2013-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2013

savings of $ over 93,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s Trial Lawyers have launched an attack to undermine MICRA and its protections and we need your help. Membership has never been so valuable!

WAYS SSVMS/CMA IS WORKING FOR YOU! Physicians in El Dorado, Sacramento and Yolo Counties are saving an average of $93,748 this year.

Are you a SSVMS/CMA member? 2012 SIERRA SACRAMENTO VALLEY MEDICAL SOCIETY MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

El Dorado, Sacramento and Yolo counties $28,147

$7,976

$38,865

$24,996

Miami & Dade Counties, FL

$190,088

$46,372

$201,808

$146,089

Nassau & Suffolk Counties, NY

$127,233

$34,032

$204,684

$121,983

Wayne County, MI

$121,321

$35,139

$108,020

$88,160

FL-NY-MI Average

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$118,067

$30,538

$132,639

$93,748

(Non-Invasive)

Sierra Sacramento Valley Medical Society 5380 Elvas Ave, STE 101 Sacramento, CA 95819 Phone: (916)452-2671 Email: info@ssvms.org Join online today www.ssvms.org * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

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Medicine 3

PRESIDENT’S MESSAGE Medicine Under Legislative Attack

2013 Education Series

David Herbert, MD

Hobbies of Some of Our SSVMS Members

EDITOR’S MESSAGE Do You Feel the Burn?

Stayin’ Alive: My Treatment for Hep C

Nathan Hitzeman, MD

Dr. J.R.

EXECUTIVE DIRECTOR’S MESSAGE Flying Solo? Contact SSVMS First

Hepatitis C Cure with Oral Medications

Lorenzo Rossaro, MD

Aileen Wetzel, Executive Director

A Posit on Medical Decision Making

The Perilous Flight of a Small Practice

Sean Deane, MD

Volunteers Receive “Health Care Heroes” Recognition

BOOK REVIEW “Song Without Words−Discovering My Deafness Halfway Through Life”

Chris Stincelli, Associate Director

Health Reform − Physicians Leading Change

Paul R. Phinney, MD

IN MEMORIAM Earl F. Wolfman, MD

Eugene S. Ogrod, MD

Reviewed by Jack Ostrich, MD

Crossword Puzzle

Created by John Belko, MD

The Volunteer

John Loofbourow, MD

Board Briefs

SSVMS Alliance Names 2013 Grant Recipients

Meet the Applicants

Barbara Andras and Celeste Chin

Classified Ads

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

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 Garden of the Gods in Colorado Springs, CO, is one of the most beautiful rock formations in the country. It is a beacon for outdoor enthusiasts including beginner to advanced climbers. Sports and hobbies provide us a getaway from our daily duties, and this issue offers a glimpse into the hobbies of some of our SSVMS members (page 17). From rock climbing to book binding, from sailing to fishing, from knitting to park docent character re-enactments, all offer us a way to unwind. Our cover picture is of a rock climber at Garden of the Gods, and was taken by photographer Dave Black. More of Dave’s work can be appreciated at www.daveblackphotography.com.

July/August 2013

Volume 64/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

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

Give Us A Break. The physicians at The Doctors Center are available to assist you with minor fractures. We’re not competing for your patients’ business – we’re here to help you meet the demands of those unscheduled appointments and patient emergencies – 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. The Doctors Center is open from 8:00 a.m. to 8:00 p.m. Lab tests, x-rays and ECGs are performed on site to allow immediate diagnosis. No appointment is ever needed. We accept assignment for Medicare and are providers for most HMOs and PPOs.

The Doctors Center new hours are 8:00 a.m. to 8:00 p.m. JOANNE BERKOWITZ, M.D. Board certified in Internal 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

The Doctors Center Medical Group Inc.

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

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.

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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President’s Message

Medicine Under Legislative Attack By David Herbert, MD MAY YOU LIVE IN INTERESTING times! This pithy curse, which may or may not be from ancient China, would appear to apply to the present era of medicine. We’ve had health care reform, EMRs, HIPAA, decreasing reimbursement from Medi-Cal and Medicare, and the great recession – and this is only on the administrative side of medical practice. Just when we thought that things had gotten about as “interesting” as they could, along come serious attempts to end MICRA (The Medical Injury Compensation Reform Act) and to expand the practice of non-physicians. Each of these will require a forceful, coordinated response, if we are to preserve patient safety and the affordability of care. And who else besides organized medicine is able to do this? The assault on MICRA is not a surprise. By limiting the non-economic damages in medical malpractice awards to a still hefty $250K, California has avoided the extreme awards that have caused malpractice rates to skyrocket elsewhere. For example, New York has no caps on non-economic damages, and OB-GYN physicians practicing in Long Island pay average premiums of about $204,684, while those in El Dorado, Sacramento and Yolo counties pay an average of $38,865. For internists, the premiums are about $34,032 versus $7,976. The average MICRA savings for our three-county area is $93,748! These big premium differences increase the cost of care and can make solo and small group practice unaffordable. But the higher awards without caps on non-economic damages translate directly into higher fees for trial lawyers,

and so they have repeatedly tried to repeal MICRA. This year they have started a campaign to put an initiative before the voters to do just this, if they can’t convince the legislature and Governor Jerry Brown to do it. Perhaps hoping that medicine will be too busy fighting changes to MICRA to pay attention to changes in the scope of practice of non-physicians, legislators have introduced over a dozen bills to expand the practice of non-physicians. These range from allowing nurse practitioners to practice without physician oversight, to allowing optometrists to screen, diagnose, and treat diabetes, hypertension, and hyperlipidemia. Other bills may leave more room to find a compromise that protects patient safety: allowing physical therapists to see patients for some period of time without a physician’s diagnosis or orders and expanding pharmacists’ ability to provide vaccinations and smoking cessation drugs. Acting alone, each of us can have but a limited effect on misguided efforts such as these. But together we can and do have a powerful voice that protects patients and maintains our ability to practice. In California, this is the CMA. If you are a member of SSVMS and the CMA, thank you! And consider also supporting CALPAC (the political arm of CMA). If you, and perhaps your group, are not actively participating in organized medicine via membership, this is the time to reconsider so that we can most effectively advocate for good medical care. davidherbert166@gmail.com

July/August 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.

EDITOR’s Message

Do You Feel the Burn? By Nathan Hitzeman, MD

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

I VISITED A FRIEND FROM medical school last year in L.A. He is an Emergency Department doc who works four days on and four days off. He picked me up at the airport with a surfboard strapped to his car roof. On the way to a favorite Vietnamese restaurant, I probed him about his job and any interesting cases he saw in the ED. He didn’t seem all that interested in talking about work, saying something to the effect that, “patients don’t take care of themselves.” Then, as we were getting on “the 10,” a surf buddy of his called and his face lit up as he heard the surf report. In a study published in the August 20, 2012 Archives of Internal Medicine, nearly half of over 7,000 doctors surveyed experienced at least one sign of burnout. “High emotional exhaustion” and “cynicism” were the most common reasons. Forty percent of physicians reported being unhappy with their work-life balance (vs. 23 percent of the general public). Emergency physicians, internists, neurologists, and family physicians were at highest risk; dermatologists and pediatricians were at lowest risk. In this issue of SSV Medicine, we profile a few of the ways docs unwind. Whether it be rockclimbing, fishing, sailing, acting, or collecting garden gnomes, we strive to find balance. Docs are typically overachievers, and not surprisingly, we like to outdo ourselves in running, bicycling, hiking, or whatever. I can’t remember an application to our residency program where “hiking” was not listed on the hobbies section. The whole world must be hiking! Some of us make it into The Sacramento Bee for our extracurriculars, be it cardiac surgeon Frank Slachman for his mountain climbing, or internists Kay Judge and Maxine Barish-Wreden for their tips on Integrative Medicine.

If you really want to be inspired by work-life balance and alternative practice styles, try checking out the Sonoma Medical Society’s Winter 2013 issue at www.scma.org/ magazine/?vol=64&num=1. For sure, they are hippies, but they are doing something right! Traditionally, physicians have been practicing reactionary medicine – stamping out disease after it happens. But how do we teach our patients to be well-rounded, well-balanced, to live fulfilling and healthy lives, and to find wholeness? How do we find that for ourselves? If only the answer were as simple as buying a $20 multigrain loaf of bread at Whole Foods, or buying an energy drink made for physicians (think of the possible names: DoctorGo, MonsterMD, EnergyRx, or perhaps Triplicated). My personal idol is climber Chris Alstrin who is on the cover of this issue. The younger brother of my best friend growing up, we used to give him a hard time for following us around. While we became working stiffs, Chris “works” by making documentaries of climbing and other activities around the world. He has been snowed in at base camp on Everest for weeks at a time, witnessed an inspiring traditional funeral while climbing in Vietnam, learned to eat with his right hand in Pakistan (while learning to do something else with his left), and felt the cold breath of creation in Antarctica. I’ll never have that kind of work-life balance, but medicine itself is an adventure. We see the world through our patients. There are endless stories, triumphs, pitfalls, and negotiated steps. It’s not easy, but it’s not boring either. And if we have a little left at the end of the day, who knows where our inspiration will take us next! hitzemn@sutterhealth.org

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Executive Director’s Message

Flying Solo? Contact SSVMS First Resources for Physicians in Solo or Small Practice

By Aileen Wetzel, Executive Director SOLO AND SMALL-GROUP PRACTICES are the mainstay of the American health care system. Even in the Sacramento region, the birthplace of health maintenance organizations and home to some of the largest medical groups in the country, many of the area’s residents receive their medical care from physician offices with only one or two practicing doctors. Solo and small-group practices play a crucial role in our community’s health care safety net. For this and myriad other reasons, it is worth paying close attention to the plight of solo and small-group practitioners (see Dr. Sean Deane’s article in this issue about establishing a solo practice). Every medical practice is different, but each requires the same basic resources to be financially successful and to deliver high-quality medical care. In order to provide quality medical care, a physician’s practice must be efficient and well run. There are a plethora of resources to help physicians succeed and to keep practices viable. You just need to know where to find them. As a medical society executive, I frequently struggle with how to educate physicians and their staff about the many resources that are available at no cost through SSVMS/CMA. Emails, articles, newsletters and faxes announcing the latest resource inevitably arrive at the wrong time and most likely do not address the one specific issue that is keeping you awake at night. Don’t spend any more of your valuable time scouring the internet for answers to your questions or in an attempt to locate the perfect

resource. Simply remember three words: Contact SSVMS First. And what is keeping you awake at night? Have you done everything you can to resolve an issue with a payor, including appealing, and have been unsuccessful in getting the payor to resolve the issue? Is your staff spending an unreasonable amount of time chasing down authorizations or verifications? Have you been presented with a health plan contract and you’re not sure if the terms are consistent with California law? Do you need guidance on selecting an EHR or assistance with e-prescribing requirements? Does your practice manager need a primer on hiring and training qualified staff? Need help navigating HIPAA 5010 transactions or preparing for ICD-10? Problems with the Medical Board? Need assistance with Medicare and/or MediCal provider enrollment? Need guidance on how to handle an audit? Thinking about retiring or selling your practice and wondering where to start? Are you receiving unreasonable requests for medical records or untimely requests for refunds? Whatever your question or need:

Contact SSVMS First (916) 452-2671 or info@ssvms.org awetzel@ssvms.org July/August 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.

