth and fifth grades. Sixth through twelfth grade students participate as individuals or groups in junior

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and senior divisions. Their projects may take the form of an exhibit, paper, documentary, performance or website. Our medical society has been involved with the county competition for the past several years, through our medical museum, presenting awards for the best projects related to medical history. Out of 204 projects, there were 16 that fit into the Medical History theme this year. We presented the following three awards. 2-D (Poster) – Florence Nightingale – This was a poster done by two fifth grade students at Russell Ranch Elementary School in Folsom, Emille Doroy and Layla Sanchez. The clear and informative timeline poster covered her birth in Florence, Italy, her participation in caring for the wounded in the Crimean War and eventually her death. Her considerable impact on the nursing profession, social reforms and the practice of charting were also covered. Website – A Fuel for the Pancreas: Insulin – This website (http://92304929.nhd.weebly.com) was created by Hersh Pathak and Jasmanbir Singh, juniors at Folsom High School. It is a well organized and beautifully illustrated website discussing both a brief history of diabetes and, in more detail, the evolution of insulin in its treatment and how its discovery saved lives worldwide through commercial production and distribution. Paper – The Structure of Penicillin – This paper (https://docs.google.com/file/d/0By-WBPz YZRaBVTR6alZEeExwN3c/edit?usp=sharing) was written by Sundaram Gayathri, an eighth grader at Folsom Middle School. Rather than the usual history of penicillin, it explored the discovery of its structure and how this led to the ability for

synthesis and the creation of other antibiotics. Twelve other organizations give similar awards for projects related to their theme, such as Sacramento History and African American History. A goal of these “Special Awards,” which usually consist of cash to help students defray the cost of their project, is to encourage them to think of topics outside their history textbooks. If you have visited our Museum of Medical History, you have probably seen the wonderful exhibit on the Flu Epidemic of 1918-19. This

exhibit, done by three girls from Elk Grove, won second place at National several years ago. If you are interested in participating in future History Days as a volunteer or judge, or have questions, please contact me at ssvmsmus@ winfirst.com. References: The website for Sacramento County History Day is: www.sachistoryday.org The website for California State is: www.historydaycalifornia.org The website for National is: www.nhd.org

Careless Narcotic Prescribing continued from page 23 in physicians adhering to the following process, which is recommended by the Medical Board: 1) Document appropriate history and physical examination. 2) Establish a diagnosis and an objective measure of pain that justifies use of opiate. 3) Obtain informed consent from patient for opiate use, such as an opiate contract. 4) Perform periodic review of patient condition and effectiveness of the therapy. 5) Obtain further consultations from colleagues and/or appropriate specialists if pain is difficult to control. 6) Maintain accurate records. 7) Perform annual review of the patient at a minimum. 8) Provide adequate and appropriate documentation of NP/PA supervision. This joint medical and pharmacy conference provided much food for thought. The admonitions were obviously intended for pain and addiction specialists and pharmacists who are filling large amounts of opiate prescriptions. The main message delivered to attendees was: It is time for the pendulum of liberal prescriptions to swing back to the more conservative days. Providing opiates on demand is not working very well. In fact, the increase in opiate prescribing has directly caused a substantial increase in opiate-related deaths. However, a significant problem encountered in controlling use of opiates was only touched

upon. That is the stress associated with denying patients drugs they have been accustomed to for many years when prescribing was more liberal. A few of the presenters acknowledged that physicians have been prescribing opiates to please their patients, and that physicians often lack the skills and temperament to deal with patients misusing or abusing drugs. But none of the presenters provided any direct answers to the question as to how we will deal with the onslaught of complaints to medical boards from patients denied their usual opiate dose. The conference speakers did not propose means to reduce the number of complaints by patients denied their favored drugs. But physicians are on firm and safe ground denying long-term prescriptions for opiates to patients who have no objective evidence of anatomic or physiologic dysfunction that justifies the substantial risks associated with the use of chronic opiates. For more information, and to see Power Point presentations and the entire conference on video, go to the California Medical Board website www.mbc.ca.gov/pain_forum_february_2013.html. Bruce Barnett, MD, JD, is Chief Medical Officer with California Correctional Health Care Services and President of the CA/NV Chapter for the American Correctional Health Service Association.

