2014-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2014

Confidence The feeling you have when you are affiliated with Hill Physicians. Francisco Garcia, M.D.

Hill Physicians provider since 2008. Uses Ascender preventive care reminders, RelayHealth online communication tools and Hill inSite to review eClaims and eligibility.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.

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

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Medicine 3

PRESIDENT’S MESSAGE The Quest for Value

José A. Arévalo, MD

EDITOR’S MESSAGE ACA Growing Pains

Nathan Hitzeman, MD

EXECUTIVE DIRECTOR’S MESSAGE 10 Covered CA Tips for Physicians in 2014

2014 Education Series

How Sweet It Is! The search for finger-lickin’ good sugar substitutes

Jack Ostrich, MD

Money and Medicine

Glennah Trochet, MD

Aileen Wetzel, Executive Director

Medical Students Defend MICRA

A Conversation with Dr. Julie Freischlag

John Paul Aboubechara, MS I

Most Memorable Scut Work Experience

Adam Dougherty, MPH, MS IV

IN MEMORIAM Orrin Stuart Cook, MD

A “Meaningful Use” Story

Sean Deane, MD

James P. Hamill, MD

Being There

John Loofbourow, MD

IN MEMORIAM Joseph H. Masters, MD

Covered CA, Insurance Companies and Me

Bob LaPerriere, MD

Ann Gerhardt, MD

Meet the Applicants

Are Medications Worth the Cost?

Board Briefs

Gerald Rogan, MD

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 Our cover photo of Canada geese was taken by Dr. Chris Swanson early one morning this winter in El Dorado Hills. This species of bird is native to North America. It breeds in Canada and the northern United States in a variety of habitats. Canada Geese occur year-round in the southern part of their breeding range, including most of the eastern seaboard and the Pacific coast. Canada Geese are primarily present as migrants from further north during the winter. By the early 20th century, over-hunting and loss of habitat had resulted in a serious decline in the numbers of this bird in its native range. With improved game laws and habitat recreation and preservation programs, their populations have pretty much recovered.

May/June 2014

Volume 65/Number 3 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2014 Officers & Board of Directors José A. Arévalo, MD President Jason Bynum, MD, President-Elect David Herbert, MD, Immediate Past President District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Tom Ormiston, MD

District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Lorenzo Rossaro, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD 2014 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Richard Gray, MD Karen Hopp, MD Maynard Johnston, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD

District 1 Jeffrey Cragun, MD District 2 Richard Pan, MD, Assemblyman District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large John Belko, MD Natasha Bir, MD Helen Biren, MD Gregory Blair, MD Kevin Elliott, MD Alan Ertle, MD Benjamin Franc, MD Karna Gocke, MD Thomas Kaniff, MD Vijay Khatri, MD Don Wreden, MD

CMA Trustees District 11 Barbara Arnold, MD

Douglas Brosnan, MD

CMA President Richard Thorp, MD

CMA Imm. Past President Paul Phinney, MD

AMA Delegation Barbara Arnold, MD

Richard Thorp, MD

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 Glennah Trochet, MD Sandra Hand, MD Lee Welter, MD Albert Kahane, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Adam Dougherty, MS IV Shahid Manzoor, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

A Major Help With Minor Fractures. 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 hours are 8:00 a.m. to 8:00 p.m. (Please arrive by 7 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.

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. ©2014 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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President’s Message

The Quest for Value By José A. Arévalo, MD MANY OF US SEE OURSELVES as valuable to our patients’ health, but how others perceive our value is becoming increasingly relevant. The quest for quality in health care has been with us since the landmark 1910 Flexner Report that resulted in over half of the “lower quality” medical schools closing. In recent years, the quality movement has evolved into the quest for value. Achieving high value for patients has become the overreaching goal of health care delivery with value defined as health outcomes achieved per dollar spent. The latest innovations in health care delivery focus on this unified goal: providing high-value, patient-centered health care. “High-value health care” and “value-based care” have become the latest buzz words in health policy and are manifesting in major delivery system innovations. Newly-minted accountable care organizations (ACOs), global budgets and outcomes-based financial risk arrangements make up an increasing portion of payer contracts. One local successful ACO example is Golden Life Healthcare which has reported a 15 percent reduction in costs during their first year. These new agreements are yielding new practice enhancements like variation reduction, service excellence, patientcentered medical homes and chronic care coordination programs. Undoubtedly, value advocates will quote the recent March 17 JAMA Internal Medicine study by Rand Corporation of nearly 300,000 Medicare patients with type 2 diabetes, congestive heart failure or emphysema. It demonstrated that even slight improvements in the coordination of care for these patients led to significant reductions in hospital admissions, the use of emergency departments and fewer complications, while saving up to $1.5 billion. Improving performance and accountability in health care depends on having a shared goal

that unites the interests and activities of all stakeholders. Outcomes, the numerator of the value equation, are innately condition-specific and multidimensional. Measuring, reporting, and comparing outcomes are perhaps the most important steps toward improving them. This helps us make good choices about reducing costs, the denominator part of this value equation. Costs refer to the total cost of care for the patient’s medical condition. In the past, the failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices, which imposes substantial costs of its own. As health reform progresses, physicians will increasingly need to be active participants in defining and promoting these concepts in order to ensure that new models of care are delivering true value-based care for patients. Value-based accountability will result in physician practices striving to adopt strategies to become more patient-centered, taking on riskbased contracts, pursuing clinical integration, and adopting new care delivery methods. Aligning reimbursement with value in this way rewards providers for efficiency in achieving good outcomes while creating accountability of care. Physicians should consider how the components of value-based care work in their practice and what initiatives they are already working on that might support and fit into the increasingly popular concept of value-based care. Delivering low cost, high-quality care is a win-win for patients and physicians alike. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases. arevalJ@sutterhealth.org May/June 2014

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

ACA Growing Pains 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.

THE WRITERS IN THIS ISSUE speak to the many facets of health care reform. Our executive director, Aileen Wetzel, formerly worked for CMA and is a policy wiz. Our society president, Dr. José Arévalo, is a medical director who must balance cost, access, and quality. Dr. Glennah Trochet is our former County Health Officer who has a public health perspective and kindness for our more vulnerable populations. Dr. Gerald Rogan has worked in contractor administration for the Medicare and Medi-Cal Programs. Drs. Ann Gerhardt and Sean Deane are among a rare species of private practice docs struggling to run solo practices amongst increasing health care complexity. Many of us remain skeptical of big government and increased regulation and complexity imposed onto the private market. The ACA is very complex (over 11 million words, see Oceans and Clouds of Words by Dr. Loofbourow in our last issue). However, the overall thrust of the legislation is to insure more Americans, which at the end of the day, many docs support. While I wish it did more to cover all the 50 million uninsured Americans, I’ll take the 10 million more insured (7 million on exchanges + 3 million more on Medicaid) as a major step forward. Still “Un-Covered” in California is the undocumented lady I saw in the student-run clinics last week with severe bleeding fibroids. Expect to see her again in your ED soon. It often takes a crisis to bring people together. The ACA was a response to a crisis not yet appreciated by most of the public, and hence it was not well received. If only health care could somehow encompass a terrorist attack, a lost plane, a kid fallen in a well – those things garner unanimous support and mobilize incredible manpower. But slow motion crises with yearly double-digit premium increases do not. Unfortunately those with inadequate

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health insurance are still perceived as having brought it upon themselves – deadbeats. My sister-in-law works 25 hours a week for Target and gets no health benefits. She cannot find a full-time position. She is also taking classes at a community college. She is not a deadbeat. Even if you subscribe to the deadbeat theory, caring for these deadbeats with expensive ED visits still bankrupts the system. Malcolm Gladwell – motivational speaker, New Yorker staff writer, author of books on business and social issues – was recently interviewed by Forbes on health care. He states the problem with Americans is that, “we aren’t, as human beings, very good at acting in our best interest.” Some amount of government regulation or mandate seems to be warranted. He draws analogies with safety advances in the auto industry. He then goes on to describe the two main challenges of America’s health care system as technology and social dynamics. Technology marches forward whether we like it or not. Social dynamics, such as the growing income disparities and a culture of violence and increasing poverty, are much more complex to deal with. I recently met with some of our state legislators regarding health care reform. I was amazed at how many of them look at health care in a very different light. They do not appreciate the in-the-trenches perspective we have. We need to speak up. We need to be heard. Physician leadership may make or break health care reform. At the end of his interview, Malcolm Gladwell was asked about future topics that should be addressed in the interviewer’s blog. He replied, “Help people understand what it is really like to be a physician.” I would ask you, dear Reader, to do the same. Tell your stories. hitzemn@sutterhealth.org

You have to pay for workers’ compensation insurance. But...