The Perilous Flight of a Small Practice By Sean Deane, 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.

THOSE OF US WHO HAD THE questionable pleasure of enjoying television in the 1980s may recall Tales of the Gold Monkey, an adventure series that I have the dubious honor of saying I dropped everything for once a week. The plot centers on a 1930’s charter pilot running a small cargo business in a Grumman Goose amphibious plane. The flights were to dangerous and unique destinations, surrounded by the intrigues of strange government operatives, all on remote and poorly-understood islands between two countries in conflict. Think Japanese spies, French magistrates, secret negotiations, and lost golden idols − accented with an inebriated copilot named Corky and a one-eyed dog, who always seemed to know what went wrong when smoke inevitably spewed from the engines once an episode. Little did I know that my journey into the business of a small medical practice as a community allergist would be in many ways the medical version of Tales of the Gold Monkey. It was 2009. The world was reeling from global financial disaster. The evaporation of endowments and 401(k) plans had suddenly and simultaneously drained grant and departmental budgets and reversed retirement plans for private doctors around the country. As the rumors of physician layoffs, hiring freezes, and looming insolvencies in the large health systems roiled around our final training years, the world of independent practice seemed an attractive option for many of the nascent subspecialists, myself included. Starting early, I sent out exploratory resumes − and to my surprise, in return came an offer

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from a generous local physician hoping to retire and transition his practice to a new colleague. The idea was to work as an employee for two years while things got established, and then set out on my own. It was a golden opportunity, and in many ways, a gift. I accepted – but with the growing realization that after nearly a decade of learning and practicing my trade communally among my colleagues in the halls and crowded nursing stations of academic medical centers, I had no idea what it would be like to be the only physician in the building. And I had even less of an idea what it was like to run a business. I was ready to learn, though, and so I fired up my Grumman Goose for an adventure, albeit without the dog. A little over a year after completing my fellowship, I began making the transition from employee to business owner, from passenger to pilot. The first step seemed easy enough after a few evening business classes with the Small Business Administration. I made some phone calls, settled on a law firm to establish a medical corporation, and mailed a check. A few thousand dollars later, the business had a tax ID, and the process of contracting with insurance could begin. Logically, I thought, it began with the mother of all insurers – Medicare. I assumed enrollment would be a breeze, since I was already individually credentialed and had a Medicare number through my volunteer faculty appointment and the clinical work as a hospitalist that, upon discovering I couldn’t bear to part fully with inpatient medicine, I had carried with me through fellowship and

beyond. Moreover, Medicare had moved to an online enrollment process that automatically selected the correct forms and forwarded the information to the correct person based on context questions. Even so, I was wary after learning that the process could take as long as six months, if all went wrong. Therefore, I dutifully started on it in time to make sure everything was in place before I saw my first patient. I filled out the online form, hit “send,” and mailed off the necessary paper signature forms, only to receive a letter from a person we’ll call Todo saying that the Medicare contractor felt the wrong forms were submitted and that it all needed to be redone. After days of trying to contact Todo, leaving message after message, I finally received a telephone call back.

Online Enrollment Nightmares When I related that I had used the online enrollment system, as Medicare strongly encouraged, Todo coolly informed me that the system had gotten it wrong, and instructed me to fill out the paper forms instead. He noted that the corporation’s first patient would not be seen for several months and that Medicare enrollment forms couldn’t be submitted anyway until 30 days before the first patient was seen – meaning that the corporation could be required to service patients without pay for as long as five months. I was, to say the least, incredulous at the revelation, but followed his instructions and pulled the application. As the months passed, most of the other necessary contracts with private insurers were completed, until the 30-day mark came. As before, the necessary forms were filled out online using Medicare’s PECOS system, and the same types of forms that Todo had rejected a few months earlier were again generated. This time, some weeks after submission, I received another form letter from a person

we’ll call Koji, informing me that there were a number of missing items. Certain that I had checked and rechecked the submission, I pored over my copies and, sure enough, everything was there. So I called – and called, and called, and called. There would be no response from Koji. Indeed, to this day, I have never heard from Koji. Exasperated, I called the general Provider Enrollment line, and there encountered a series of people we’ll collectively call Bon Chance Louie. Louie looked through the submission – check, check, check. “Yup, it’s all here. Koji should get it soon.” Weeks went by, until I got another letter, this time from Calvin. More things missing. Phone calls to Calvin – several – were finally returned. “Oh, don’t worry, if Louie said it’s all here, it’s all here.” More weeks. By this time, the corporation was seeing patients. My predecessor had been in practice since the 1970s, and so a large number of those patients were enrolled in Medicare. As a result, I was taking on extra moonlighting shifts, regularly withdrawing funds from my personal savings, and funneling whatever I could to the corporation to cover the supplies to treat the patients and pay the overhead. Lucky for me, I discovered that Kraft Mac and Cheese still held some allure for my wife and son. I called Louie again: “Who’s Calvin? No,

July/August 2013

Little did I know that my journey into the business of a small medical practice as a community allergist would be in many ways the medical version of Tales of the Gold Monkey. – Sean Deane, MD

Koji is handling your file. Yes, it’s all here. I don’t know why Koji isn’t returning your calls. I don’t know who Koji’s manager is – maybe you can send a fax to Koji about the problem, and write at the top that you would like it to go to her manager...” “Oh, wait – it looks like part of your file went to Koji, and part to Calvin, but there is no way to tell which parts. I’ll escalate this.” I asked Louie why the system would send different parts to different people – “I’m not sure, we really aren’t trained on that system.” “Sorry, I don’t know who I’m escalating it to.” “No, I don’t have any contact information for the department that handles escalations; they don’t tell us who they are.” Scenes from Terry Gilliam’s Brazil danced in my head as I marveled, fuming, at the absurdity of it all. My concern was only heightened by the knowledge that, even if and when the elusive collation of the forms in question was accomplished, they were the very same ones rejected as erroneous months earlier by Todo. More weeks went by untiI, finally, I received the corporation’s new billing number together with a letter stating that the forms were all correct after all, and welcoming the practice to Medicare. From Koji. Approved by ... Todo. I’d had enough plot lines with this single contract application to fuel an entire full-length adventure episode in the tropics − in a hurricane.

With EHRs, perhaps we’re all flying in a fog without a map.

Navigating EHRs Having navigated through one storm, my Grumman Goose soon found itself in another: electronic health records (EHRs). HIPAA had rendered the billing system of my predecessor’s practice nonviable through regulatory requirements that, nearly overnight, “bricked” all of the office systems formerly in use. For years, essentially all of my clinical activity had been in a fully electronic environment, and I ached for a return to clicking instead of scribbling. To my chagrin, I discovered that many of the EHRs available to the small practice insert contract language that absolves the vendor of any but a token liability for breaches in patient

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privacy. After discussing the problem with some of my colleagues from other practices that were already signed up, hoping for another interpretation of the language, I found that in most instances, the contracts had been inked without any sort of outside legal opinion. In just one example, a “free” EHR that my colleagues had used turned out to have contracts that surrendered copyright for any notes placed in the chart to the EHR company, and granted permission to the EHR company to independently contact patients for “any purpose” once their personal information had been entered in the system. Of course, the 35 pages of legalese that contain this language are hidden from the unwary provider, with only a small print reference saying, “By clicking below, you accept our terms and conditions...” overshadowed by a large attractive button that proudly says, “Create my EHR.” According to the website, 150,000 physicians and counting have accepted such terms and conditions. I wonder how many of those 150,000 were aware of the contract details before clicking that button? To be sure, between federal HIPAA legislation and the proliferating “me-too” laws that state legislatures have inexplicably found necessary to throw in, the sheer complexity of regulations renders even seasoned attorneys and EHR companies bewildered. With EHRs, perhaps we’re all flying in a fog without a map. To my dismay, when I sent an EHR contract out for review, nearly $1,000 of billable hours were charged for the time the attorney needed to spend researching the law before they could even look at the contract. Similarly, as I was bewailing the contract language of EHR systems, a personal contact in the business told me, “We can’t keep up with all the individual state regulations, so we just send out our standard contract and wait for it to come back redlined.” For a large organization, that’s all well and good. Legal costs incurred in review are miniscule compared to the aggregate revenue, and a large organization is a big enough fish that the EHR companies are eager to modify