…none of the presenters provided any direct answers to the question as to how we will deal with the onslaught of complaints …

bruce.barnett@cdcr.ca.gov

May/June 2013

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BOOK REVIEW

None But The Brave A Novel of the Surgeons of World War II Author Anthony Goodman, MD, ISBN-13: 978-1463507985, Deer Creek Publications Group 2012, 472 pages, $18.95

Reviewed by Jack Ostrich, MD IN THE EARLY DAYS OF World War II, it became clear that a majority of able-bodied young American physicians would be drafted and most would be sent to serve in combat zones. The War Department wisely allowed medical communities to organize themselves, undergo basic military training, and then be sent together to overseas assignments. In Sacramento, Dr. Orrin Cook, a Mercy Hospital radiologist and World War I veteran, brought together surgeons and anesthesiologists from the Sacramento region who became the backbone of the 51st Evacuation Hospital. And Dr. Cook became Lieutenant Colonel Cook. The 51st trained in disparate climes, from Fort Lewis, Washington, to the desert training center near Banning, California, close to where General Patton had prepared his men for the fight for North Africa. In 1943, the 51st embarked for Algeria, then went to Italy, France and finally Germany as the allied armies advanced. They returned to the USA in 1946. In Dr. Anthony Goodman’s book, None But The Brave, we follow the personal and war experiences of three physicians who have long been colleagues at a suburban Philadelphia hospital. Two, John Hammer (“Hamm”) and Steve Schneider, are surgeons, and Ted McClintock is an anesthesiologist who has always worked closely with Hamm and Steve. They are sent to England in 1943 to train for the eventual invasion of mainland Europe. Hamm and Schneider are married, Schneider not happily. McClintock is a sharp-witted southerner, single and carefree. Hamm and McClintock enlist for active duty after Schneider

is drafted. Hamm is quiet and thoughtful and his motives are altruistic. McClintock’s motives are based on friendship with the other two and an I’ve-got-nothing-better-to-do-anyway attitude. Schneider sees his letter from his draft board as a ticket to a temporary respite from his unhappy marriage. He is remorseful about leaving his two small daughters, but not his wife. He thinks that somehow, in his absence, the marriage will heal. He is an agnostic Jew who reminisces that, as a child and young man, he was constantly embarrassed by the accents and mannerisms of his Orthodox Jewish German-born parents. All three land in Normandy on D-Day, Hamm and McClintock by ship and Schneider in a glider. Over the next 300 pages, Dr. Goodman, who himself served in Viet Nam, presents a lively and poignant narrative of the three men as they confront wartime medical practice. Their innate courage and dedication serve them well as they are shot at, bombarded and even briefly taken prisoner as they continue to care for their wounded patients. When a group of female nurses joins Field Hospital Charlie-7, Schneider is soon smitten by WAC Captain Molly Ferrarro, a surgical nurse. They become lovers, and spend a day and a night in newly-liberated Paris. Schneider becomes guilt-ridden over his infidelity, but cannot abandon his love for Molly. In December 1944, Charlie-7 is posted in a small town in Belgium that becomes the center of The Battle of the Bulge. It is overwhelmed by casualties and they are overrun by German troops and tanks. One of the medics witnesses the May/June 2013

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. 27

massacre of 86 American POW’s by order of Obersturmbannfuhrer Joachim Peiper. (Peiper was imprisoned after the war as a war criminal, and was murdered in his home in 1976. The murderer was never caught.) After the German counteroffensive was rebuffed, Charlie-7 entered Germany and found itself stationed “at a concentration camp near Weimar, Germany.” It is there that Schneider reunites with his uncle Meyer Berg, whom he assumed was long dead. Berg is himself a physician and had met Schneider when Steve had visited his German relatives in Germany prior to Hitler’s ascendancy. Schneider is transformed by his uncle’s quiet strength and basic optimism in spite of the horrors he has experienced. They bring each other up to date and trade memories. Steve spills out his story of his love for Molly and his unhappy life in Philadelphia. He asks for advice, and Berg tells him to “follow your heart.” The book ends in a brief epilogue narrated by Hamm’s son, Jacob Hammer, who is preparing for a Passover Seder at his home in Philadelphia