YOU DON’T HAVE TO In California, rates for workers’ compensation insurance are soaring. In the second half of 2013, rates increased by an average of 8.7%.1 That’s after a 10% increase in the first half of 2013.2 Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/132023_010114_ amended_ppr_filing_complete.pdf

SSVMS members, call 800-842-3761 to see if you can save!

Are you paying too much for your workers’ compensation coverage? Finding out is easy. Just call 800-842-3761 to compare your current policy with workers’ compensation insurance available through the Sierra Sacramento Valley Medical Society. This members-only program is available through Mercer. As the world’s leading insurance broker, Mercer can provide the outstanding service and expertise you deserve. Call Mercer at 800-842-3761 today to get your free, no-obligation quote.

2 Source: Business Insurance, https://www.businessinsurance.com/ article/20130925/NEWS08/130929901

SPONSORED BY:

Mercer Health & Beneﬁts Insurance Services LLC • CA Ins. Lic. #0G39709 67133 (5/14) Copyright 2014 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

Executive Director’s Message

10 Covered CA Tips for Physicians in 2014 By Aileen Wetzel, Executive Director

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

CALIFORNIA’S HEALTH BENEFIT exchange, Covered California, is now in full swing, with over one million individuals enrolled. The California Medical Association (CMA) has developed several resources to help educate physicians and patients on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Whether your practice is participating or nonparticipating with one or more exchange plans, here are 10 pointers as Covered California takes root in 2014: 1. Verify your participation status with the health plans. The directory on the Covered California website has been removed due to reported errors in the data. Even if you did not intentionally contract with any exchange plans, CMA urges physicians to check their participation status directly with participating plans. Contact information for each of the plans participating in the exchange can be found on CMA’s exchange resource page. 2. Review any contracts or contractual amendments for exchange participation. If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, plan-specific contacts can be found in CMA’s Exchange Resource Center. 3. Be aware of the off-exchange products that utilize exchange plan networks. Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-

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network for commercial products that use an exchange network, as these ID cards will not have the Covered California logo on them. For instance, a Blue Shield card may read “individual PPO” in the upper right and list “enhanced PPO” as the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network. 4. Know who can help patients get more information on exchange plan eligibility and enrollment. For practices getting exchange enrollment questions that they are unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the Covered California enrollment assistance website https://www.coveredca.com/ enrollment-assistance/. CMA has developed a FAQ for patients, which can be found in CMA’s Exchange Resource Center. 5. Assess your practice’s policies on extending credit to and collections from patients. Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, premium due dates and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider their strategies for protecting themselves against such potential financial risks. 6. Be prepared for exchange patients in grace period coverage limbo. Exchange enrollees receiving subsidies, currently 85 percent of those in Covered California, will be allowed three months of premium delinquency before being terminated for non-payment. If a practice renders services to these patients in the latter two months of the three-month grace

period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and will give notice to certain physicians of record as to the patient’s status. 7. Know the participation status of physicians, facilities, and other providers that you refer to or use on a regular basis. Covered California plans will require that physicians provide advance notice to patients if they are being referred to an out-of-network provider or an out-of-network provider is included in their treatment plan. If, however, the provider shows as participating in the plan’s directory, the practice cannot be held liable for the inclusion. 8. Be aware of the patient cost-sharing across exchange plans. Covered California will expect participating plans to encourage physicians to consider patient cost sharing. For example, high out-of-pocket costs for things like

brand-name drugs, imaging and specialty care could impact treatment compliance. 9. Let no envelope from a health insurer go unopened too long. Exchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope or email that is easy to overlook. 10. Stay current on significant developments of Covered California that may impact your practice. Stay up to date with exchange developments impacting physicians by subscribing to CMA Alert and CMA Reform Essentials, free newsletters available to both members and nonmembers. For more information on Covered California and CMA’s exchange resources, visit www.cmanet. org/exchange, or call SSVMS for one-on-one assistance. awetzel@ssvms.org

When change moves you in a new direction, choose the right navigator. In health care, success requires diligence and foresight—two qualities that will prove important in the days to come. As reforms take effect over the next decade, will your organization be ready?

We’ve helped physician practices and medical groups nationwide strengthen their operations and position their business for success. Discover how can make a difference to yours.

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May/June 2014

A Conversation with Dr. Julie Freischlag Vice Chancellor for Health and Human Services and Dean of the School of Medicine at UC Davis Health System Speaks Candidly

By Adam Dougherty, MPH, MS IV

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.

JULIE A. FREISCHLAG, MD, assumed her new post in February 2014, most recently serving as professor, chair of the surgery department and surgeon-in-chief at Johns Hopkins Medical Institutions. Freischlag has more than 30 years of experience leading patient-care services and education and training programs as chief of surgery or vascular surgery at nationally-ranked hospitals and top medical schools. Her national leadership includes serving as a former governor and secretary of the Board of Governors and a regent and present chair of the Board of Regents of the American College of Surgeons. She is the current president of the Society for Vascular Surgery and a past president of the Association of Veterans Administration Surgeons and the Society for Surgical Chairs. Freischlag is the editor of JAMA Surgery and a member of the editorial boards of the Annals of Vascular Surgery, Journal of the American College of Surgeons, and British Journal of Surgery. Baltimore Magazine named her “Top Doctor,” and Working Mother Magazine selected her as one of the “10 most powerful moms in health care.” Freischlag received a bachelor’s degree in biology from the University of Illinois and a medical degree from Rush University Medical College in Chicago. She completed her surgical residency and post-residency vascular fellowship at the David Geffen School of Medicine at the University of California, Los Angeles. • How has your transition to Sacramento been so far?

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So far it has been very pleasant. We’ve been here for a month now, and bought a house about four miles from here. One of our sons is a freshman in college at the University of Maryland, and he even decided to do spring break here! The one who had the toughest time was the dog, but I think he is now finally acclimated and is enjoying the warm weather. We have very friendly neighbors, and there are so many great neighborhoods. I’m getting adjusted to the health system and the medical center, and every day I’m trying to meet everyone at their place of work to see how they operate. • What has surprised you most about UC Davis? I’m so encouraged by all of the great energy and impressed by the sense of pride of everyone I’ve met. People are very proud to tell me what’s great about our health system, but then are also able to identify what can be improved upon. I’m happy to see that our community is putting its trust in me very quickly, and I think I’m most impressed with the attitudes I’ve encountered. There are so many great things going on in the Medical Center and School of Medicine that I’m still getting acquainted with. The best gift I received was the success of the LCME visit, which will allow our efforts in medical education to be more creative in the future as opposed to corrective. I want to continue learning from our students in the short term as well including our regular Lunch with the Dean, and I’m planning to visit all the

student runs clinics. • How have your past experiences prepared you, and how does that mold your vision? My strengths stem from my experiences at many centers, including training at UCLA and young faculty at UCSD, working at the VA, and hospitals in Milwaukee and Baltimore. I try to collect the good things that these health systems do, but also identify experiences to improve upon. I like to think of myself as an “insideoutside person,” someone who understands and loves UC from within while bringing in my other experiences as well. I’m very excited by the new effort and unique opportunity to create a unified UC health effort, and I’m already speaking with the other UC deans on parallel issues that we can address statewide such as patient care, saving money or clinical research. I’ve also been a chair, running a specialty division in multidisciplinary clinics which helps me understand some of the institutes and centers better. I’ve done research, and I still see patients which keeps me involved on the front line. • How much clinical work do you anticipate undertaking? I’ll probably see patients in clinic and operate a couple of times a month, and I plan to partner with another vascular surgeon. I specialize in thoracic outlet patients, treating athletes from all over the country. I’ll be doing some teaching with the vascular residents, and I’m also planning on implementing leadership training for the medical students and faculty. My biggest mantra is everyone should be a leader in something, whether it’s your office or research lab or clinic, you should be striving to make things work better, with a focus on what we all can do to take better care of the patient. We used to be trained around the notion of “when is the doctor available,” but today it needs to be “when is the patient available” and how can the health care team address their needs? • How can we bridge the divide of “interdisciplinary care efforts” with the complications we see today in “protecting turf and scope of practice”? We’re now looking at value-based care

in the era of ACOs, and we will eventually see administrators and companies paying for the entire event of care, reimbursing everyone involved, as opposed to paying for individual services. Until that time, framing it as “how would you want it if it was you?” is the most helpful. If you had liver cancer, would you rather come back three times to see the radiation therapist, oncologist, and surgeon for three different plans, or would you rather things be delivered together through coordinated teams on the same page in one place, from looking at the pictures to hearing what it is like to have surgery, in conjunction with education with a nutritionist? Centralizing the payments around how the patient does will drive much of this. Looking ahead, we’ll choose three or four types of diagnoses to work on this. Some are already working well, like cardiovascular care and our cancer centers. Letting our chairs choose areas to enhance will allow teams to develop better and allow departments to drive their success stories. • How can we empower technology in training to improve patient care? One of the things that impressed me the most is the advance in telemedicine and communication through our Technology Center, and we are way ahead of the curve on