their contracts to make a catch. However, the Grumman Goose practice is not Pan Am, and a few key losses early on can be catastrophic. Solo and small group practices share the same mandate as large institutions to adopt EHR systems, but unlike large systems, small practices have virtually no bargaining power. Furthermore, I learned that the EHR vendors often carefully word contracts to ensure that there is no real recourse in law for breaches of contract or patient privacy that the vendor might commit. Legislation to protect the small practice from such predatory contracts could mitigate the problem, unfortunately, our elected officials have, thus far, chosen to stack the deck the other way, perhaps averting a conflict between the great powers of EHR companies and government by quietly surrendering those islands in the middle that Grumman Goose practices call home. Recently, in fact, the government has taken further action to lay blame for the actions of outside vendors squarely on the shoulders of the medical practice, even when those actions are beyond the practice’s control. The AMA described it thus in a recent article: “For example, if someone paid to shred patient files instead throws the documents into a trash bin and causes a breach, the practice also is subject to enforcement violations caused by that business associate...” (Lubell, J., HIPAA Gets Tougher on Physicians, amednews.com, posted February 4th, 2013.) The enormous scale of large medical organizations permits them to absorb this liability and move on. Not so the small practice, which would almost certainly be put out of business if the fines under existing statute were fully enforced for such a breach. Physicians in our society are perceived as rich and powerful, and it may be that few in the general public would rally around legislative measures to protect us from our vendors. These bumps in the road were single moments among many, and I am told they are a shared experience for other independent practices in today’s regulatory milieu. However, as those moments arose, they were dealt with,

and in the end, the practice and I both survived. I think private practice, as a whole, will continue to survive. I’ve had the good fortune in my career, thus far, to continue concurrent activity in a small practice environment, a large group environment, and an academic environment. Each has its benefits, each, its downsides. Yet, whatever the coming changes in healthcare bring, I’m confident that each will remain, altered perhaps, but intact in all the ways that mean anything. Why? Because we love what we do, and we will always find a way to do it. The true experience and privilege of medicine is simple, and it is universal. It’s the moment another person takes our outstretched hand, and we both know that there’s a chance to help. My first year of running a practice isn’t over yet, but a few things are certain. The engines will sputter again (and start again), and though there may be some political maneuvering in a changing time around our healthcare island, the white hats will eventually win for the greater good. But if anyone finds a one-eyed dog with a knack for fixing planes and a preternatural aptitude for navigating the U.S. healthcare system, please send him my way.

…we love what we do, and we will always find a way to do it.

staff@mountainsideallergy.com

July/August 2013

Book Review

Song Without Words Discovering My Deafness Halfway Through Life Author Gerald Shea, ISBN-13: 978-0-306-82193-6, Da Capo Press, 2013, 308 pages, $25.99

Reviewed 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.

I FIRST MET GERRY SHEA in 1960 when, as freshmen at Yale, both of us were selected as tenors by one of Yale’s many a cappella singing groups, called The Duke’s Men. We remained friends through all four undergraduate years and have been friends ever since. Gerry had a clear, accurate voice and was a natural “ham” with a grand sense of humor and an Irish gift of gab. But throughout our college years, neither I, nor anyone else who knew him, had any idea that he was markedly hearing impaired. That he subsequently went to law school and worked at Debevoise and Plimpton, one of New York City’s most famous and prestigious law firms, became fluent in French and eventually helped run the firm’s Paris office, as well as doing international contractual work for Mobil Oil, is quite astonishing. In May of 2012, my wife, Mary, and I visited Gerry and his wife, Claire, at their Paris apartment on rue d’Astorg. He had just submitted his final version of the book to the publisher and we celebrated with some champagne at their home and then dinner at one of Gerry’s favorite restaurants, Brasserie Balzar, on rue des Ecoles near the Sorbonne. Over dinner, in spite of the high level of ambient noise, we all successfully talked and listened as he spoke about his life as a hearing impaired person and how he came to write his book, which he dedicated to Claire. I have, of course, since read the book, as has Mary. Gerry had chicken pox at age six and recalls that soon afterwards, he sensed that many familiar words had become unclear, and sounds

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of wind or splashing water and birds and crickets had become dim or simply no longer were present. He developed tinnitus which he likened to an “immortal buzzing of locusts day and night in the summer, fall, winter and spring” and that condition further interfered with aural input. He learned to lipread to some degree, but that did little good in lecture halls where he might be seated quite a way from the speaker. Some teachers in grade school and in college and law school helped him one-on-one when they were made aware of his difficulty, but most could not or did not. Law school presented immense challenges, especially since most of the classrooms were large halls and the students were often seated alphabetically by last name, so he was usually quite far from the teacher’s podium. Plus there was a new vocabulary to learn. He coined the neologistic noun “lyrical” to describe what and how he was hearing, and gives the reader a very good sense of how he used these often nonsensical constructions to translate into standard English as well as French. He recalls some lyricals from law school lectures: “While thus protory is topical require sections in appliance?” / While thus?/ why this?/ why does?/ promontory is topical?/ (Ahah!) promissory estoppel/ require/ section/ actions/ “Why does promissory estoppel require action in reliance?” Ahah! And once, in a quiet moment with his girlfriend, after she had listened to him sing, she

told him she enjoyed listening to him sing, “I love two kittens,” or so he thought she had said. And then he sifted through the lyricals. ”Two kittens//kissin/lissen/listen?” Got it! Listen. And so he “juggled lyricals” to make sense of such academic materials and “intermittently got things straight.” His book, however, is not at all simply a recital of his personal struggles and triumphs as a hearing impaired person in the world of international law. He also gives us a concise review of the physics of sound and the physiology of the human ear and acoustic nerve and cortex. He writes with deep feeling about how the deaf have, through the ages, interfaced with the spoken word, and he has strong opinions regarding the use of sign language and mankind’s efforts to amplify sound. He reviews the history of education of and for the deaf, beginning in the 16th century with Juan Pablo Bonet, a Spanish priest, who developed a sophisticated sign language; and later, in the early 19th century, he details the efforts of Auguste Bebian, a teacher of the deaf in Paris, who strongly promoted sign language, and who influenced the American educator, Thomas Gallaudet. Gallaudet founded the (primary and secondary) American School For The Deaf in West Hartford, Connecticut, and Gallaudet University in Washington, DC, was later named for him. It is the only university for the deaf in the world, and American Sign Language is its lingua franca. But Gerry has little good to say about Alexander Graham Bell who strongly disbelieved in sign language and thought that “prelingually” deaf persons could be taught to speak intelligibly. It was Bell who was responsible for introducing Anne Sullivan to Helen Keller, and Gerry has a great deal to say regarding the Bell-Sullivan-Keller relationship. For the past 30 years or so, Gerry has used a variety of hearing aids, but has always eschewed cochlear surgery.

I last saw Gerry this past March in San Francisco where he had come during a coastto-coast book signing tour. Before I left the gathering, he asked to do a song with me, an ancient Civil War ballad called “Aura Lee” which we had sung numerous times in the Yale Glee Club. The tune is the same as Elvis Presley’s, “Love Me Tender.” He took the first tenor part, and we dropped the starting note a bit to make it easier on our septuagenarian vocal cords, and also make it easier for Gerry to hear. I took the melody line. We received polite applause from the assembled. I told him that I thought our duet sounded good, and he said, as far as he could tell, it did indeed. Read Gerry’s book. It is very informative and inspiring. And the next time you hear a cricket or the wind in the trees, or the distant honking of barely-visible migrating cranes, you might be more inclined to savor the moment. jmost119@aol.com

July/August 2013

Crossword Puzzle

Created by John Belko, MD

Answers on page 30. ACROSS 1 ________ andersoni, a vector for Rocky Mountain Spotted Fever 11 An abscess larger than a boil with more than one draining opening 18 Commonly used test to screen for autoimmune disease (abbr.). 19 Gram-positive branching, beaded, filamentous rod that is weakly acid fast. 20 ____-fuschin stain; Used to stain certain bacteria like Campylobacter fetus 21 Enzyme that transcribes single strands of DNA into single strands of RNA (abbr). 22 fibroepithelial polyp or skin ___. 23 Electronic Data Systems (abbr). 24 _____ Law- TB of the peritoneum is always associated with pleural TB 26 __sign; Inability to extend the leg when lying with the thigh flexed on abdomen 27 ____ Sign- Diminished sensation in the testes and scrotum in tabes dorsalis 28 ____ Fly- vector for 72 down 29 Genitourinary (abbr). 30 Pertaining to the ear 31 Equal Rights Ammendment (abbr). 32 First continuosly cultured human malignant cells (cervical carcinoma). 34 Used to treat Tylenol poisoning (abbr). 35 Neurotransmitter and used in the treatment of Parkinson’s Disease (abbr). 36 Prot. enables influenza to bind to cells via its attachment to sialic acid 38 ___ and parasite exam performed on stool. 40 ____ Law; An early description of the pattern of X-linked inheritence 42 Severe mosquito-transmitted virus in the US with 33% mortality and high morbidty 44 ___-Sternberg cell 47 Major provider of medical research grants (abbr). 48 ____ cells have potential to develop into many different cell types in the body 49 One third of the world’s population are infected with this bacterium (abbr).

50 Peyer’s patches are part of this collection of lymphatic tissue (abbr) 51 ____-Najjar syndrome. 53 to reduce a fracture by moving the bones back into a normal position 56 Major coronary artery (abbr) 58 oculus uterque (abbr). 59 A type of inflammatory bowel disease 62 ____ vaccine was the original poliovirus vaccine 65 __Effect; Paradoxically reduced antibacterial effect of penicillin at high doses 66 intravenous drug abuser 70 Bordetella____, causes a highly contagious disease also called whooping cough 74 ____ burgdorferi 75 Organ of sight 77 Eosinophilic Esophagitis (abbr). 78 Medical Assistant (abbr). 79 Artificial yeast construct used to map complex genomes or clone large genes (abbr)

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80 Virus identified thought to cause hepatitis now not felt to cause disease 81 Alternative to total proctocolectomy w/permanent ileostomy in UC pts (abbr). 82 ____ Death (Y. pestis). 85 Transverse ___; 86 Influenza is an example of this type of virus 89 Stem cell transplant (abbr). 90 allantoic ____ becomes the urachus in humans 91 Rodent borne virus which causes an aseptic meningitis 93 satisfy fully 97 Pertaining to the bladder 98 An unpleasant feeling that is conveyed to the brain by sensory neurons 99 Known as a chemotactic cytokine but may also have a role in host defense 101 Dark and tarry stools associated with upper gastrointestinal bleeding

104 Insect acts as intermediate host for the cestodes Raillietina spp 105 Vehicle for cutaneous infections with Sporotrhrix schenckii 107 Blood type 108 Heal 109 Continuing education (abbr). 110 Extrinsic allergic bronchioloalveolitis (abbr.) now hypersensitivity pneumonitis 111 Nitric oxide (abbr). 112 Gonococcus (abbr). 113 The cough associated with croup sounds like the bark of a ____. 115 Reactive airway disease (abbr). 116 A popular term for a collimation scan interval in CT or equivalent in MRI 117 Influenza-like illness (abbr). 119 Commonly used over the counter product to treat head lice 121 Low density lipoprotein (abbr).