in April 2004. Jacob is a physician and he contemplates the recent death of his father even as his children and grandchildren are clamoring for the Seder to begin, but they cannot start until the last two guests have arrived. They are Molly and Steve and they are present for their fiftyeighth consecutive Seder at the Hammer home. Enjoy the book, as it is certainly enjoyable to read. A few typographical and statistical inaccuracies will bother only pedants. Then google on “51st Evacuation Hospital” to read Dr. Ted Rulison’s transcribed memories and to look at the dozens of pictures from the American training camps. Say a silent prayer for their service. The Greatest Generation indeed. (Reviewer’s note: Many thanks to Dr. Rulison, with whom I had two very pleasant and informational telephone conversations, for his help in fleshing out the story of frontline medicine and surgery in World War II). jmost119@aol.com

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

www.bloodsource.org

not-for-profit since 1948

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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.

A Posit on Availability of Doctors’ Notes to Patients “Patients should have unimpeded electronic access to their doctors’ notes.”

Background: With the rise of electronic medical records, patients are getting more immediate access to their health information (e.g. lab and imaging results, health maintenance reminders). This mirrors trends in other industries. In a 2012 article published in the Annals of Internal Medicine titled, “Inviting patients to read their doctors’ notes,” over 13,000 patients were invited over one year to have full access to their primary care physicians’ office notes. By the end of the study, over 80 percent of patients reported satisfaction with this transparency. Up to eight percent reported worry, confusion, or offense at what they read. At the end of the study, most physicians surveyed expressed not being bothered by this practice; however, about one-fourth of them ceased providing access. (http://annals.org/article.aspx?articleid=1363511) Note: Posits are aggressive statements intended to promote discussion. Therefore comments are particularly relevant. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or SSVMS Board of Directors. Results: 26/Agree – 57/ Disagree. Commentary follows: It is not a matter of keeping information from patients, but some complex diagnoses need a live professional to interpret the meaning and set the context for the patient. –Robert Forster, MD It’s the patient’s chart; they should have unimpeded access to the records. The only exception would be psych records (which could impact therapy/treatment course); and the doctor should be able to build in a delay of release of records to allow the MD to call the

patient first if there is something concerning that needs to be discussed. –Andrew Last, MD Disagree. Some psychiatric records are sensitive in content. – Jimmark Abenojar, MD I disagree. I think giving patients access to their notes can lead to a lot of confusion. – Uppinder Mattu, MD While in agreement, this may make the notes less objective for fear of adverse patient satisfaction ratings. –Ben Balough, MD Access to summary, instructions would be beneficial, but unimpeded access to records is not a good idea, as this may change how doctors chart, especially in regards to psych diagnoses or concerns, and may lead to miscommunication. We give our patients a summary print out that contains relevant info at the end of each appointment, but not diagnoses, or PE. – Katharina Truelove, MD Agree. I have always understood that patients have a right to a copy of their medical records, with some few specific exceptions (e.g., psychiatric notes). Is that not the case? –Stephen A. McCurdy, MD Fairly obvious to me why one wouldn’t want all the notes visible. A lot of private thoughts, reminders, etc., are placed in the MR, many of which I would not want them seeing. I would probably continue to write my notes as I do now, but I know that many patients would be upset at what is there. That’s the way it is. Of course, anger leads to malpractice filings. Also, I’m sure many doctors would change their recording habits and the notes would be without a lot of important information. It’s a bad idea. –Maynard Johnston, MD In general, I support greater transparency in May/June 2013

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.