May/June 2014

Dr. Julie Freischlag

The toughest part is when the most appropriate response is to do nothing.

that in training and in care for patients. I think the best thing about technological advances is the ability to expand our reach, looking at patients long term, and the fact that we do have outcomes data now to assess the risks and benefits of procedures and treatments. • Two of the biggest issues UC students face today are increasing tuition costs and a constant threat to Graduate Medical Education (GME) funding for residency slots. How do you see this being rectified in the future? The one thing I can do in my position is continue to look for more scholarships and monies to help you do what you want to do, helping those in need, but also creating new ways to reward students who do great things, making sure students understand the implications of debt, finding ways to manage and defray them so the debt doesn’t drive what you want to do in your career. For GME, it will be participatory in why we need training in primary and specialty care, particularly in areas like mental health and the combined training programs. I think our innovative program to accelerate training is the way to go, and to have other streamlined programs makes a lot of sense for those who are surer so they can focus their efforts. GME is going to be tough because they aren’t going to give us more years to train, so enhancing education with what we have now, innovating, and being vocal about the fact that decreasing GME now will have effects 10-15 years later. • In the era of health reform, how can UCD best position itself as a better provider in the community? California is leading the way, not because we are necessarily faster, but because most other states are slow. The key is there won’t be that many more resources, so decreasing costs, keeping up value and efficiency are central, and with that we need a lot of healthy people. The push to make California the healthiest state in the next 10 years is the right way to go, teaching patients how to stay healthy, teaching about the genetic diseases they inherit, looking at obesity and what we eat, teaching all the people we

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serve in this region to be more healthy. It will take education, and as a surgeon I know that we love fixing disease, but there will always be patients to take care of. Having the patient and their family understand what they can do for early diagnosis and early treatment is more important. For providers, it is being able to focus on prevention as well as treatment since we often forget that aspect, using social media and making sure people can access information as opposed to just being told. And focusing on the patients of tomorrow, educating kids in middle school about the importance of healthy behavior, is a real opportunity. • What kind of future do you see for our student-run clinics? That’s one thing that really impressed the LCME from an educational standpoint. Students tell me the patients love it because it gets the patients in the door for care, with avenues to more specialized care, if needed. I can see more availability of educational tools at our clinics like lectures, videos, discussions, where we can talk to patients to do more education. I hope to visit all the clinics soon to see where they may already be doing these kinds of things, and who may be amenable to expanding these efforts. • Any comments on the primary care vs. specialty care divide in relation to health care cost growth? Primary care is critical, that is “your doctor” and really the person who helps you figure it all out, who refers and educates, considering what kinds of things need treatment or not. The toughest part is when the most appropriate response is to do nothing. We all like something, even expect an intervention, but there are times when none of that is superior. From overuse of antibiotics, to advanced cancer or vascular disease where there is nothing else to be done that will help. We know how much is done in the last year of life; some of it is successful, but much is not. I think the primary care interaction with the doctor who knows you and you trust can help the family make those decisions with the specialists to assess risk and benefit. The next step where the PCP is central is

the concept of appropriateness, not “can we” but “should we” and what is going to happen if and when we do it. Making sure we know what the patient actually wants, that they understand what the intervention is going to cost them in pain, hospital days, etc., versus what it will actually give them later. • Looking ahead for UC Davis Health System, what is our next horizon? I’m doing a lot of homework to see what people are passionate about, where they want to go. We need to develop five to seven signature programs of excellence that when people say the word, they immediately think “Oh, that’s UC Davis.” We need to continue our community outreach, and create a network outside the tertiary hospital, finding places where outpatient procedures can take place, increasing primary care access throughout the community, and integrating a network of care throughout the region. Focusing on those “hard to find and touch” is essential, and I think getting students

involved in outreach and education to improve access to appropriate care can accelerate this, and build on our focus on prevention. apdougherty@gmail.com

Remember When

May/June 2014

A “Meaningful Use” Story The arduous transition from paper and pencil to electronic recordkeeping

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.

“IF EVERYONE ELSE WAS JUMPING off a bridge, would you do it too?” Over the last year, I discovered that the correct answer to this question is, “Yes.” Lest my children read this article someday, I should probably qualify my statement with the fact that it applies only to choosing an electronic health record (EHR). Over the last year I converted a practice from an all paper environment (with the APSCO pencil sharpener mounted on the wall) to one that is all digital. My training years included exposure to a variety of facilities, with varying degrees of electronic health record systems. For the most part, I found that each inspired users to develop new and particularly inventive expletives. Thinking I knew the lay of the land, I hoped to do it right the first time and simply choose the best of them. Most people raise their eyebrows when I tell them that the holy grail of electronic health records already exists, that it’s a readily available government product, and that it’s free. Vista/ CPRS, the electronic health record system of the Department of Veterans Affairs, is intuitive, comprehensive, and easy to customize on the fly for routine tasks that matter, like progress notes. Anyone can simply download versions of it by navigating to www.vistapedia.com. Furthermore, I was informed by those in the know that interfaces to work with the outside world (labs, etc.) could be built relatively easily. The only catch? Despite the fact that it is among the most clinician-friendly systems out there, almost no one else is using it in our market. Although there are some commercial versions available (see www.medsphere.com), local consultants to help install and support

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Vista/CPRS are conspicuously absent. Thwarted in my initial hopes of using Vista/CPRS, I embarked on a search for a commercial electronic medical record system instead. In so doing, I encountered a great deal of very impressive sales pitches, and had great difficulty moving beyond that. In one example, I sauntered up to the vendor display for a large national EHR system that I had never used, but had been thinking quite a bit about. I figured that a large system would have an equally large and well-trained support staff to handle any mishaps or training issues that might arise. The sales staff were friendly and gave an excellent presentation about the virtues of the system. “Great,” I thought.

What is a progress note? Then I asked for a real-time example of how I could write a progress note. Fully five minutes of awkward silence ensued as the salesperson attempted to navigate the system to figure out a way to write such a note, until I realized that the salesperson was not exactly clear on what a progress note was. In other cases, I had vendors come out to my practice to demo the system, only to find that there was no way to spend time with a fully-operational training environment until a purchase contract was in place. Months of EHR purchase misadventures ensued. In some cases, the systems were reasonable or even good, but the contracts contained clauses so hellish that they singed the eyebrows of every legal consultant I asked to lay eyes upon them − at not insignificant expense. Some examples from actual publicly available contracts – “You hereby transfer and assign to us all right, title and interest in and

to all De-Identified Information that we make from Your Health Information or Your Personal Information;” “We may use Your Health Information and Directory Information…to contact your patients on your behalf for any purpose for which you would be permitted to contact them;” and my personal favorite – “We offer no assurance that your use of the Services under the terms of this Agreement will not violate any law or regulation applicable to you.” In other cases, the contracts were reasonable, but the system just didn’t work. Hoping for a large system that would integrate with the systems of my colleagues with shared patients, I eagerly pursued one system that is both a large company and is used by a number of my primary care colleagues locally. Everything seemed promising until I discussed with the salesperson that the implementation was for an allergy and immunology practice. “Allergy? Unfortunately, we don’t have an allergy template yet.” “Oh − when do you think you will have that available?” “We don’t really have a timeline.” “Well, I’d be happy to help create a template.” “We made a decision not to allow custom templates to be created.” “So there’s no way for an allergist to use it?” “Nope.” I glumly considered the prospect of giving the battered APSCO on the wall a few more years of service life. Determined to give it one last go, I decided to go with a small company that almost no one had ever heard of. No one, that is, except for one of my outside contractors that had run across it with other clients, liked the aspects of it that pertained to their job, and reported that other clients seemed to like it. That person’s familiarity with the system would presumably make things much easier in the transition. The company had offered me a contract with the right words, and allowed me to practice a bit with it before committing. Their product had seemed imperfect but usable for the everyday

tasks I tried on it. It did need customization to work for an allergy practice, but the company assured me that this would be easy to do once the ball was rolling. I did my further due diligence, verified that the system was approved with Medicare for “meaningful use” (http:// oncchpl.force.com/ehrcert), and took the contract plunge.

Dr. Deane glumly considered the prospect of giving his battered pencil sharpener a few more years of service life.