122 Orange County (abbr). 123 Saccular, fusiform, or dissecting are types of this (abbr). 124 Measures the time it takes for blood to clot comparing it to an average (abbr). 125 Along with 8 Down, the causative agent of syphilis DOWN 1 ____ Field microscopy used to look for spirochetes 2 Common cause of aseptic meningitis in infants and children 3 Rheumatoid Arthritis (abbr). 4 Substance capable of inducing a specific immune response 5 Presence of this enzyme helps differentiate S. aureus from other staphylococci 6 A tracing representing the heart’s electrical action (abbr). 7 Chemical symbol for sodium 8 Along with 93 Across, the causative agent of syphilis 9 Sphincter of _____ 10 Antimicrobial produced by Nocardia also used to assess platelet function 12 ______ disease is a synonym for altitude sickness 13 The unit for the dose absorbed from ionizing radiation 14 Footling _____ presentation is where the feet are the presenting part 15 Ubiquitin like (abbr). 16 Loud, unpleasant, unexpected, undesired sound 17 Type of renal cell carcinoma with chromosome 3p deletions, mutations of VHL gene 24 A hollow concretionary or nodular stone often lined with crystals 25 Rotavirus is an example of an ____ virus 33 ______virus is a cause of gastroenteritis with starlike pattern on EM imaging 37 First noble gas to be discovered- Atomic weight is 39 and atomic number is 18 38 A combining form meaning tumor; ___gene 39 Apnea-hypopnea index (abbr.). 41 Symbol for selenium; element with antifungal properties 43 An inherited connective tissue disease causing blistering of skin (abbr). 45 Early adopter (abbr).

46 Syphillis and Marfan’s are causes of aneurysms in this section of aorta (abbr). 52 Very strong wind 53 A contagious infestation of the skin by the human mite 54 ___ alkaloids; Once used to induce uterine contractions and control bleeding 55 Aldolase reductase inhibitor pulled off the market 57 Dead on arrival (abbr). 60 Species of borrelia transmitted by soft body ticks causing relapsing fever 61 A ____ mutation does not change the amino acid sequence encoded by a gene 63 Syndrome characterized by craniosynostosis and syndactyly of all the fingers 64 ___ cycle 67 It has the longest subarachnoid course of all the cranial nerves 68 Direct antiglobulin test (abbr). 69 Parasitic infection transmitted by 28 across 71 Lipoglycopeptide antimicrobial used to treat complicated skin infections 72 Ceftriaxone is often administered this way when there is no peripheral IV (abbr) 73 Contagious bacterial infection that is a frequent cause of food-borne outbreaks 76 Yeast artificial chromosomes (abbr). 83 Agents inhibiting this enzyme are used to control blood pressure (abbr). 84 ____-Feil syndrome 87 Known as a chemotactic cytokine but may also have a role in host defense 88 ___ bacteria require the presence of molecular oxygen to grow 92 Alternative to milliliter (abbr). 94 Obstructive sleep _____. 95 asparagine (abbr). 96 Extrinsic allergic bronchioloalveolitis (abbr.) now hypersensitivity pneumonitis 100 Cytosine arabinoside (abbr). 102 Hemorrhagic fever virus 103 ____ Body 104 Pertaining to, or affecting, a limb 106 Device used to manage cervical spine injuries 114 Adenosine diphosphate (abbr). 118 Hawkeye state (abbr). 120 HLA-__; MHC class II cell surface receptor found on antigen presenting cells

The Volunteer By John Loofbourow, MD An aged man, wasted yet tall, volunteered for the operation. We surgeons, four in all, were standing at our station. He revealed no history of ills or operations, and made a mystery of past and occupations. If one who’s lived so long’s a treasure trove of time, to hoard it ‘til it’s gone must be a sort of crime. What had he seen or done; That never should - or will be known to anyone the day his voice is still? Did he like to choose truthfulness to lies? And when he was accused, make amends, not alibis? He didn’t say. Yet he gave permission to cut his body, through limitless incision as if it were his duty. We scanned the manual for detailed instructions. Naomi grasped her scalpel to start the hand dissection. And on his wrist we read words and numbers in a line. In faded black they said: USArmy ‘42-‘69 His cadaver stiff and thin taught Anatomy that day though soaked in formalin. Why? He didn’t say. john@loofbourow.com

July/August 2013

SSVMS Alliance Names 2013 Grant Recipients By Barbara Andras and Celeste Chin

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 SSVMS ALLIANCE IS A 501c(3) non-profit organization dedicated to improving the quality of health in our community through education, community health project funding and granting scholarships to those seeking careers in the medical field. With the state and national alliances, we develop awareness, action and advocacy for quality heath care legislation, and we actively participate in their projects. This year the Alliance is pleased to announce the recipients of our 2013 grants. SSVMSA received 26 grant proposals totaling $160,000, and was able to fund $27,175. The following are the award winners: A TOUCH OF UNDERSTANDING — Funds will be used to provide educational materials for 5,250 students in the Sacramento region who participate in the anti-bullying workshops with special focus on those with disabilities. CCHAT CENTER — Provides funding for follow-up auditory screening for up to 150 lowincome infants per year who failed their initial hearing exam at birth. Early detection of hearing disabilities can result in successful treatment to improve hearing, which is paramount for the ability of children to succeed in school. SENIOR GLEANERS — This grant will fund a new “Adopt-A-School Program” in the Robla Elementary School District in Sacramento County, providing emergency food for families, all of which are at or below poverty level. Senior Gleaners’ Adopt-A-School Program (separate from the SSVMS teaching program of the same name) provides food to needy school districts, in this case giving at least 26,315 pounds of emergency food to 2,400 students. FIESTA EDUCATIVA — Workshops provide access to services for Latino families with a

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loved one with disabilities. Grant dollars will be used to cover the costs of the events which benefit up to 500 family members and caregivers. PEOPLE REACHING OUT — This grant will support the “My Smile” Project which educates and engages girls ages 10-14 years old about the dangers of alcohol and drug use. Mentors, older youth from their community, will guide up to 600 young girls. ROSEVILLE HOME START — This organization transitions homeless families into affordable, permanent housing. Funding will provide two fitness machines for the onsite gym program which will benefit 50-100 adults who will attend classes one-two times per week over the course of one year. CSERF (Community Service, Education and Research Fund) — Funding will support the Sierra Sacramento Valley Medical Society’s “Walk with a Doc” program, taking place in various community parks, improving the health of the many participants. We have also announced our scholarship awards for students attending nursing school. Besides maintaining high academic standards, these students have participated in community service. We awarded $3,850 to five deserving nursing students from American River College, CSU Sacramento, Sacramento City College and UC Davis. We are looking forward to another year of promoting health in our community. If you would like to join our membership, we invite you to visit our website: www.SSVMSA.org. Our membership is open to physicians, spouses/ partners and friends of medicine. bandras@surewest.net

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For more information on these important benefits, and the special SSVMS First-Time Buyers program, please contact Marsh at: 800-842-3761 or email us at CMACounty.Insurance@marsh.com

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim. Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

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Hobbies of Some of Our SSVMS Members Sandra Hand, MD – Re-enactments I subscribe to the notion that all work and no play makes for a dull conversationalist at a party. It can also make one a bit lopsided. Years ago a colleague in the Walnut Creek area approached my pediatrician husband and me about joining with them in the Society for Creative Anachronism (SCA), at that time a 20-year-old re-enactment organization that strives to preserve and bring the ancient ways and crafts alive. The time period for the re-enactments spanned the years from 900 (early Viking) to Renaissance periods. At the time we had two young boys who were more into Gameboys than page boys. A family playing together is a happy family, we thought. We started going to Renaissance fairs, the closest being in Vacaville. We explored our personal ancestral roots and settled on being a Scots-Irish family for those sometime events. Kilts were fairly easy costumes to make and wear. But it didn’t stop there. Both my husband and I have strong history interests and are welltrained researchers. The guilds and research attracted us. We eventually joined the SCA and more costuming ensued − and crafts − and music. My husband started building and playing harps. Being a harpist created a great backstory for the personas we brought to the fair. Eventually the boys grew up − tolerating our playing and extracurricular activities, though one voted with his feet finally, to not leave the 20th century and all things technological ever again. In 2003, I sustained a back injury from which it was difficult to recover. Yes, the bracing in the costuming helped, but rehabilitation from the surgery was slow and uneven ground became a real barrier to walking in and around

the re-enactment sites. One day the local newspaper ran an ad for costumed street docents to help out in Old Sacramento. Nearby parking and flat streets beckoned and I needed to walk for exercise. So we joined the Old Sacramento Living History Program and adopted a new era − 1849-1872, Gold Rush and Early Railroad days in Sacramento City, as it was then known. “Bringing the Past Alive” is the tag line for the organization. Being physicians and accustomed to meeting strangers every day and putting them at ease, the street docenting came naturally and the Renaissance fair experience had nurtured the latent ham in us both. We spent about a year researching various people who had lived and walked around in Sacramento. Eventually we were asked to portray Judge Edwin Crocker and his wife Margaret who, together and with Central Pacific railroad wealth, created the Crocker Art Gallery as the first intentionally public art gallery on the West Coast. My husband has a natural talent for the role, having a lovely full beard. He also has been a prominent Father Christmas for many years now during Christmas

July/August 2013

Dr. Sandra Hand

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.