There is a significant risk for misinterpretation of medical records, so access should never be unlimited.

health care from costs to patient information. The more information patients have access to, the better they can make a decision that is right for him or herself. Of course, ideally, this decision is made alongside and with the guidance of the patient’s physicians. –Allen Tong, MD I feel they should have partial access to their notes as with “Meaningful Use” concept. Providers can write the section for their patient in plain simple English for their understanding, and there should be sections that are left to the professional’s access only. –Kenneth Corbin, MD There is a significant risk for misinterpretation of medical records, so access should never be unlimited. Objective entries such as labs or imaging are acceptable for access. Subjective comments in records can be helpful in patient care, but not beneficial for the patient’s knowledge. When physicians start getting reimbursed for phone calls and emails in response to patient inquiries, I’ll be more supportive of patients having more access to their records. Extensive responses necessitate making an appointment now; otherwise, there is the potential for large amounts of physician time going unreimbursed. –Clifford Marr, MD Though patients ultimately do have access to these notes, such direct electronic access will increase the likelihood that doctors will alter the presentation of the note to make it less informative (from a medical perspective) and less candid. This further reduces the effectiveness of the chart note as a tool for providing medical care. – John Gisla, Jr., MD We should all be generating our documents with this in mind, and patients should have the opportunity to consult with their doctors about the meaning of what is in those documents. A move toward a highly secure national database for both written records and imaging (in full DICOM file format) should also be pushed. There are some records to which patients should not have such direct access, namely psychiatric records for reasons that should be obvious, unless the doctor who authored them agrees. –Don Udall, MD

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As part of Meaningful Use Criteria for EHR, certain items are already required (e.g., Problem list, Medication and allergy lists). Unimpeded access would generate unnecessary calls from patients to MDs without any proven benefit. – Kuldip Sandhu MD Since 1981, we have provided all patients with a duplicate copy of their chart notes with every visit. It has never been a problem and most patients are very appreciative of the gesture. Only rarely does a patient object to something that was written or call to correct a note that they feel was inaccurately reported. For sensitive matters that we may not wish to share with the patient, we can use a section of our EMR called secure notes, but we do not exercise this option very often. Providing a patient access encourages the physician to chart completely and accurately, which is not a bad thing. So my only question is: How come it has taken so long for everyone else to do this? –Joanne Berkowitz, MD The downside of having full access is that the patient may not fully comprehend what is being written. –Hui Cheong, MD I think that if physicians know that patients, patient’s families and potentially litigants will be able to see everything in a physician’s notes, then physicians will have no choice but to become much more guarded in what they dictate on an every day basis. It could hamper the free flow of communication between physicians, which is really what the notes should be for, not for patient consumption. –Sidney Scudder, MD Anyone who has ever tried to explain TSH, free T4 and total T3 results to a patient knows how horrific and time consuming unfettered patient access to results can be. –Ann Gerhardt, MD The qualifier “unlimited” is the problem for me; a physician should have some right to write and keep private thoughts in a sheltered place, even when they refer to a particular patient’s medical care; those thoughts ought to remain private until/unless made available to someone else: a consult, a lab or test result, an operation report. Granted, that is not now the case because ultimately a patient has full

access to the record through his lawyer. That invasion of physician privacy is one reason we may choose to practice defensively, crafting each medical record note for use in court, obtaining unreasonable tests, and consults or referrals that inflate the cost of care. Physicians should have as much right to private thoughts as anyone else. –John Loofbourow, MD With the transition to electronic records, many MDs are now required to type their own notes. Because of time constraints being imposed on practitioners at the same time, many are using “boiler plate” templated notes. These include the required elements to be able to bill and collect for services rendered. Unfortunately, many physicians do not pay careful attention to the vast quantity of text which is automatically inserted into the record. Still, others “block copy” previous H and Ps and reinsert them into the record. This is a form of “dry labbing it,” essentially cheating, or more properly, fraud. –Gerald Upcraft, MD Although there may well be advantages to providing immediate access to our notes, such as correcting errors and elaborating on complaints, there will also be problems. Physicians will be less likely to make forthright observations about patients that may not be well received by them. Our comments about appearance, cognitive function, mental health, hygiene, substance abuse, high-risk behaviors, inappropriate behaviors or comments by patients, dress, affect, etc., will invariably offend someone. That will then lead patients to request the right to edit or append notes and thus precipitate conflict. The purpose of the physician’s note is first and foremost to record our findings, not to avoid insulting patients. Secondly, it is for communicating with other physicians. – Michael Patmas, MD Doctors often makes notes intended for their own use in the patient’s records based on observations in the exam room that are not intended as part of the diagnostic process and would only serve to strengthen the eight percent of responders to this study who were worried, confused or offended. –John Posten, DO I address certain issues that act as reminders