Upgrades vs. functionality T’s crossed and i’s dotted, the day came that the practice changed hands, and the digital revolution was to begin. It did not do so. Edvard Munch must have been prescient in capturing the essence of a failed software rollout. The system did, in fact, provide a means to do common things that the casual user would look at before buying it, such as write freehand progress notes, index patients, and code for billing. However, a buggy software “upgrade” eliminated large swathes of the functionality that my contractor had liked, while I discovered

May/June 2014

Dr. Deane still manages a smile amid the tedious EHR requirements.

that “easily customizable” to the designers meant that it was easily customizable only by hiring one of their designers to recode the system, provided that they didn’t have other projects to do first, and provided the necessary customization was very limited. It became immediately apparent that critical sections of the notes generated in actual patient care would be nearly unreadable, and that the speed of the production system was slow enough to render real-time entry of data during the patient visit infeasible. Other defects soon appeared − prescriptions for many of the drugs used in Allergy simply could not be entered correctly, functionality to generate many of the reports we needed was not engineered into the system, and frequent crashes occurred with attempts to enter routine data. Interfaces with clearinghouses broke down, causing delays in billing. As the system failures

mounted, I called outside labs to find out what was happening with promised interfaces, and discovered that the EHR was still pending evaluation with them − meaning that at the time we purchased the system, no active interface could be created, even if it worked. Efforts to contact support frequently reached only an answering machine; logging into the promised real-time chat support system yielded only a wait icon (that did indeed herald an interminable wait) followed by an announcement that support was not available. We were lucky. I had heard horror stories of EHRs that proved to be less than what they were anticipated to be, and our practice had decided from the get-go to maintain paper charts until we were fully confident we could convert to the electronic system as our legal medical record. The dream of abandoning the APSCO had to wait, however, and because we were committed to the billing portion of the system, there was no feasible alternate for that. It meant reimbursement delays and a lot of extra manual work for our biller, but we were able to pull through without disruptions in patient care or provider communications.

Silver Lining As with every cloud, however, this one had a silver lining. We stayed on paper for a year longer than anticipated instead of fully committing to an EHR system, a process that can be difficult to reverse once initiated. In the process, an unanticipated contract breakthrough occurred that allowed our practice to purchase an EHR that I knew well, had used for years in other settings, and which already interfaced with a number of my colleagues’ systems. The APSCO has gone by the wayside, and all the things that I loved about having an EHR in the other settings I practice and have practiced in have now come home to my private practice, as well. I can message or quickly write a letter to my patients in minutes while their labs are at my fingertips; I can send consult reports to my colleagues at the click of a mouse (and in many cases, receive their notes with the same click), and I can much more easily search

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through what used to be hundreds of pages in the charts of my sickest patients to find that one missing detail needed for a critical management decision. Meanwhile, through the process of seeing the other side of what an EHR can be, I have learned some valuable lessons about the challenges of systems transitions. I suspect that we will all face many more of those in the coming years as the dust settles from the ACA. It’s not perfect yet − the challenge of entering accumulated data on all of our active patients into a system all at once is not for the faint of heart, and getting pharmacies to route our patients’ refills appropriately is not as easy as it might seem − but the challenges are, for the most part, anticipated ones, while the benefits have overall been well worth the invested effort.

Words of Advice

5. Murphy’s Law must be respected. Even with a backup. 6. Whenever possible, use what everybody else is using. In the end, for the small practice, I think this selling point is about the only one that matters. “Too big to fail” probably applies to EHRs in the same way it does to banks. 7. There are situations in which #6 is impossible. Sometimes, the contract is unsignable. Sometimes, the system works for only a certain spectrum of specialties. Sometimes, the vendor just won’t sell it to you at any price. In these situations, be prepared for the possibility that paper remains the best option available to you, and bide your time. In closing, before jumping off that bridge like everyone else, spend a lot of time and effort to look down and get a very good sense of what the landing will be like below. Unfortunately, it will always be a leap of faith!

For my colleagues who are in transition sdeane@mountainsideallergy.com from paper to electronic records, I offer the following advice: 1. Have an attorney well-versed in HIPAA, and check any prospective EHR contracts before you sign them. INC. It’s expensive, but it may yield A REGISTRY & PLACEMENT FIRM surprises that are well worth the dollars to discover. 2. Do NOT use price as a primary decision point. The opportunity costs Nurse Practitioners ~ Physician Assistants caused by an unfortunate choice of systems will outweigh any potential savings. “Free” systems may come with their own unanticipated costs − check the contracts or terms of use, and ask yourself how much peace of mind is worth. 3. Use caution in presuming that certification of an EHR for meaningful Locum Tenens ~ Permanent Placement use equates to the system actually working. Certainly, it means someone V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 certified it according to specified FA X : 8 0 5 - 6 4 1 - 9 1 4 3 criteria. Before it went live, someone also certified www.healthcare.gov tzweig@tracyzweig.com according to specified criteria. w w w. t r a c y z w e i g . c o m 4. Have a backup.

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May/June 2014

Being There By John Loofbourow, MD

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

A PRIMARY CARE PHYSICIAN − or generalist by whatever name − can ideally prepare and accompany a patient in that transcendental experience that is dying and death. Family Medicine physicians, in particular, are ipso facto, concerned with the health of family. Therefore, provided the patient agrees, the physician should encourage the participation of family and friends; the life-long advantage of Being There for death is highly significant for both survivors and physician. A doctor personally attending the dying patient was routine 100 years ago. Perhaps that was, in part, because nothing else could be done. Remember the Luke Fildes painting of a doctor sitting resignedly at the bed of a patient? While the painting may be overly dramatic, the details stand a closer look: The physician’s demeanor; the neglected cup and potion; the disarray; the child’s parents; the darkened humble room. This doc is not attending nobility, but a family that lives at the edge of life. The doctor can do little except Be There. Isn’t that precisely the nature of death, that physicians can offer nothing except comfort, advice and − most important under the circumstances − our presence? We seem to have forgotten − or become fearful of − just being there for family and friends of the dying patient. Maybe we are afraid of failing in a role of scientific omnipotence. Because omnipotence implies guilt and deception when it becomes impotent. Yet the nature of life’s end is too critical a matter to give over exclusively to well-meaning hospice teams, hospitals, nursing homes, or institutional types. Being There completes the circle of life, and being human, and being a physician. Why should we abandon our patients and families in their extremis?

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In my own experience, though that was decades ago in Woodland, when house calls were still common, being there is eminently doable. My practice included something that could be called House Rounds: regular visits, usually one afternoon each month to those who had difficulty getting to the office due to the limitations of chronic illness. The best features of those monthly visits were quiet, unspectacular moments of shared humanity. They occasionally led to the time when death visited as well – and by then was expected. The downside of house rounds was that better diagnostic and treatment options were not in hand. Yet it seems ironic that as portable diagnostic and treatment becomes ever more reasonable, available, and effective, we still use technology almost exclusively in offices and institutions. There is no serious barrier to home visits, or to being there today, even during the current medical perfect storm. Medicare regulations have been modified to allow primary care physicians to charge for end-of-life discussions as part of a health assessment. It seems certain that ACA administrators will use the same sort of hocus-pocus for physicians caring for younger people. The topic of dying is almost impossible to introduce quickly or easily; it is best addressed personally, in advance, rather than through a pamphlet or website. Many books on the subject are rather tedious or dense.1 The material provided by CMA is helpful. I suggest it is well worth the exercise, and the discipline, to make up a simple, easily understood one- or two-page letter to communicate with terminally-ill patients. I have fashioned one for patients themselves to use, but it can be modified for use by a clinician.

A doctor personally attending the dying patient was routine 100 years ago.

Sir Luke Fildes’ painting The Doctor (1887, The Tate Britain Museum, London)

The physician who hopes to “be there” is wise to think about the process and plan for it − as we do with any other aspect of medicine. I suggest it is well worth the exercise, and the discipline, to make up a simple, easily-understood oneor two-page letter to communicate with terminally-ill patients. john@loofbourow.com 1 The Tibetan Book of the Dead ISBN D-55337090-1 Bantam 1994. Chapter 3, Preparing− practicing is the term later used−for Death, has practical suggestions about giving up cherished things, old conflicts, and finally, your own body. The rest of the book is heavy, and couched in remote philosophical terms, where death is a partly conscious temporary condition between lives.