Dr. Joanne Berkowitz. below. Sacramento Bee Photo/Randall Benton

season. This was not an uncommon Christmas pastime for Victorian business and professional men post Charles Dickens’ popularization of the Christmas season as a time of gift giving and treasuring children instead of an excuse merely for hooliganism and public drunkenness. Margaret is there by his side keeping order and handing out candy sticks. Though Father and Mother Christmas (as most 21st century visitors call her) do advise broccoli, apples and carrots for stocking inclusions, the kids predictably groan at this! My husband switched from harps to fiddles and squeeze boxes and tin whistles. And following in the spirit of the judge, he has started a singing group in which Margaret participates happily, just as she did in her own day. The Crockers were also early members of the Civic Music Association as well as art collectors. Margaret requires a certain level of uppercrust dress, and researching her jewelry has led me into many antique stores and hours of web-searching for just the historically-correct look. Eventually, I wrote a guide for appropriate period-correct jewelry for our members available on our website OSLHP.com − much more interesting than all the policy and procedure manuals I was writing for my county medical director responsibilities. Since the Crockers didn’t actually arrive

in Sacramento until 1852, we needed Gold Rush characters for the big Gold Rush Days celebration. Enter JD Borthwick, another of our split personalities. (Google him and you may encounter a misdirected picture of my husband due to some strange Wikipedia shenanigans. A good lesson on the reliability of that source! We quickly corrected the site.) This persona, historically a second son of a Scottish physician and baron who roamed around the Gold Rush area drawing pictures for the London papers, also uncovered in my husband an uncanny talent for games of skill and luck. (His skill, your luck). For me, Nancy Officer, a many time great ancestress of mine who made the overland trek on the Oregon trail, also appeared to take her place on the historical boardwalks as a very proper lady in her aprons and calicos. Our organization has a passion for historical accuracy in costuming and behavior, and we give it much time and energy. It pays us back in wonderful companionship and unending intellectual stimulation as we uncover new aspects of that time and its folks. So if you wish to brave the heat and the dust, just as the Sacramento City denizens did in their time, wear hats and adequate sun protection and come down and have tea with Nancy or Margaret and try your luck gambling with JD during Gold Rush Days. Or join us for a romp through ghost stories from the Sacramento archives during Ghost Tours in October. Or just visit any second Saturday around the Museum grounds in Old Sacramento and you will undoubtedly encounter one of our ilk ready to take you back to Sacramento’s early days.

Joanne Berkowitz, MD – Bookbinding I am excited about my newest hobby! I have been studying bookbinding with a master binder for nearly two years now. I spend a halfday a week in his shop and then work in my own workshop the rest of the week. I spent two weeks in Telluride, CO, at a bookbinding school last year and a week in San Francisco at a binding restoration course, and am hoping

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Above: Dr. Thom Atkins and his stowaway. At left is Dr. Julita Fong.

to return this year to Colorado for a paper conservation course. I restore old, damaged and antiquarian books, mostly for the Friends of the Sacramento Public Library, but also for my friends. It’s a lot like putting people back together, but without the blood or lawyers!

Thom Atkins, MD – Sailing Sailing – that’s my hobby, I share a 35-foot cruiser in the Bay Area and try to sail at least once a month. When I am out there, everything else falls away. The wind, the ocean, and sometimes another boat is the only thing I attend to – there isn’t anything quite like it. Last summer we had some ocean adventures down to Capitola and back. We even encountered a stowaway, who hitched a ride with us for 20 miles or so. Sailing teaches you patience and planning – and affords an experience of the world not seen any other way.

Julita Fong, MD – Fishing I did not start fishing till I was 62. But I can’t think of a better hobby! In 2012 my fishing buddy and I brought home 51 salmon, 48 albacore tuna, 6 halibut, 11 ling cods, 45 other bottom fish, and 290 Dungeness crabs. Contrast this with hitting a golf ball − frustration at most.

July/August 2013

Dr. Jason Bynum, above.

Jason Bynum, MD â&#x20AC;&#x201C; Woodworking

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In 2010, my wife and I moved to California from Colorado to take a position as an inpatient Child/Adolescent Psychiatrist here in Sacramento. In the process, we used most of our liquid funds in the down payment and had sold most of our furniture in Colorado to ease the moving process. Nice house with blank walls and no place to sit. When I saw the prices of end tables, coffee tables, shelving, chairs, and decorative pieces, I quickly searched for a more cost efficient manner to furnish our home. Enter my journey into woodworking. This may be how I started out with my hobby, but it has taken on a significantly deeper meaning to me. In our profession as health providers, I take pride in the help I give, but the

simple fact is no matter how hard I work, there is always more to do. I think, evolutionarily, we are programmed for more tangible rewards for our labor. Woodworking is this outlet for me. After a weekend of sweat, sawdust, and hopefully no injuries, I have something to show for my labors. Positively, my joints are becoming a little more square, the angles have fewer gaps, and the finishing is getting less blotchy. It is physical, tangible, and visual. I think my gift to society is the knowledge I have gained in years of education, but my gift to myself is a nice new mahogany end table with mortise-and-tenon casing. And Iâ&#x20AC;&#x2122;ve only caught my table saw one time, losing a small dent in my first digit. My wife tells me I can only count to nine and seveneighths now.

Stayin’ Alive: My Treatment for Hep C By Dr. J.R., a personal story MY WIFE AND I HAVE EMERGED through the “treatment tunnel” onto the other side of the mountain. We have run the gauntlet. The toxic effect of 28 weeks of Hepatitis C therapy1,2,3 eases daily. Going away is the constant salted, silver foil taste in my mouth, dry mouth, low-grade nausea, anemia that caused lightheadedness and shortness of breath from brisk walking, constant itching all over, mild insomnia, and periodic trouble concentrating. My body’s natural oil is returning to the sandpaper skin of my hands and feet. My flaky nails are starting to grow normally. Weekly aches and pains are fading, and I no longer need oatmeal baths. Strength and endurance return to my muscles as does my sense of virility. I lost 22 pounds from 210 to 188, but not all of it was burdensome fat. As I write, there is no genotype 1B Hep C virus detectable in my white man’s body, which, as luck would have it, is empowered by my Il28B genotype CC.4 My liver inflammation tests, AST and ALT are normal for the first time since 1971, when I was infected by Hep C from drawing blood on a patient as a doctor in training. We had dangerous blood draw needles then, and some blood transfused into patients was purchased from needle-sharing IV drug addicts. My patient had received two units of transfused blood when I drew her at U of M hospital. Hopefully, we have avoided a miserable death by liver failure. My tests for liver cancer remain negative. The early cirrhosis found on my liver biopsy may start to resolve or not get worse, and my platelet count, now below 70,000, and low white count, at 1,000 absolute neutrophil count,5 will increase.

This article concerns what I required to successfully endure Hep C treatment, having abandoned treatment in 1999 when it was too toxic for me and given the stresses in my life at that time. First, we had hope for a cure. To increase my chance of success, I added pretreatment with complementary herbs to boost my immunity,6 exercised to stay strong as long as possible, and, during treatment, swallowed vitamins B-12, folic acid, D, and E daily. My docs agreed that I qualified for disability during treatment. My employer granted me a leave of absence from full-time work, but without any guarantee of a job when I returned. (Not to worry, Obamacare is the full employment act for primary care). My wife is retired and dedicated to help me. I had enough money to pay my bills until I could work again. My home was in good repair. I had heat, hot water, a heating pad, warm clothes, a refrigerator, a bathtub, food I could tolerate, and, most important, a loving wife. I had given up alcohol decades ago, or I would be dead already. My daily life was relatively stress-free so I could focus on taking my pills regularly on time. I gave up travel in airplanes and avoided crowds and little children because my white blood count was dangerously low. I stayed off my horse. I kept a daily log and used pill boxes to avoid missing doses. I had health care insurance − Medicare part C assigned to Kaiser Permanente. The three drugs cost $7,208.70 per 28 days, plus the cost of Procrit − up to 20,000 units weekly to treat the anemia. I paid small co-pays for drugs, visits to see my nurse practitioner monthly, and my GI doc twice during treatment. KP paid for 28

July/August 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.

weekly blood tests to monitor my blood counts, and to measure the viral load monthly. The total cost of treatment is expensive, but cheap over a course of a lifetime. Thanks to Merck and its inventors of Victrelis for saving my life! Thanks to KP for helping me so much! Thanks to President Lyndon Johnson and Wilbur Mills for enacting Medicare! Thanks to my dad, a WWII vet, who helped save our way of life! To reduce the speed of muscle loss, I walked on days I felt strong enough. I bought a new down hooded jacket with extra liner to keep me warm when others were outside in shorts on a brisk winter day. Some days I wore it inside, too. I avoided situations when my irritability might damage relationships. I was careful with e-mails.

Remember When?