(such as “consider drug seeking behavior”) that would certainly lead to problems if patients could view my notes. –Marc Walter, MD The problem is that many patients don’t know how to interpret the information they see. For that reason, patients with access to their medical information tend to make more appointments than those who don’t. –Richard Gray, Jr., MD Disagree – specifically with “electronic access” – this is a term with too many variables for me to be able to agree unconditionally. BUT, I agree that all patients should have unimpeded access to all physician’s notes, though I always like to be able to delay access 24 hours, to allow note completion, so electronic access may be too instantaneous for me to agree without that caveat, and then there are security concerns, etc. –Steven Littlewood, MD Patients’ access to their medical records has already gotten me in hot water. One patient saw “Borderline Personality Disorder” on their Problem List (completely justified in my opinion), and that lead to many subsequent discussions. I have avoided using the term “obese” in my notes and rather say “weight concerns” or “elevated BMI.” I wrestle with how to objectively document patients acting disagreeably, disrespectfully, or hostilely. Documenting poor hygiene can be challenging, although generally these folks aren’t looking at their health records online. I document “patient declined” now instead of “refused” as the latter implies that we argued about something. Lastly, I avoid acronyms like “sob” for fear that they may be misconstrued! So much for the safety that incomprehensible doctor’s scrawl once allowed. –Nathan Hitzeman, MD I do not think patients should have unimpeded access to correspondence between physicians discussing a patient’s care. This information may seem offensive and confusing to the patient and may result in disruption of the patient-doctor relationship. –Amy Wandel, MD Notes need to be discussed with and interpreted to patients, to prevent misunderstandings and unnecessary anxiety. – Robert Meagher, MD

May/June 2013

Physicians will be less likely to make forthright observations about patients that may not be well received by them.

Board Briefs March 11, 2013 The Board: Received an update regarding the Child and Adolescent Health Services Committee from Mary Jess Wilson, MD, Chair. Approved the 2012 Year-End SSVMS Financial Statements and Quarterly Investment Report and Recommendations. Approved appointments to the 2013 Emergency Care Committee: Peter Hull, MD, appointed Vice Chair, and appointed the following hospital emergency department directors, Justin Wagner, MD, Sutter Memorial Hospital; Deven Merchant, MD, Sutter Davis; Roel Farrales, MD, Mercy General; Matthew Donnelly, MD, Mercy Methodist. Approved the nomination of Alexis Lieser, MD to the CALPAC Board representing Senate District 1. Approved the Membership Report: For Active Membership — Jimmark V. Abenojar, MD; Matthew J. Boren, DO; Bradley S. Briercheck, MD; Stephanie K. Brown, MD; Burch R. Bryant, Jr., MD; Marie R. Carlisle, MD; Robert C. Carlisle, MD; Jason S. Chang, MD; Elbert H. Chen, MD; Peter B. Chiu, MD; Michael I. Chow, MD; Abbegail M. Collantes, MD; Hillary M. Crawford, MD; Anh N.H. Dan, MD; Matthew D. Danielson, MD; Catherine A. Davis, MD; Matthew L. Donnelly, MD; Alan R. Ertle, MD; Roel D. Farrales, MD: Xin Gao, MD; Phat T. Giang, MD; Laura M. Grigor, MD; Robert M. Ghrist, MD; Bruce L. Gordon, MD; Ryan N. Gorton, MD; Sabrina M. Gunion, MD; Noel C. Hastings, MD; Cheng Ji, MD; Lia C. Keller, MD; Steven Khine, MD; Mohammad R. Kordouni, MD; Andrew H. Lee, MD; Jeffery J. Leinen, MD; Petey Leohaburanaki, MD; Hong Y. Li, MD; Katie M. Lukasek, MD; Sandra Mendez, MD; John B. Mitchell, MD; David J. Moller, MD;