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May/June 2014

Covered CA, Insurance Companies and Me By Ann Gerhardt, MD

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

I COULDN’T WAIT FOR OCTOBER 1, 2013 and the chance to access health insurance through Covered California. The Patient Protection and Affordable Care Act isn’t perfect, but it’s an honest effort and the closest thing we’ve got right now to universal health insurance. I wanted to be a part of the change and finally divest myself of the contrived access to health insurance that I’ve wasted money on for years. Though most people believe I’m rather healthy, long ago the insurance companies rejected me for a minor condition that hadn’t cost anyone much money or impeded my years of sports competition. I was one of those for whom the ACA was intended. For insurance, I pay myself as an employee of a staff leasing company in order to have access to their group insurance plan. I pay myself $8 per hour for 30 hours per week plus the company’s fees. They deduct the cost of premiums, extract their fees and pay the premium, taxes and a monthly deposit to a Health Savings Account. What’s left is a paycheck for $81.06 every two weeks. All this for an insurance company I don’t like: The high cost pays for nothing because of a high deductible and the company routinely denied payment for the few services I need. I wanted a top-of-the-line, non-HMO plan with a non-profit company whose business practices had not given me headaches as a provider or denied essential care to my patients. Four companies signed up to provide Covered CA plans in Sacramento County: Blue Shield, Anthem Blue Cross, Western Health Advantage and Kaiser Permanente. Only Blue Shield fit my criteria. So, at 8 am on October 1, I logged on to

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Covered CA, along with thousands of others… and contributed to the site freezing up. I could see the companies and the Bronze, Silver, Gold and Platinum plans. What I couldn’t do was sign up or download an application, either online or on paper. I was all over that site for over an hour, to no avail. Even my tech-savvy spouse couldn’t solve the problem. Over the course of two weeks, I tried the site twice more, each time inching closer to the goal. Then I took a time out, after all the publicity indicated that there were bugs to work out over which I had no control. The ACA was very popular and online demand had exceeded website capacity. I cheered Covered CA on. Certainly excess demand is better than none at all, and even more proof that the ACA is needed. Early in November, I tried again and easily signed up. Me and platinum Blue Shield – a match made in my dreams…until I went to the SSVMS Board meeting and heard Dr. Richard Pan talk about ACA plans having limited provider panels. According to him, insurance companies had signed up only the minimum number of doctors necessary to satisfy the ACA’s requirements. I had assumed that all Blue Shield plans would use the same doctors. Silly me. Back to Covered CA, which, rather than be responsible for inaccurate insurance company provider panels, directed people via “View provider directory” to each insurance company’s site. This totally-smart move responds to the age-old issue of inaccurate insurance company doctor panels. For years, company websites have failed to update their provider lists, padding their panels with relocated, resigned and dead doctors. True to Dr. Pan’s predictions, my two

doctors weren’t on the list. Dashed were my dreams of supporting Covered CA and dumping my current insurance. Then I had the bright idea of signing up for an individual Blue Shield plan outside the exchange. After all, the ACA made it illegal for them to deny me insurance based on a pre-existing condition, and I certainly wasn’t expecting an ACA premium subsidy. The Blue Shield website, however, lumped all new individual plans together. The provider panel, premium and plan specifics for all plans initiated in 2014 equaled their Covered CA plans. What brainiac came up with that logic? I needed to verify my findings. The Blue Shield “Contact Us” tab didn’t include email, so I called all three of the telephone numbers sprinkled throughout the website. EVERY one led me down a digital selection tree to a promise of talking to a real human…and within seconds the line hung up. I tried on different days, and at different times of day. I understood they were busy with Covered CA calls, so I continued to call for weeks, all with the same outcome. And I continued to pay myself $8 per hour, so I wouldn’t lose my current insurance in the process. Since telephoning wasn’t working, I looked online and found a variety of sites listing a variety of addresses for Blue Shield sign-up offices. One cold, blustery day I walked the mile from my home to a quiet “sales office” hidden on the fifth floor at 1215 K Street in Sacramento. The two kind souls who work in what turned out to be a government relations office (a euphemism for lobbying) were surprised to learn that the Blue Shield site called them a sales office, but said I wasn’t the first who had wandered in. Another two months went by and emotionally I had given up. However, I still hated my insurance coverage arrangement and needed to be absolutely sure I was SOL. I drove to the Blue Shield office in El Dorado Hills and waited in a pastel lobby with soaring ceilings for a silver-tongued man who apologized profusely. Yes, the panels were limited. Yes, all the new 2014 individual plans match the Covered CA plans. (They don’t have an extra person or two

in the building to dream up some other plans?) Yes, they had underestimated the demand and had not reduced unemployment by hiring more telephone receptionists. He believes that things will change in the future, but I lost my chance to be a part of ACA change. I don’t blame Covered CA, much. Sure it was slow going in the beginning, but the site is up to speed now. By mid-November I had a plan and a company and only needed to pay the premium. It was Blue Shield that let me down. I had excluded the other companies for what I viewed as incompetence or “care”-related business practices, only to discover Blue Shield’s faults. In researching this article, I’ve found that no one has all the answers and that the answers change from one expert to another. Other counties have different companies and, at times, opposite problems. But why??? Exactly how tough can it be to verify a doctor’s participation in a panel, publish that panel, sign people up for insurance, send them a card and pay for their care? Isn’t that what these companies do all the time? We need universal health care. algerhardt@sbcglobal.net

—William Nakashima, MD

May/June 2014

Are Medications Worth the Cost? By Gerald Rogan, 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.

WHY DO NEW PRESCRIPTION drugs cost so much? The short answer is drugs usually are priced at what the market will bear. When there is no competitive market, the price appears unconstrained. Federal law requires Medicaid programs to receive favorable pricing. No such law applies to Medicare. Medi-Cal attempts to negotiate even larger discounts for each drug with each manufacturer, on a confidential basis. Sometimes California State negotiators gain a larger “volume-based” discount than smaller states obtain. Sometimes, California garners no additional discount. For drugs that are usually self-administered, such as pills and self-injections, Medicare, under its Part D program, relies on private market forces to apply price controls. The “private market forces” control utilization based on the patient’s willingness and ability to pay the copayment and deductibles, and by higher copayments for some drugs, a method known as “tiering.” Many plans offer four tiers of copayment percentages. Preferred drugs, such as generics, may be on a lower percentage copayment tier. “Market forces” apply when there are two or more products that offer comparative effectiveness (e.g. statins). For physician-administered drugs covered under Medicare B, such as anti-cancer infusions, Congress provides a reimbursement formula: “Average Sales Price” (ASP) plus five to six percent (depending upon site of service). The Center for Medicare and Medicaid Services (CMS), or one of its contractors, periodically calculates the ASP for each drug. The allowances are posted in the Medicare fee schedule data base. What “ASP” pricing means is that each

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pharmaceutical company may charge whatever it wants to charge, just as it may for pills. “Market forces” rarely apply to Part B covered drugs, because most Medicare beneficiaries have supplemental secondary insurance or secondary Medi-Cal coverage. Those without secondary insurance usually qualify for financial help from foundations, detailed below. Rarely does anyone pay a substantial co-pay. Several factors weigh into a company’s retail price decision. It is common to consider the relative market size of each dominant payer group, competitive products, and marketable assertions of comparative value. Typically, new pills for a disease will be priced similarly to existing drugs, or higher if the increase can be justified by some additional benefit of the new drug. Factors of negative press and adverse market forces may apply, but usually appear to be given low or no weight. Good examples are the two new pharmaceuticals for hepatitis C, each of which is priced higher than the first generation pills that, with interferon and ribavirin, constitute triple therapy. The duration of treatment with one of the new pills is only 12 weeks vs. a minimum of 28 weeks required by one of the drugs it replaces. By contrast, some high-priced anti-cancer drugs provide only a three-month overall survival benefit without cure. The “value” of such anti-cancer drugs, calculated by cost per year of remaining life, may be orders of magnitude lower than hepatitis C drugs. In our country, such value calculations appear irrelevant to payment policy by taxpayer supported programs. Many patients cannot personally afford the cost of some new oral drugs to treat chronic

disease, such as for HIV, hepatitis C, multiple myeloma, or rheumatoid arthritis. To help access (and perhaps avoid widespread public protests), most companies provide indirect financial support for lower-income patients through grants given to “third-party” compassionate financial support foundations. Under this arrangement, the patient’s insurer pays its share of the high price and most of the patient’s share is paid by the support foundation. With this approach, access and high insurer payments are assured. Costs are indirectly transferred to all the insureds covered under that plan. In the U.S, some folks argue that insurers and public programs should negotiate as a buyers’ group like the VA system does and, if needed, not cover a drug of low value. Such advocates point to other developed countries that seem to have successfully implemented this approach. Some patients find cheaper sources of drugs from other countries with some success. The FDA seems to have a problem with this approach, which some of us embrace to assure public safety and others eschew as pathetically paternalistic. At a March 2014 meeting of the California Technology Assessment Forum, (www.ctaf.org), the new drugs for hepatitis C were discussed, including the relative value. The forum’s consensus was that the new drugs for hepatitis C offer low value, but improve outcomes for some patients and, with a shorter duration of toxic side effects. This may be the first time the Forum explicitly considered value. One expert opined that new hepatitis C drugs in the pipeline are likely to cost even more. A small group of community advocates (www.JohnMartin-AIDSprofiteer.org) attended the meeting for about one-half hour. Standing silently in the back of the room, dressed in casual attire, each held a sign protesting the high cost of the new hepatitis C drugs. I spoke to them. These advocates mentioned the benefit of the Ryan White Program that is funded with $25 billion per year (pre-ACA) to cover the HIV drugs which may cost $17,000 per year per patient. While HIV drugs are taken for a lifetime, an additional $50,000 per course of Sofosbuvir