Friends brought me movies to watch. Interesting books, books on tape, and music helped pass the time fruitfully. I read all the back issues of JAMA and Scientific American. I cleaned the garage and gleaned old business papers in storage. There are over 3.2 million people infected by Hepatitis C in the US.7 The new treatment works well for most folks who take a full course of treatment. But one must tolerate it. If treatment is abandoned, resistant virus can emerge. I was lucky; the treatment worked so well that my doc allowed me to stop it after 28 weeks, instead of 48. The longer course of treatment would have been even tougher to endure. But endurance is better than untimely death from liver failure. I have no faith in a liver transplant because it is reinfected rapidly and one must take immunosuppressants. My two choices were clear. Endure the treatment or die young and ugly. I took the treatment and now tell the tale. I have no evidence of infection for the first time in 42 years, following an entire career as a physician. My new favorite song is “Stayin’ Alive” by the Bee Gees, and I am trim enough to look good swing dancing. It is time for dance lessons and the next Sonoma Red and White ball!8 Good luck to the readers and their friends who need treatment. You can take it if you are committed and have help. References 1 Pegasys once a week www.pegasys.com/patient/for-patients/ expect/how/proclick/index.html 2 Ribavirin, 600mg every 12 hours archives.who.int/eml/expcom/ expcom15/applications/newmed/ribaravin/APP_REBETOL.pdf 3 Victrelis 800 mg every 8 hours www.merck.com/product/usa/ pi_circulars/v/victrelis/victrelis_pi.pdf 4 www.natap.org/2011/HCV/021411_02.htm 5 www.everydayhealth.com/health-center/neutrophil-definition. aspx 6 www.docmisha.com 7 www.cdc.gov/hepatitis/hcv/hcvfaq.htm 8 svgreatschools.org/redandwhite.html

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Hepatitis C Cure with Oral Medications A Dream Coming Through

By Lorenzo Rossaro, MD SOME BABY BOOMERS (born between 1945 and 1965) were ecstatic to hear that late this year or the beginning of next year, the FDA may approve an oral regimen without Interferon for the treatment of Hepatitis C. For over 20 years, patients have suffered the side effects of Interferon injections: first by itself with a paltry less than 10 percent chance of cure, later with the addition of ribavirin (with its own side effects) and a cure rate of 50:50 if you were lucky, and now with protease inhibitors and a more promising 60-80 percent cure rate. Still, as described by Dr. J.R. in his personal fight with Hepatitis C in this same issue of SSV Medicine, it is not a benign treatment. At last, the new era of Interferon-free therapies for Hepatitis C is around the corner! Even more exciting, the new oral regimens may be more efficacious, while having significantly fewer side effects and a shorter duration of treatment. One of the pharmaceutical companies in the running for the best products to arrive first in the market is starting a phase three trial comparing eight weeks versus 12 weeks of therapy. This length is much shorter than current standard of care, which spans from 24 to 48 weeks of treatment, and does not require Interferon injections. The trial design includes arms with as little as a single pill a day, which contains two direct antiviral agents, as opposed to the current 11 to 15 pills a day. In phase one and two clinical trials, this new drug has shown a greater than

90 percent cure rate for Hepatitis C genotype 1, which is the most difficult to treat and most common in the U.S. Hepatitis C affects at least five million Americans and 170 million worldwide. It is the most common cause of cirrhosis and liver cancer in the Western world, and the most frequent indication for liver transplantation. Liver cancer is on the rise because of the epidemic in the Baby Boomers in the 60s-80s, and the “lag” time of 20-30 years from infection to cancer. And it is expected to continue to increase in the next 10 years. The good news is that liver cancer can be prevented by eliminating the virus before the liver becomes cirrhotic, and even then, the risk can decrease by a factor of 10. The other good news is that viral clearance, in the absence of other liver co-morbidities (i.e. alcoholic on non-alcoholic liver disease, co-infection with HIV or with Hepatitis B, etc.), is associated with partial or total reversal of liver damage, including reabsorption or clearance of scars as seen in repeat liver biopsies of patients before and after therapy. The bad news is that the results of clinical trials do not always translate into the same level of success when we look at real world patients seen every day in our clinics. It is not by chance that only one or two patients out of 10 qualify for clinical trials due to extremely selective inclusion and exclusion criteria. The pharmaceutical companies tend to experiment in the most “fit” patients, with few

July/August 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.

co-morbidities and less advanced disease. Unfortunately, the typical patient I see in clinic every day often has poor means of transportation, depression or bipolar disorder, problems with addictions, and other co-morbidities that often exclude him/her from participating in clinical trials. Clinical trials also tend to exclude patients with advanced liver disease, such as cirrhosis. This is ironic as those patients have the greatest need for a cure â&#x2C6;&#x2019; in order to avoid liver failure, liver cancer and liver transplantation. It is my hope that in the future, the FDA will mandate the inclusion of the most difficult-to-treat patients in clinical trials in order to better reflect efficacy and safety in the real world. The other downside is the cost. Treatment now costs about $100K, including medications, monitoring, and side effect management. The new drugs will certainly cost more. I can only imagine the formula for establishing the cost. It will need to consider the cost of developing these drugs (one company purchased a drug from another company for $11 billion), and the benefits to the patient â&#x2C6;&#x2019; such as fewer side effects, increased efficacy, ease of administration, prevention of complications, survival, and quality of life. Most promising, though, is the possibility that a potentially deadly virus will be cured

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with a few months of therapy, as opposed to viral suppression and possible life-long therapy as seen with HIV and Hepatitis B. If we use this comparison, no matter what the cost of Hepatitis C therapy will be, it will most likely be less than life-long therapy for Hepatitis B or HIV. Certainly, with the advent of Interferonfree regimens, many patients who know how bad Interferon can be and have refused to start therapy in the past, will soon come back to us and ask for therapy. Many of those who failed Interferon will come back and want to try the new oral regimens. Still, the vast majority of patients with Hepatitis C, perhaps up to 70 percent, do not even know they have it. These patients are the ones targeted for screening. A recent report published in the NEJM estimates that the minority of Hepatitis C patients in the U.S. are diagnosed, referred to care, and treated (see chart). Although the estimates of the total number of Hepatitis C patients in the U.S. varies from three to five million, there is a general agreement on the percentage of the undiagnosed (never tested, ~50 percent), diagnosed (HCV Ab+ with/out HCV RNA confirmation, ~34 percent) but without referral to care, treated but failed therapy (~8 percent), and treated successfully and cured (~8 percent).1 If primary care providers embrace the CDC recommendation to offer screening to all Baby Boomers, another estimated 800,000 patients will be diagnosed in the next few years.2 With shorter, safer, and more successful therapies lasting only two to three months, many patients will ask for treatment and many lives will be saved. lorenzo.rossaro@ucdmc.ucdavis.edu References 1 Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. NEJM 2013;368(20):1859-61. 2 Rein DB, Smith BD, Wittenborn JS, Lesesne SB, Wagner LD, Roblin DW, Patel N, Ward JW, Weinbaum CM. The cost-effectiveness of birth-cohort screening for Hepatitis C antibody in U.S. primary care settings. Ann Intern Med. 2012 Feb 21;156(4):26370.

A Posit on Medical Decision Making “Medical decision making based on personal experience at the bedside should take precedence over medical decision making using population-based guidelines or so-called evidence-based medicine.”

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 the SSVMS Board of Directors. Results: 24/ Agree – 37/Disagree. Commentary follows: Two quotes from Hippocrates (c. 460 BC – c. 370 BC): “There are in fact two things, science and opinion; the former begets knowledge, the latter, ignorance.” “Life is short, and Art long, opportunity fleeting, experience perilous, and decision difficult.” −Gregory Rogalski, MD Medicine is not a pure science. The legal profession has tried to make it so for years without success. Now, in the name of measuring cost effectiveness, government and administrations are again pushing for science as the only criterion for measuring success. This begins the “dumbing down” of medicine, because everyone will be measured by the same science-based criteria, making checking boxes the measure of excellence. −Gregory Joy, MD Very bad to be against guidelines. − Mohammad Kabbesh, MD While we all like to believe our “gut” reactions are correct and our experience should trump, there are many examples that show using the evidence results in better outcomes for our patients. This goal of better patient care should take precedence over our feelings that we know best. That does not mean that there is no role for clinical judgment. It is an art to know who is sick and who is not, to put

the pieces of the puzzle together, arrive at the correct diagnosis, and treat our patients with care and compassion. Decision support based on evidence-based medicine takes away none of this. −Margaret Mentakis, MD I personally feel that medical decision making should be based on the theoretical knowledge and practical clinical experience that the decision-making physician has and rendered with review of evidence-based medicine. (Remember evidence-based medicine is a “guideline!”) −Elisabeth Mathew, MD I agree with both statements – depends on the circumstance. −Julita Fong, MD I never saw a patient named “population.” All medicine is personal. Guidelines are helpful but not specific enough for an individual patient. Evidence-based medicine probably began before the time of Asclepius. The evidence is more detailed, but the paradigm has not changed. −Gerald Rogan, MD I agree in general terms. Doctors are trained not only by their formal schooling and attendings, but over time. Their clinical decisions are informed also by their many observations over years of practice. It is helpful to be guided by the experiences of others, as embodied in published studies as a starting point and guideline to focus thinking. But as each individual patient presents with uniquely personal life circumstances and combinations of co-morbidities, as well as individual expressions of those physical challenges, the treating physician needs to discern which of the available modalities will address THIS patient’s July/August 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. 25

…if you wanted to practice so a physician would want you to take care of his family, the key is to know your limitations in knowledge and experience…

needs. The studies yielding “evidence-based” information only present statistically-modeled patients, not your patient. In my opinion, the best doctors treat according to their discernment of the whole patient. In my early days, we called this “holistic” medicine. Now I think it is just common sense. −Sandra Hand, MD This almost doesn’t merit discussion – if we consider ourselves to be scientific and rational physicians, and have any respect at all for the scientific method, we have to accept and respect new evidence and adjust our behavior and practices accordingly. Any single experience at the bedside may inform our judgments, but is too subject to all the unique variations from one individual to another to rely on that alone or over the evidence of many patients or whole populations. −Francisco Prieto, MD The physician should be able to decide based on personal experience as applicable. Evidence-based medicine is great if available. However, some of the “evidence-based medicine,” especially in pediatrics, is underpowered. −Ernesto Rivera, MD Medical decisions are often inaccurate or information available is incomplete to make accurate decisions at the bedside or clinic rooms. Population-based and evidenced-based care provides the most consistent quality of care that can be provided without personal or patient bias. Guidelines provide the tools to provide consistent care when used in practice. Guidelines do not dictate that this is the only care that can be provided. Exceptions to care outside the guidelines can be provided when discussions about care are well documented in patient charts. −Rajan K. Merchant, MD Completely disagree. −Anne Igbokwe, MD When I was teaching, I made the medical students unhappy when I told them, “The best education we can give you in two years is a rational approach so you won’t kill too many patients when you graduate!” My orientation to the residents was titled, “How to be a doctor’s doctor,” when I explained if you wanted to practice so a physician would want you to take care of his family, the key is to know your limitations in knowledge and experience and thus when to refer. So my answer to Sierra Sacramento Valley Medicine