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Suzanne C. Montoya, MD; Craig H. Morris, MD; John G. Moser, MD; Christopher K. Mosley, MD; Navin C. Nakra, MD; Renuka D. Nandan, MD; Caroline Nguyen, MD; Kristen L. Nichols, MD; Noeun G. Oh (Kwak), MD; Christopher T. Oide, MD; Nikolas K. Paech, MD; Michael J. Palchak, MD; James S. Peng, MD; Maria L. Parayno, MD; Ramon A. Perez-Egana Monge, MD; Dolores A. Policicchio, MD; Daniel A. Poon, MD; Paul D. Reynolds, MD; Michael R. Salomon, MD; Charandip K. Sandhu, MD; Satpreet S. Sekhon, MD; Emily J. Siegle, MD; James H. Smith, MD; Dwight B. Stalker, MD; John J. Tiedeken, MD; Lam T. Van, MD; Andy H. Vila, MD; Justin B. Wagner, MD; David T. Walters, MD; David C. Yang, MD; Pandu R. Yenumula, MD; Norman Y. Yeung, MD: Scott C. Yu, MD; Sarah L. ZwehlBurke, MD. For Resident Membership — Kevin J. Burnham, MD; Benjamin A. Keller, MD; Roy A. Poblete, MD; Sarah R. Takekawa, MD. For Reinstatement to Active Membership — Meredith A. Bean, MD; Sonja Sorbo, MD. For Reinstatement to Government Membership — Connie Mitchell, MD. For a Change from Active to Active 65/20 — Geoffrey Woo-Ming, MD. For Retired Membership — Sallie O. Adams, MD; Bruce N. Burdick, MD; Dale R. Butler, MD; Paul N. Cloninger, MD; James E. Hine, MD; John M. Osborn, MD; Alan M. Roth, MD; Zubeda A. Seyal, MD; Larry J. Wolff, MD. For Resignation — Richard G. Areen, MD; Asma Azhar, DO (transferred to Riverside); Phillip A. Cole, MD (moved to Oakland); Linda E. Copeland, MD (transferred to Fresno-Madera); Vahid Feiz, MD (transferred to Alameda Contra Costa); Mathew S. Foley, MD (moved to New York); Diana Z.L. Gascon, MD (transferred to Los Angeles); Andrew H. J. Huang, MD (moved to St. Louis, MO); Ilya Khamishon, MD; Anne K. continued on page 34

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; Jason P. Bynum, MD, Secretary.

Abenojar, Jimmark V., Psychiatry/Child & Adolescent Psychiatry, UC San Diego 2005, 129 C St #5, Davis 95616 (530) 643-7546

Ghrist, Robert M., Internal Medicine, Univ Texas 1981, The Permanente Medical Group, 1955 Cowell Blvd, Davis 95616 (530) 757-7070

Khine, Steven, Radiology, Univ Illinois 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Akin, Paula L., DO, OB-GYN, Kansas City Univ 1995, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3350

Giang, Phat T., Anesthesiology, Rosalind Franklin Univ 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6893

Ko, John Y., Cardiology, UC Los Angeles 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Arizaga Peverini, Silvia C., Internal/Geriatric Medicine, Unv of Montemorelos, Mexico 1990, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Gordon, Bruce L., Emergency Medicine, Louisiana State Univ 1971, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222

Lacayo, Karla T., Psychiatry, Univ of San Carlos, Nicaragua 1983, Mercy Medical Group, 1792 Tribute Rd #350, Sacramento 95815 (916) 924-6400

Gorton, Ryan N., Emergency Medicine, Univ North Carolina 1998, CEP-Sutter Davis Hospital, 2000 Sutter Pl, Davis 95616 (530) 756-6440