therapy for hepatitis C is taken only once and is usually curative. The total cost for hepatitis C treatment, as high as $150,000, equals nine years of HIV therapy. HIV patients probably live more than nine years with treatment. If so, then the hepatitis C treatment is cheaper than HIV treatment over a lifetime. The cost of hepatitis C treatment compels us to reflect upon the cost to society of parenteral drug addiction, the predominant source of hepatitis C contagion. It may be politically fashionable to blame a pharmaceutical company for a high price, while also praising it for its inventions. Underneath these arguments is the fact that self-destructive behavior diminishes all our lives, which leaves us all with many competing agendas to juggle in the public form. We also must face the dilemma that health outcomes may be proportional to the ability to pay. jerryroganmd@sbcglobal.net

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May/June 2014

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more information or to register, visit www.cmanet.org/events or call CMA’s Member Help Center at (800) 786‐4262.

June 18: The Power of the Pen – The Physician’s Responsibility in Prescribing and Referring for Medi‐ Cal Patients 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, the physician’s role in prescribing/ ordering/referring, and increase awareness of fraud and abuse in prescribing and referring. 1.00 CME CREDIT. July 2: HIPAA Breach Notification and California Requirements 12:15 – 1:15 p.m. Every medical practice in California has obligations to report breaches of unsecured patient information, in some cases within 5 days to California authorities, and promptly for HIPAA compliance. This webinar will review and simplify these requirements. 1.00 CME CREDIT. July 16: Recipe for Financial Success: Key Steps to Increasing Your Net Income 12:15 – 1:15 p.m. Physicians and office managers need business management skills, particularly in the financial area. This webinar will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms. 1.00 CME CREDIT. July 30: What to Expect from a Medi‐Cal Audit 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the role of utilization oversight and claims monitoring, increase understanding of the audit process and possible outcomes, and understand common problems and methods to improve documentation. 1.00 CME CREDIT.

September 10: HIPAA Update: Are You Compliant with the Final Omnibus Rule? 12:15 – 1:15 p.m. The Final HIPAA Rule went into effect in 2013. There are so many changes to HIPAA privacy, security, breach and enforcement that this rule is referred to as an "Omnibus Rule." Many changes have a profound impact on medical practice workflow. Changes are also relevant if you use an electronic health record. This webinar provides an overview of the HIPAA changes and key steps medical practices can take to comply with HIPAA. HIPAA enforcement penalties can be severe for medical practices who are not compliant! 1.00 CME CREDIT. September 17: Managing Difficult Employees and Reducing Conflict in the Practice 12:15 – 1:15 p.m. This information‐packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set practice values; and reduce conflict in the practice. 1.00 CME CREDIT October 1: Family Medicine, Frontline of Care 12:15 – 1:15 p.m. This webinar will review strategies to help the provider take a pro‐active approach to dealing with external pressures, as well as review basics in documentation, prescribing, referring, and practice management. 1.00 CME CREDIT. October 8: Protect and Preserve Your Patient Relationships 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/patient relationship. 1.00 CME CREDIT

Physician members of Sierra Sacramento Valley Medical Society and the California Medical Association may register for webinars at no cost. Call CMA’s Member Help Center at (800) 786‐4262 to register or for more information.

How Sweet It Is! The search for finger-lickin’ good sugar substitutes

By Jack Ostrich, MD ONE DAY IN 1877 − some say 1878 and others 1879 − a Russian chemist named Constantin Fahlberg left his lab at Johns Hopkins and went home to have dinner. He was in Baltimore as a postgraduate student to study and classify the many compounds derived from coal tar. Explosions and fires were, thankfully, uncommon. He sat down to dinner and, as he took his first bite from a dinner roll, he noted a sugary taste on the crust. Soon thereafter, he dabbed his lips with his napkin and discovered that the napkin had a sweet taste as well, and so did his fingertips. He did not finish his dinner. He realized that he had somehow transferred a sweettasting substance from his hands to his food and recalled that he had failed to wash his hands prior to leaving the lab that afternoon. He rushed back to his workplace at once and tasted everything on the desk top where he had worked that day. He tasted stuff in beakers and dry residues on the desk itself. He found the sweet substance in and on a beaker that had boiled over earlier in the day, and he remembered he had hurriedly cleaned up the mess just before he had left for home. Fahlberg was subsequently able to reproduce the substance, and characterized it as anhydroorthosulphaminebenzoic acid. He named it “saccharin” and rapidly realized its commercial potential. He took out American and German patents for the compound, much to the dismay of his program director, Professor Ira Remsen, who believed in pure science unadulterated by mercantile considerations. Fahlberg soon returned to Europe and became wealthy due to the sale of saccharin.

He died in 1910 at age 60 and is buried near Moscow. Remsen died in 1927 at age 81, and one of the main chemistry buildings at Johns Hopkins is named in his honor. And so the modern era of non-nutritive sweeteners began. But many centuries before Fahlberg forgot to wash his hands, Romans were making a syrup (sapa) by boiling mashed-up grapes in leaden pots. They noticed that, even after the pots were scrubbed clean, the lining and also the outer shell of the pots had a sweet taste, and they correctly deduced that there was more than pure plumbum in the pots. It turned out that what they were tasting were salts of lead, especially lead acetate, and it was used for a couple of thousand years as a cheap sweetening agent until the dangers of lead poisoning were appreciated.

Beethoven’s 10th? Beethoven’s death at age 56 may have been caused by lead toxicity, the lead having entered his body as a sweetener in his beloved German riesling wines. The great composer was a wine toper of some note (no pun intended), and when he was sipping what he thought was a luscious beerenauslese, he was instead probably slurping an ordinary kabinett laced with lead salts by an unscrupulous wine merchant. Otherwise − who knows ?− we might have had a 10th Symphony and a 6th Piano Concerto! In any event, saccharin was the only synthetic or “artificial” sweetener until a new generation of sloppy chemists emerged in the 20th century. In 1937, a chemistry graduate student, Michael Sveda, was studying new antipyretic drugs at the University of Illinois. One day, he picked up his cigarette that had been lying at the edge of his workbench, and as May/June 2014

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he took a drag, realized that the wrapper tasted sweet. The cigarette had become coated with some sort of dust on the workbench surface, and that dust was eventually called cyclamate. It was successfully mass produced and brought to market by Abbott Labs in the late 1950’s as “Sucaryl,” and Sucaryl was designated as “GRAS” (Generally Recognized As Safe) by the FDA in 1958. But that designation was rescinded in 1969 when animal studies suggested increased risk of urinary bladder cancer in lab rodents which were fed the stuff.

Cancer Risk Cyclamate is still widely used in Europe and Canada, and in spite of a more recent retrospective review by the FDA that revealed no increased cancer risk for mice or men, it remains banned in the USA. So when you are in Canada, A variety of popular sugar substitutes was sampled in this “taste test.” The sweeteners varied in color from white to a faint light brown.