the posit is: Medical decision making should be individualized based on the physician’s understanding of his/her limitations in terms of actual experience and how up-to-date he/ she is in evidence-based management of the presenting problem. −Geoffrey Woo-Ming, MD There is not a best answer. I identify four factors that favor scientific guidelines and evidence-based medicine over personal experience and the art of medicine. 1) The explosion of medical data and knowledge. 2) Reimbursement reduction by payers for physicians’ time. 3) Significant reduction of work hours for physicians in training (i.e. less experience) 4) Less responsibility for a patient by a single physician (less off hours coverage and hospitalists). Little time is available to understand the uniqueness of a patient; physical examination is very cursory. I learned at my 50th reunion that most of the time for bedside rounds at Stanford is spent in front of computer screens. A medical colleague and his wife taking their first-born infant to be seen recently were unnecessarily troubled by being abruptly told of possible serious and rare diseases the gland swelling may represent. The traditional physician-patient relationship and rapport is vital to our profession. −Richard Park, MD I disagree with a caveat, while I disagree with the statement as it stands. I do agree that EBM has, by some, been taken to such an extreme, that therapies are not tailored to fit patients and sometimes, that can be detrimental. We must take BOTH experience AND evidence into account when deciding on optimal treatment for patients. −John Posten, DO I disagree, in general. When we have a patient that fits the inclusion criteria for a massive population-based, randomized, controlled, double blind, multicenter trial, then we should rely on the conclusions of said trial (or national guidelines based on said trial). However, unfortunately, there are many studies that will never happen due to cost, ethical issues, and other feasibility obstacles. For questions that lie in that realm, personal experience and anecdotal evidence is all one can go on. Consulting the literature is always recommended. −Don Udall, MD

Volunteers Receive “Health Care Heroes” Recognition By Chris Stincelli, Associate Director THE SACRAMENTO BUSINESS JOURNAL has honored SPIRIT hernia surgeons Drs. Ben Hunt, David Kissinger, Christian Swanson and John Young, and SPIRIT volunteer, Ophthalmologist Dr. Richard Jones, as 2013 Health Care Heroes for giving selflessly of their time and expertise to help the underserved in our community.1 Sacramento Physicians’ Initiative to Reach out, Innovate and Teach (SPIRIT) was established in 1995 as part of the Society’s Community Service, Education and Research Fund (CSERF), a 501(C)(3) non-profit organization that seeks to improve access to health care for those who are not eligible and cannot afford health insurance. The hernia surgeons, Dr. David Kissinger, from The Permanente Medical Group, and Drs. Ben Hunt, Christian Swanson and John Young, from the Mercy Medical Group, each perform approximately eight free hernia repair surgeries each year for SPIRIT patients. They provide preand post-operative care to the patients in their offices, and the surgeries are performed in their respective hospitals, which support their efforts by donating the necessary support services and staff. Dr. Young was one of the founders of the SPIRIT Hernia Repair Program in 1995. He was joined by Dr. Swanson in 1996, Dr. Kissinger in 1999 and Dr. Hunt came on board with SPIRIT in 2012. Together, the surgeons have performed over 380 hernia repair surgeries for SPIRIT patients, and over 66 percent of the patients have returned to work following their surgery. Ophthalmologist Dr. Richard Jones, in

addition to running his own practice with another physician, provides free cataract screenings and surgeries through the SPIRIT program. Patients are seen in his office for preand post-operative care and the surgeries are performed at Mercy General. In 2009, Dr. Jones helped Sacramento County institute diabetes retinal screenings by assisting the SPIRIT program in donating $10,000 to buy a Digital Mydriatic Retinal Camera. The screenings are performed at the Sacramento County Primary Care Center and then sent to Dr. Jones’ office to be read. To date, he has screened 891 patients for diabetic retinopathy. As SSVMS past president, Dr. Jones has been a leader with SPIRIT since its inception in 1995. He believes it is a physician’s duty to volunteer. Through SPIRIT, Dr. Jones was involved in initiating a consortium of all major local health care systems and institutions to coordinate reliable and consistent outpatient clinics to treat the uninsured. Congratulations to our volunteer physicians for their tireless work on behalf of the SPIRIT Program. Interested in becoming a volunteer with the SPIRIT Program? Contact Kristine Wallach, Program Director, at (916) 453-0254, or kwallach@ssvms.org. You can read more about the programs offered through CSERF at www. ssvms.org/programs.aspx cstincelli@ssvms.org 1 www.bizjournals.com/sacramento/print-edition/2013/05/24/ volunteer-spirit-hernia-surgeons.html

July/August 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.

Health Reform−Physicians Leading Change By Paul R. Phinney, MD, President, California Medical Association

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.

AS I AM SURE MOST OF YOU are acutely aware, the medical profession in our country is undergoing rapid unprecedented change. In a little more than five months, major provisions of the Patient Protection and Affordable Care Act (ACA) – the driving legislation behind the national effort for health care reform – will be implemented, undoubtedly reshaping the national system for delivering care for years to come. Some of you have already felt the effects of the ACA in your day-to-day practice. Perhaps you have treated a patient whose only avenue for coverage was a temporary high-risk pool plan designed to ensure that his or her pre-existing condition could no longer be denied coverage. Or maybe you have simply noticed an influx of young adults into your office, a result of the provision allowing children to remain on their parents’ insurance until age 26. While these reforms are laudable, the bulk of the planned legislative reforms will be introduced and overseen by an entirely new entity in the nation’s health care delivery model – state-based health benefit exchanges. Beginning on January 1, 2014, these statebased exchanges will introduce new, online insurance marketplaces through which consumers will be able to purchase health coverage subsidized according to their income levels. Between the exchanges and the planned expansion of Medicaid programs across the country, as many as 32 million Americans are expected to gain coverage over the next few years. With the January deadline drawing near, the pace is frantic, and as providers begin to plan

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for this massive influx of new patients, state and federal regulators are still issuing guidance outlining exactly how these exchanges will function. We are changing out our jet engines mid-flight, while the runway we approach is still being built. But while there is still much to be done, California physicians are making progress toward a successful implementation. Only days after the federal enacting legislation was signed, California emerged as the leader in ACA implementation by authorizing formation of its own health benefit exchange. Now called Covered California, our state exchange has since that time selected an executive director and board who have been aggressively assembling and preparing for the opening of a successful marketplace in 2014. This progress has not come easily. Throughout the effort, the exchange board has been faced with input from many competing interests. Every decision, no matter how large or small, has come with comments and suggestions from payors, consumer advocates, hospitals and, of course, your California Medical Association (CMA). CMA staff has worked diligently to position our association as a prominent stakeholder in the development and future function of Covered California, ensuring that our state does not end up with a model of health care in which quality is measured in dollars, value is available only to those who can pay for it, and medical decisions are controlled by payors and regulators rather than by doctors. Only physicians know how to balance medical care wisely as we figure out how to

realign incentives towards a sustainable health system and stable fiscal future, and our leadership at this juncture is critical. Furthermore, with important major tasks still yet to be accomplished, design and implementation of the exchange continues to hold significant risks for California physicians. Only now, roughly five months before the exchange goes live, is the model contract being finalized. Following that, the exchange must select which insurance providers will be eligible to offer a plan in the new, online marketplace. As these decisions are finalized, it is vital that physicians pay attention, educate themselves and choose wisely the nature and extent of their future participation. The choices we make today – both individually and collectively – will have important ramifications for how medicine is practiced in California for years to come. As you consider these choices, you can rest assured that CMA will be there to help.

And as we begin to land our re-tooled aircraft on a brand new runway, the efforts we have made as physicians and as CMA members will help to ensure a safe, sensible and successful journey into a professional future we have helped to both envision and create. With only months to go, it is critical that we remember and reaffirm the importance of physician leadership in the California health care reform effort, knowing that absent our involvement and our effort, the default future would have been much different. Physician leadership – in the vision for, implementation of and provision of medical care going forward – is the only way to ensure the people of California have access to the health care system they truly deserve. Thank you for your leadership. It has – and will – make all the difference.

We are changing out our jet engines midflight, while the runway we approach is still being built.

Paul.Phinney@kp.org

July/August 2013

USER 133 Akron Street Rochester, NY 14609-7618 (585) 482-8092

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In Memoriam

Earl F. Wolfman, MD 1926–2013

A gentleman physician is the phrase that comes to mind to describe Earl. I initially met him when I was an internal medicine resident at UC Davis. Earl and his surgical team were consultants on my patients. The TV show prima donna surgeon image was definitely not Earl. His soft-spoken gentle manner was support to house staff and reassuring to patients. It was so apparent that he cared for each and every student or house staff in his charge. Earl was, along with founding Dean, C. John Tupper, MD, a Michigan emigrant. It is hard to describe his career here at UCD. He, with others of the first faculty, laid the foundation figuratively and literally of the UC Davis Medical School and the UC Davis Medical Center we see today. In the beginning, there was nothing but an idea promoted by the local medical societies. They lobbied the legislature to create the school. The founding faculty arrived to find no buildings, no curriculum and no students. From that sparse beginning came the bustling campus, many buildings, and renowned faculty we have today. I know he was proud like a parent of the result of those early efforts. The support from the local physicians created a different collaborative relationship not often seen in town and gown situations. But faculty like Earl reached out and embraced a relationship with the practicing medical community who responded as volunteer faculty. Later, many UCD Medical School grads would settle like seeds around the mother tree and help build the community of physicians we have today.