Lane, Nathaniel G., Emergency Medicine, Univ Colorado 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Armour, Ryan A., DO, Neurology, WUHS College of Osteopathic Medicine 2007, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Berejnoi, Kirill V., Family/Geriatric/Palliative Medicine, Military Medical Academy, Russia 1994, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Berger, Anthony L., Emergency Medicine, Albany Medical College 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Boren, Matthew J., DO, Emergency Medicine, Nova Southeastern Univ 2002, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222 Chang, Jason S., Neurology/Sleep Medicine, Univ Vermont 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 Crawford, Hilary M., Emergency Medicine/Sports Medicine, Ross Univ 2005, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222 Dein, John R., Thoracic & Cardiac Surgery, Duke Univ 1981, Mercy Medical Group, 3941 J St #270, Sacramento 95819 (916) 733-6850 Earp, Ryan D., Emergency Medicine, Univ Michigan 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Ekanayake, Ruwan B., Emergency Medicine, New York Medical College 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Grigor, Laura M., Infectious Disease/Internal Medicine, Univ of Medicine/Pharmacy, Romania 1995, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Li, Hong Y., Anesthesiology, Sun Yet-Univ, China 1986, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Gunion, Sabrina M., Emergency Medicine, Univ Illinois 2008, CEP-Sutter Memorial Hospital, 5151 F St, Sacramento 95819 (916) 454-3333

Livoni, Raquel R., Family Medicine, Univ Arkansas 2007, 6500 Coyle Ave #5, Carmichael 95608 (916) 853-1155

Hadi, Ehsan M., Neurology, Univ of the Punjab, Pakistan 1997, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3670

Lukasek, Katie M., Emergency Medicine, SUNYDownstate 2007, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222

Hastings, Noel C., Emergency Medicine, Univ Washington 2009, CEP-Sutter Memorial Hospital, 5151 F St, Sacramento 95819 (916) 454-3333

McNeil, Andrew C., Infectious Disease, Rush Medical College 1994, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4016

Henry, Melinda A., Emergency Medicine, Mayo Medical School 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Higgs, David E., Emergency Medicine, Univ Michigan 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Ji, Cheng, Radiology/Neuroradiology, Sun Yet-Sen Univ, China 1988, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5826 Jones, Cameron L., Emergency Medicine, Drexel Univ 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Katz, Andrew J., Pediatrics, Baylor College 2000, Mercy Medical Group, 8220 Wymark Dr #200, Elk Grove 95757 (916) 667-0600

Gao, Xin, Pathology/Cytopathology, First Shanghai Med Univ, China 1989, The Permanetne Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2300

Keller, Lia C., Dermatology, Univ Southern California 1990, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 631-3010

Gentilello, Larry M., General/Trauma Surgery, Albert Einstein 1982, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Khan, Rana M., Gastroenterology, Univ Punjab, Pakistan 1996, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3370

Mitchell, John B., Orthopedic Surgery, Univ Wisconsin 1982, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Mohr, Peter J., Cardiology, Tufts Univ 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Moller, David J., Neurological Surgery, Loma Linda Univ 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490 Montoya, Suzanne C., Family Medicine, UC Davis 1997, The Permanente Medical Group, 2345 Fair Oaks Blvd, Sacramento 95825 (916) 614-4040 Morse, Eric D., General Surgery, UC Los Angeles 1985, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3600 Moser, John G., Emergency Medicine, Tufts Univ 1992, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222 Nandan, Renuka D., Anesthesiology, Ross Univ 2003, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

May/June 2013

Nguyen, Caroline, Family Medicine, Univ Montreal, Quebec 1998, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222

Rocha, Sean B., Orthopedic Surgery, Univ Massachusetts 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2030

Tiedeken, John J., General Surgery, Drexel Univ 1994, 4232 H St #2, Sacramento 95816 (916) 475-1222

Niedermeier, Michael W., Emergency Medicine, UC San Francisco 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Salomon, Michael R., Emergency Medicine, Loyola Univ 1984, CEP, Sutter Davis Hospital, 2000 Sutter Pl, Davis 95616 (530) 756-6440

Oh, Noeun G., Radiology, Robert Wood Johnson 2005, The Permanente Medical Group, 2025 Morse Ave, Sacramento 98525 (916) 973-5720

Sandhu, Charandip K., Anesthesiology, Creighton Univ 2005, UCDMC, 4150 V St #1200, Sacramento 95817 (916) 734-5028

Oide, Christopher T., Radiology Univ Southern California 1991, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Sekhon, Satpreet S., Nephrology, Punjab Univ, India 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5230

Paech, Nikolas K., Emergency Medicine, UC San Francisco 2008, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222