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be aware that the powder coming out of your Sweet’N Low packet is cyclamate, not saccharin. Don’t get caught with a few extra packets as you re-enter the USA or you might find yourself detained by a U.S. border agent. (Just kidding.) Next, in 1965, a chemist employed by Searle Pharmaceuticals named James Schlatter was working on the chemical structure of gastrin as he and his colleagues sought to create anti-ulcer drugs. He licked the tip of his index finger to help pick up a loose piece of paper and noticed − you guessed it − a sweet taste. So he was the first person on earth to taste what we now call aspartame. Searle was later bought by Monsanto which sold its pharmaceutical division to the giant European company called Pharmacia which, itself, was eventually merged with Pfizer which sold its aspartame trademark “NutraSweet” to the J.W. Childs Associates equity firm. The latest sweetener was created, this time on purpose in 1975, by two chemists at King’s College London working under contract to the British agribusiness firm of Tate & Lyle. Leslie Hough and Shashikant Phadnis were synthesizing derivatives of plain sucrose to see if they could concoct a super-sweet substance that would have little caloric content. Phadnis, himself, tasted each discovery and tried to compare it to the taste and sweetness of its parent compound, good old cane sugar. One day he indeed found one, hundreds of times sweeter than cane sugar, and he dubbed it sucralose. It was eventually named “Splenda.” Tate & Lyle have retained the Splenda trademark, but have licensed the manufacture of sucralose to others. It is the most popular artificial sweetener in the USA and aspartame (NutraSweet, Equal) is in second place. All of the synthetic sweeteners have been widely criticized for being expensive and of little use to promote weight loss. Even a cursory look at Internet-based information reveals a great deal of worry regarding their potential toxicity. Aspartame, in particular, has been attacked as a possible cause of leukemia and some solid cancers. The American Cancer Society, however, has gone on record as disputing those claims and has stated publicly that it considers the

substance to be safe. Beginning in the 1830s, chemists such as John Stenhouse in Scotland, who is credited for discovering erythritol, were extracting non-carbohydrate sweet substances from maize and berries and even wood chips. As a class, they are called “sugar alcohols” or “polyols.” They are now used widely in “sugar free” manufactured foods and as sweeteners in toothpaste. The simplest sugar alcohol is methanol, or “wood alcohol.” The ones used most commonly in manufactured foods are mannitol, xylitol, sorbitol and erythritol. The latter is least likely to cause gastrointestinal distress and is often combined with other “natural” low-calorie sweeteners such as monkfruit and stevia to give the products a more sucrose-like taste and appearance. None of the polyols promote tooth decay and may have, in fact, a protective effect for teeth and gums. Stevia, a family of plants native to the Americas, has been used for centuries as a sweetening agent by South American natives. It is almost non-caloric and deemed GRAS by all the world’s countries, although its GRAS status in this country was granted only a few years ago, in 2008, by the FDA. It is the most popular non-nutritive sweetener in Japan. Monkfruit, the common English name for Siraitia grosvenorii, for many centuries has been cultivated in the Far East for its sweet extract. In 1995, Procter & Gamble patented an efficient process to obtain the glycosides responsible for monkfruit’s sweetness. It is available in powder and liquid form and, when combined with erythritol and a bit of molasses, it is sold under the trade name “Nectresse” as a granular powder.

Obesity and Diabetes That is pretty much the present status of the sucrose wannabes that are available to us today. All of us are are aware, of course, that first world rates of obesity and Type 2 diabetes continue to rise even as the availability, variety and sales of non-nutritive sweeteners have skyrocketed. So, you ask, how do they taste? To try to answer this, I sat down a few weeks ago with fellow Editorial Committee member (and board-certified gourmet) Dr. Bob LaPerriere

who had assembled 12 samples of various sweeteners. All were in small plain translucent plastic cups, labeled only with numbers from 1 to 12. Bob had put them into the cups a couple of weeks before I arrived and swore that he could not recall which was which. He had a list of each cup’s contents somewhere or other. We tasted each one in turn, straight from the little cups using the tip of a finger or a tiny spoon, and we cleansed our palates with tap water. Of the 12 samples, 10 were powdered or granulated and included plain white cane sugar, turbinado sugar, stevia, monkfruit, pure xylitol, and two liquids − agave syrup and liquid stevia (called “EZSweetz”). All the powders were snow white except the turbinado sugar and the monkfruit extract called “Nectresse” that, as noted earlier, contains a tiny amount of molasses and, so, has a faint light brown color. All were pleasantly sweet except for saccharin (Sweet’N Low) that had bitter and medicinal overtones that generally were not nearly as noticeable after the powder was dissolved in a few ounces of water. My own favorite was sample number 2, that turned out to be good old C&H cane sugar. My tasting note reads, “Tastes just like sugar!!” Sample number 12, a clear watery liquid, also had a “medicinal” taste, but was very pleasantly sweet after a few drops were placed in a few ounces of water. It turned out to be liquid stevia. I gave high marks to the stevia powder as well, which was made to look and have a mouth-feel similar to cane sugar by being compounded with maltodextrin. Plain xylitol powder was very pleasant with no strange overtones or aftertaste. After I returned home that day, I looked at my Colgate toothpaste tube to see what the sweetener might be. It was saccharin. Saccharin and sorbitol are used in Crest toothpaste. So now you know more than you ever did before (and probably more than you ever wanted to know) about non-nutritive sweeteners. Are they necessary? Do they serve any medical purpose? Who knows! There will be, I am sure, more to come.

We would like to thank Sweet Solutions Corp. (http://ez-sweetz. com) for kindly sending a wide variety of their products for us to “sample” for this article. Photos by Dr. Bob LaPerriere.

jmost119@aol.com May/June 2014

Money and Medicine By Glennah Trochet, MD

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

WHEN I RETIRED FROM MY position as Sacramento County Health Officer in 2011, I was advised to create a LinkedIn page, which I did. As a consequence, periodically I receive e-mails and telephone calls from medical recruiters seeking physicians with my particular set of skills. One call was from a very youngsounding recruiter who wanted a copy of my resume to submit to her clients who were seeking a medical director to make medical necessity decisions. Knowing this company was a for-profit enterprise, I was intrigued that they would be trying to recruit me, given my core beliefs about medicine. Then I realized that this recruiter, in addition to being very young, was also naïve. I said to her, “Before I send you my resume, let the management of the company know that if I am faced with a medical necessity decision, the best interests of the patient will override any other consideration, even if it constitutes a monetary loss to the company. If they still want to see my resume after that, let me know and I will send it.” I did not expect to hear back from her, but she called several days later. She told me that after receiving the information I had given her, the management no longer wished to consider me for the position. In my opinion, some professions should not be entered for monetary gain: religion, education and medicine are three of these activities. It does not mean that those who minister in religion, teach in education or practice medicine shouldn’t make a good living in these careers, but rather that they answer to a higher calling that requires a measure of selfsacrifice and putting the well-being of another before their own. There is much truth in the saying, “No

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margin, no mission,” and I am not opposed to keeping an eye on the bottom line when providing medical care. However, for-profit schemes have an inherent conflict of interest that we should not allow in medicine. When the primary reason for the existence of an organization is to provide profits to its shareholders, inevitably a patient’s needs may cause a decrease in profits. When faced with the dilemma of providing appropriate medical care at a loss of profit, most for-profit company decision-makers choose to deny the medical care in favor of the profit. If they do not, they don’t stay employed for long. In the beginning of the 20th century, physicians were paid for their services directly by their patients. With the increase in technology and its costs, most people could not afford hospital care. So Blue Cross was born in the 1930s to insure everyone who paid its premiums against hospital charges. Physicians wanted a similar product for their charges, and Blue Shield was created to pay physician fees. Initially, both companies charged all members the same premium, regardless of health status. Seeing that there was money to be made, for-profit companies were created that had lower premiums than Blue Cross and Blue Shield. They stacked the deck in their favor by insuring only healthy, young people and by excluding the elderly, the sick and the poor. With this business model, they made a hefty profit. With the risk pools of Blue Cross and Blue Shield consisting mostly of people with higher health care needs, they could not sustain their flat premiums. Their premium structure changed, ending up with the merger of Blue Cross and Blue Shield in 1982 and conversion to for-profit in 1986.

The government helped profits by taking responsibility for the risk pool of the poor (Medicaid) and the elderly (Medicare) and those on dialysis (thank you Richard Nixon); while the healthy, employed population was insured by for-profit companies that were able to exclude pre-existing conditions. No wonder Medicaid and Medicare costs keep increasing! The Affordable Care Act has helped even things up a little: no longer can insurance companies exclude pre-existing conditions from coverage. They must offer a basic list of services for the premium, young people can stay on their parents’ insurance until age 26, and they can no longer retroactively cancel a contract. But we still need to do better. Imagine if all Americans were in the same insurance risk pool: young, old, healthy, sick, rich and poor. What would our premiums look like then? Surely they would be closer to the non-profit Blue Cross/Blue Shield premiums of the 1930s. What if this insurance was not

for profit and those who administer it, though adequately compensated, were not making millions of dollars a year? Physicians would only have to deal with one formulary, one set of treatment guidelines and one billing system. Since we would all be providers in the same insurance plan, we could refer our patients to the specialist we thought could help our patients best, without worrying if they were in the network. Whether or not such an insurance plan should be run by the government is a discussion for another time. For-profit insurance plans are politically powerful and will not go away quietly. Can we agree as a profession that the practice of medicine should be primarily for the benefit of our patients and that everyone deserves health care? If we could speak with one voice on this issue, it would be a good start towards achieving affordable health care for all. trochetg@gmail.com

World Medical Association Declaration of Geneva Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968 and the 35th World Medical Assembly, Venice, Italy, October 1983 and the 46th WMA General Assembly, Stockholm, Sweden, September 1994 and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006. AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude that is their due; I WILL PRACTISE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my ﬁrst consideration; I WILL RESPECT the secrets that are conﬁded in me, even after the patient has died; I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;

MY COLLEAGUES will be my sisters and brothers; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life; I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat; I MAKE THESE PROMISES solemnly, freely and upon my honour.