Earl was delighted to see the results of his teaching taking care of our community. Earl’s career at UCD consisted of many roles beyond that as a teacher. He was a founding chair of the Department of Surgery, Associate Dean, faculty chair of several departments, and he had several administrative posts. Even after he retired, he would respond to any call to serve UCD and the local medical societies. One of his lasting gifts to UCDMC was to create an endowed professorship in surgery. No discussion of Earl would be complete without a mention of Lois, his wife of more than 60 years. She was a constant companion and friend to us all. She was often with Earl at medical society functions supporting Earl F. Wolfman, MD the interests of the profession. In the community, we knew Earl mostly through the Yolo County Medical Society where he served as President in 1988. He also had many leadership roles in the California Medical Association, its Eleventh District Delegation and the American Medical Association. He firmly believed that, when all was said, academic medicine and community medicine had the same interests when it came to basic professional values. He supported many of us in our efforts in organized medicine. He had special abilities to guide, coach and mentor. So we take a quiet moment and say goodbye to a very special friend and mentor, our own gentleman surgeon, Earl F. Wolfman, MD. — Eugene S. Ogrod, MD

July/August 2013

Board Briefs May 13, 2013 The Board: Received an update regarding the Scholarship and Awards Committee from Margaret Parsons, MD, Chair. The Scholarship and Awards Committee is responsible for awarding grants to deserving medical students who have graduated from a high school in the counties of El Dorado, Sacramento and Yolo. The committee also recommends to the Board of Directors candidates for the SSVMS annual awards (Golden Stethoscope Award, Medical Honor Award, and Medical Community Service Award). Received an update from Assemblymember Richard Pan, MD, regarding the California trial attorneys’ launch of an all-out assault on the Malpractice Insurance Compensation Reform Act (MICRA). Since 1975 the state’s historic tort reform act has helped keep malpractice premiums in-check and ensure that California’s patients have access to affordable health care. See the President’s message in this issue for additional information. Also, Assemblymember Richard Pan, MD, reported that We Care For California, a coalition to promote health care access, quality and affordability for all Californians, is mobilizing the largest State Capitol gathering of healthcare providers, workers, first responders and financers in the history of California in support of SB 640 and AB 900. These bills prevent unsustainable cuts to Medi-Cal providers by eliminating the state’s ability to implement a 10 percent Medi-Cal provider rate cut and to recover payments made to various Medi-Cal providers retroactive to June 1, 2011. The rally will take place in front of the Capitol Building on June 4, 2013 between 11 am – 4 pm. Assemblymember Pan stated that he, along with the California Medical Association, strongly encourage all healthcare workers to show their support by being a part of this event. For more information go to www.wecareforca. org. Congratulated Gabrielle Neubuerger, who was recognized at the meeting by CMA President Paul Phinney, MD, for her outstanding leadership as CMA-Alliance President 2012-2013.

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Received a report from Paul Phinney, MD, CMA President, regarding CMA’s proposed Governance Reform to modernize and streamline CMA’s policy and decisionmaking processes, and to redirect resources, presently committed to governance, to strengthening CMA’s advocacy and other member benefits and services. Component medical society leaders and medical executives are being requested to provide feedback on the report by June 1. The final recommendations will be considered by the 2013 CMA House of Delegates. Approved the 2012 Audit Report and recommendations presented by Auditor, Lindsey Kate Lane, CPA. Approved the First Quarter 2013 Financial Statements and Investment Reports, and ratified recommendations implemented by and on the recommendation of the Society’s investment advisor. Approved the 2013 Nominating Committee. The Nominating Committee is in charge of nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. The 2013 members are: Alicia Abels, MD, Chair; Ruth Haskins, MD, District 1; Pat Samuelson, MD, District 2; Barbara Arnold, MD, District 3; Ulrich Hacker, MD, District 4; Paul Akins, MD, District 5; Marcia Gollober, MD, District 6; Richard Jones, MD, At-Large Member; Katherine Gillogley, MD, At-Large Member. Approved the following nominations to the 20132014 CMA Councils and Committees: Pat Samuelson, MD, Council on Ethical Affairs; Benjamin Franc, MD, Council on Information Technology; Pat Samuelson, MD, Council on Legislation; Tom Ormiston, MD, Council on Legislation (representing the Large Group Forum); Mary Jess Wilson, MD, Council on Legislation (representing the Government Employed Forum); Pat Samuelson, MD, Committee on Professional Liability; Benjamin Franc, MD, Committee on Medical Services. The nominations will be considered by the CMA Board of Trustees for recommendation to the 2013 CMA House of Delegates. Approved the following appointments to the SSVMS Delegation to the CMA House of Delegates: Don Wreden, MD, Alternate-Delegate At-Large Office 9; Ben Franc, MD, Alternate-Delegate At-Large Office 15; Alan Ertle, MD,

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. — Jason P. Bynum, MD, Secretary.

Abbot, Christopher M., Vascular Surgery, Eastern Virginia 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Hatfield, Britt H., Occupational Medicine, University of Tennessee 1998, US HealthWorks, 1675 Alhambra Blvd., Sacramento 95816 (916) 451-4580

Ang, Christopher R., Emergency Medicine, Texas Tech University 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Khatri, Vijay P., General Surgery/Surgical Oncology, University of Manchester, England 1985, UCDMC, 4501 X St #3010, Sacramento 95817 (916) 734-2172

Budd, Scott C., Pediatrics, University of Arkansas 1989, Pediatric Medical Associates, 425 University Ave #200, Sacramento 95825 (916) 924-9337 Burns, Kevin M., Blood Banking/Transfusion Medicine, University of Texas 2006, BloodSource, 10536 Peter A. McCuen Blvd., Mather 95655 (916) 456-1500 Forest, Erin E., Hand Surgery/Orthopedic Surgery, University of Iowa 1997, Hand Surgery Associates, 1201 Alhambra Blvd., #410, Sacramento 95816 (916) 457-4263 Han, Jaesu, Psychiatry, UC Davis 1997, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 734-2614

Lloren, Richard S., Pediatrics, UC Davis 1987, Pediatric Medical Associates, 425 University Ave #200, Sacramento 95825 (916) 924-9337 Mandal, Vanessa J., Internal/Geriatric Medicine, Drexel-Hahnemann University 1997, Mercy Medical Group, 2110 Professional Dr #120, Roseville 95661 (916) 536-2500 (Multiple Member) Mullin, Patrick D., Pediatrics, Autonomous University of Guadalajara, Mexico 1978, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Poonia, Roopinder S., Nephrology, University of Rajasthan, India 1999, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-2466 Schroeder, Bradley W., Pulmonary Disease, University of Texas 2006, Pulmonary Medicine Associates, 1485 River Park Dr #200, Sacramento 95815 (916) 325-1040 Wehbe, Salim A., OB-GYN/Urogynecology, Lebanese University, Beirut 1999, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-6900 Zin, Kyi, Internal Medicine/Hospitalist, Institute of Medicine, Rangoon 2001, Mercy Medical Group/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5079

Nutting, Larry L., Pediatrics, Medical College of Wisconsin 1993, Pediatric Medical Associates, 425 University Ave #200, Sacramento 95825 (916) 924-9337

Alternate-Delegate At-Large Office 16. Approved the appointment of Benjamin Franc, MD to the Medical Review and Advisory Committee. Approved the recommendation that the composition of the Board remain unchanged due to the May 1, 2013 Reapportionment in accordance with SSVMS Bylaws, Article VII, Section 1 (d). Approved the Membership Report: For Active Membership — Christopher M. Abbot, MD; Christopher R. Ang, MD; Scott C. Budd, MD; Kevin M. Burns, MD; Erin E. Forest, MD; Jaesu Han, MD; Britt H. Hatfield, MD; Vijay P. Khatri, MD; Richard S. Lloren, MD; Patrick D. Mullin, MD; Larry L. Nutting, MD; Andrew J. Parker, MD; Roopinder S. Poonia, MD; Bradley W. Schroeder, MD; Salim A. Wehbe, MD; Kyi Zin, MD. For Multiple Membership — Vanessa J. Mandal, MD. For Retired Membership — Leonard E. Crawford, MD; Bill W. Eng, MD; Alan E. Frueh, MD; Romie H. Holland, MD.

Parker, Andrew J., Occupational Medicine, University of British Columbia, Canada 1981, US HealthWorks, 1675 Alhambra Blvd., Sacramento 95816 (916) 451-4580

For Resignation — Barry N. French, MD; Nadia S. Iovettz-Tereshchenko, MD. Ratified the April 1, 2013 action to terminate the membership of the following physicians for nonpayment of 2013 dues: Nancy Appelblatt, MD; William Bargar, MD; Reza Bayati, MD; Antony Boody, MD; Alison Boudreaux, MD; Cully A. Cobb, MD; John T. Cornelius, MD; Paul James Donald, MD; William P. Duffy, MD; Christian P. Feinauer, MD; Ronald Mark Gemberling, MD; David J. Graber, MD; Donald W. Hause, MD; Ursula Hempstead, MD; Evalyn Horowitz, MD; I. Kenneth Inouye, MD; Virginia Joyce, MD; David Katz, MD; Michael Kearns, MD; Eugene Lee, MD; Richard Lynton, MD; Kevin X. McKennan, MD; Robert R. Peabody, Jr., MD; Jagbir S. Powar, MD; Christopher J. Schaefer, MD; Rafiq A. Sheikh, MD; Robert Slater, MD; W. Taylor Vance, MD; Barth L. Wilsey, MD; John Wood, DO; Vivien Yee, MD.

July/August 2013

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Office Space Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494. Office Space to Share: 7600 Hospital Dr. next to Methodist Hosp. of Sacramento. 2400sqft, 6 exam/procedure rooms. Ideal for FP or OB/GYN. Contact K.A. Overton MD by email kaomdinc@netzero.net or (916) 681-4434. Position Available – Orthopaedic Specialty: Shingle Springs Health and Wellness Center is recruiting an Orthopaedic Specialist for one day per week in their outpatient clinic. Clinic is less than 2 years old and is conveniently located off Highway 50 West of Placerville. Candidate should be licensed in the state of California and must be knowledgeable of the surrounding area. This is a contract position and has no end date. There is the possibility of increasing clinic time as the practice grows. Please send CV to: Andrea Tayaba Human Resources Manager Email: atayaba@ssband.org Fax: 530-387-8092

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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Sierra Sacramento Valley Medicine

Saturday, July 20, 2013

Walk With A Doc is a FREE program for anyone interested in taking steps to improve their health.

LOCATION: Almond Park 5901 Almond Avenue, Orangevale

Saturday, August 17, 2013 LOCATION: Howe Park 2201 Cottage Way, Sacramento