Siegel, Emily J., Emergency Medicine, Drexel Univ 2009, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Palchak, Michael J., Emergency Medicine, St. Louis Univ 1987, CEP-Sutter Davis Hospital, 2000 Sutter Pl, Davis 95616 (530) 756-6440

Skaff, Peter T., Neurology, Albany Medical College 1997, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3670

Perez-Egana Monge, Ramon A., Internal Medicine, Univ Peruana 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Smith, James H., Radiology, Ross Univ 1999, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Yang, David C., Internal Medicine, Taipei Med Col, Taiwan 1978, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-3040

Srikulmontree, Thitinan, Rheumatology, Chiang Mai Univ, Thailand 1998, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3560

Yeung, Norman Y., Radiology, Mt. Sinai 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Sweat, Jeffrey A., Plastic Surgery, Univ Kansas 2001, Mercy Medical Group, 2200 Sunrise #250, Gold River 95670 (916) 536-2400

Yu, Scott C., Emergency Medicine, Univ Missouri 2004, CEP-Sutter Memorial Hospital, 5151 F St, Sacramento 95819 (916) 454-3333

Tarekegn, Selamawit, Internal Medicine, Univ Illinois 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Zara, Jojet L., Family Medicine, Univ Santo Tomas, Philippines 2000, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3540

Tarrar, Aymel J., Family Medicine, Ross Univ 2002, Mercy Medical Group, 8001 Madison Ave, Citrus Heights 95610 (916) 536-2420

Zwehl-Burke, Sarah L., Emergency Medicine, UC San Francisco 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6600

Plante, Deborah K., Endocrinology, Ross Univ 1998, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3560 Policicchio, Dolores A., Family Medicine, Eastern Virginia 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Poon, Daniel A., Emergency Medicine, Loma Linda Univ 2009, CEP-Sutter General Hospital, 2801 L St, Sacramento 95816 (916) 454-2222 Reynolds, Paul D., Internal Medicine, St. Louis Univ 1981, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4040

Board Briefs continued from page 32 LaHue, MD (transferred to Los Angeles); Gordon L. Love, MD (moved to Los Angeles); Lynn Y. Nakamura, MD (transferred to Placer-Nevada); Irene S. Oâ&#x20AC;&#x2122;Farrell, MD (transferred to Sonoma); Katrina U. Reyes, MD (transferred to Santa Clara); Ronald A. Rogers, MD; Peyman SalimiTari, MD (moved to Irvine); Ling Shi-Bertsch, MD; (transferred to Placer-Nevada); Theodore Swerdling, MD (moved to Long Beach); Mark D. Tyburski, MD (transferred to Placer-Nevada); Shao-Ta Yeh, MD (moved to Houston, Texas).

Sierra Sacramento Valley Medicine

Valdez, Thomas A., Family Medicine, Univ Southern California 2007, Mercy Medical Group, 9394 Big Horn Blvd., Elk Grove 95758 (916) 691-8500 Van, Lam T., Family/Geriatric Medicine, Ross Univ 2002, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 614-4040 Wagner, Justin B., Emergency Medicine, Loma Linda Univ 2006, CEP-Sutter Memorial Hospital, 5151 F St, Sacramento 95819 (916) 454-3333 Walters, David T., Emergency Medicine, UC Davis 1986, CEP-Sutter Memorial Hospital, 5151 F St, Sacramento 95819 (916) 454-3333 Wei-Shatzel, Julie R., DO, Family Medicine, Des Moines Univ 1998, Mercy Medical Group, 550 W Ranch View Dr #3000, Rocklin 95765 (916) 409-1400

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

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

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May/June 2013

16th Annual California Health Care Leadership Academy

May 31 - June 2, 2013 • Planet Hollywood, Las Vegas Welcome to the era of health reform. Increasing demand for services. Intensifying pressure for cost and quality accountability. Small practices joining larger groups seeking safe harbor. Undercapitalized medical groups sinking. Hospitals and health plans acquiring practices in a “vertical integration” (consolidation?) of the health care market.

Can physicians control their own destiny – and the future of medical practice? Hear from experts and leaders of change and attend a comprehensive slate of practice management seminars and workshops to position your practice for success. Early-Bird and Multiple Registration Discounts Save up to $200 per person when you register before May 3!

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