May/June 2014

Medical Students Defend MICRA By John Paul Aboubechara, MS I

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 MEDICAL INJURY Compensation Reform Act (MICRA) is a series of statutes that were enacted to mitigate the ongoing malpractice insurance crisis, in which soaring insurance rates led to clinic closures and decreased health care access for Californians. MICRA ensured that injured patients were fairly compensated, medical liability costs remained in check, and health care continued to be accessible to our state’s underserved patients. A proposed ballot initiative seeks to weaken MICRA’s protection by quadrupling the cap on non-economic damages. As a medical student, I am concerned that an undermining of MICRA would jeopardize my ability to practice in my home state. At a time when there is already a physician shortage in California, this initiative will simply exacerbate this problem, resulting in skyrocketing health care costs and decreased access to care for the patients that need it most. The fight for MICRA has been one that we medical students are very passionate about − not simply because it will harm the future of medicine and the state of health care in our state, but also because it is detrimental to the survival of our student-run clinics. One of the best experiences that medical students have is volunteering at the student-run clinics. These clinics provide free health care to our underserved and uninsured communities. At UC Davis, we have eight student-run clinics that care for hundreds of patients each week. Essentially, our clinics serve as the safety net for our most vulnerable population. The same goes for other medical schools across the state. As we do not charge for our services, our student-run clinics already struggle

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to remain financially viable. If this ballot measure were to pass, our clinics may be forced to close, and our community’s underserved and uninsured patients may no longer receive the care they need. Many other health care organizations, including Planned Parenthood and the Central Valley Health Network, which operate under a lean budget, will face similar challenges. We medical students join the California Medical Association (CMA) in opposing this ballot initiative. In early March, over 150 physicians, residents, and medical students gathered at the California Democratic Party’s (CDP) annual convention in Los Angeles. The CMA has done a wonderful job inspiring medical students to get involved in health policy. Thirty-two medical students from UC Davis attended, even though most of us had an exam the following Monday. Andrew Kaddis, a first year medical student, said, “I could not miss the opportunity to travel down to Los Angeles with fellow classmates to help keep our eight free student-run clinics open.” At the event, we attended the caucuses, staffed booths, talked with convention delegates and attendees and met with distinguished politicians. All of us had the opportunity to make our concerns heard. For example, in attending the veteran’s caucus, I was able to inform veterans and other interested parties how important the preservation of MICRA is to prevent an increase in health care costs. We also talked about the impact that the proposed ballot measure would have on communities that need access to care most – including veterans, children, seniors and low income

families across the state. Attending the CDP convention was a great learning and networking opportunity for us medical students who are still developing our career aspirations. Personally, I had begun medical school with little familiarity with health policy and advocacy. I did not realize that my ability to practice could be jeopardized so easily by a legislation ballot measure like this, intended to fool voters. To protect the future of medicine and health care in California, we need to stay aware of the decisions being made in our legislature and on the ballot. Fortunately, we have allies in Assemblymember Dr. Richard Pan, the CMA, patient advocacy groups and health care stakeholder organizations across the state that understand what is really at stake. Being able to attend the CDP convention was a great opportunity to do my part in advocating for the preservation of MICRA and health care in California. Furthermore, by attending this convention, we saw and met inspiring leaders. Receiving words of encouragement from Congressmember Ami Bera, MD, Assemblymember Richard Pan, MD, and CMA President Richard Thorp, MD, has

further motivated me to continue to be involved in health policy and advocacy. Although our advocacy at the CDP convention was a success, there is still a long road ahead of us before this battle over MICRA is complete. Led by the CMA, a broad coalition of advocacy groups will be working hard to inform the people of California about the detriment that the ballot initiative will pose to our stateâ&#x20AC;&#x2122;s health care. I hope that you will join us in this fight.

Over 150 residents, medical students and physicians gathered at the March California Democratic Partyâ&#x20AC;&#x2122;s Convention in Los Angeles.

jjaboube@gmail.com

May/June 2014

Most Memorable Scut Work Experience As an Internal Medicine Intern at UCD in 1974, there was plenty of scut work, including starting all the IVs. One particularly memorable night on call I was asked to restart the IV of a confused man who repeatedly pulled out his IV. Getting pretty frustrated after several restarts, I told the fellow that he was running out of accessible veins. I then pointed to the dorsal vein of the penis and told him that would be the only site left if he pulled out my latest restart. I didn’t get called again that night to restart his IV. −Mark Blum, MD My most memorable scut work was a medical school summer job in the VA morgue. My job was to “run the bowel.” I had to open the large and small gut to check for obstruction and foreign bodies. Not fun. The lab supervisor thought it was funny, though, and enjoyed delegating that task to me. −Schery Mitchell, 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 was as a junior medical student in 1971 at University Hospital in Ann Arbor, Michigan. I drew blood on an elderly patient who had been transfused with two units. I used a needle and syringe, which was the standard method at the time. Holding the red top tube between my left thumb and index finger, I stuck myself. At the time, the hospital was not liable to affiliated medical students for providing unsafe tools to perform scut work. −Gerald Rogan, MD While an intern at Seattle’s King County Hospital, we admitted the official dogcatcher of Renton, WA, about 10 miles south of downtown Seattle. He was agitated, flushed, sweating and tachycardic. He had accidentally shot himself in the right foot with a special pistol designed to

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tranquilize aggressive dogs. An assistant brought in a kit which contained a graduated set of vials of varying concentrations, based on the estimated weight of the dog. His vial was for a 60-80 pound animal. On the boxed kit it said the active ingredient was “Nicotinic Alkaloids,” made by a chemical firm in Atlanta, GA. My intern job: find out what the hell that was. After securing county clearance for a long distance call (“Keep it short, please.”), I reached the company after many rings, and a man with a heavy Georgian accent said, “Hello.” He said it was the lunch hour, and that he was the only one there. I explained the urgent basis for my call (a life might hang in the balance), and begged him to find some company handbook or brochure that could clarify the active ingredient. He replied that he “weren’t no scientist,” but that he would do his best. After a minutes-long pause, he came back on and said, “I think I got somethin’ but I can’t rightly say it, so I’ll spell it for you.” Imagining my triumphant return to the treatment team, and with pencil poised, I heard him slowly begin: “N...I...C....−”, as he spelled out “Nicotinic Alkaloids.” I returned, tail “twixt legs” to the care team, with my story of unproductive scut work. Nonetheless, the patient recovered well. −David Dozier, Jr., MD Though scut work contributed to long work hours, most scut work I did was not wasted time. Learning to draw blood from diverse sites, insert lines, read blood smears and perform gram stains and urinalyses was educational. I understand test results far better than if knowledge had been gained only from a book or algorithm. We did most all procedures, re-learning anatomical variations along the way, and gaining an understanding of procedure

to the touch than any AIDS-related illness. − Katherine Stewart, MD

limitations and what patients endure. The most irritating scut work was having to walk to the VA hospital laboratory to beg the technician for a stat lab test or to retrieve a test result because the nursing staff was too busy eating donuts to retrieve it. There I gained only an understanding of institutional hierarchy gone wrong. Interns were definitely the lowest of the low-caste. −Ann Gerhardt, MD

I was sent to disimpact a patient once. I learned the importance of face masks and nurses that day. God bless the nurses for the Missions Impossible that we send them on. − Nate Hitzeman, MD Typically when one thinks about scut work, the memories are of residency. However, my most memorable experience came during a strike by Local 250. During the strike, the physicians were “asked” to perform the duties of striking employees. My tasks ranged from being an assistant to the ostomy nurse (a real jerk) to housekeeping. It was enlightening to see how many health care professionals simply discard trash on the floor expecting someone else to pick it up (and don’t even ask about the doctor’s locker room). The nadir though, even lower than cleaning patient toilets, was being asked repeatedly to sweep the stairwells. Did I really spend eight years in medical school and residency for this? −Gary Roach, MD

As a third-year student at LA County USC Medical Center, our scut work included blood work draws, especially for any patients that the nurses deemed difficult. One patient I cared for was a young man in his 30s who had a fever and a weird red rash. Because of his “work” at a gay bath house in LA, and his reported 200+ partners per month, the nurses were afraid he had that “gay disease,” at the time known as GRID, and often equated with Kaposi’s sarcoma. His rash didn’t look like Kaposi’s, and he was in for evaluation. In those days, we didn’t usually use gloves for phlebotomy, so as to better be able to feel the veins. In his case, I used gloves – luckily, since the rash turned out to be secondary syphilis – far more contagious