2015-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2015

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Medicine 3

PRESIDENT’S MESSAGE Recruiting for Next Year’s Leaders

These Words, Our Work, Your Worth

Caroline Giroux, MD

A Mission to Brazil

John Loofbourow, MD

Jason Bynum, MD

EDITOR’S MESSAGE Oh, The Places We Will Go

Nathan Hitzeman, MD

SSVMS Summer Social

EXECUTIVE DIRECTOR’S MESSAGE Make the Most of Your Membership

Aileen Wetzel, Executive Director

GUEST COMMENTARY Objections to Workers’ Comp Proposed Changes

e.Letters to SSV Medicine

Liliana Loofbourow

A Small Heart Transplant Program That Thrives

The Art of Commenting to Government Agencies

Gerald Rogan, MD

Ann Gerhardt, MD

The Day I Caught Up

Call for Awards Nominations

Nathan Hitzeman, MD

Phoenix From the Fire

A Posit Addressing Scribes

Laura Bemis

Rogan’s Rules of Medicare

Promise in the Battle Against Schizophrenia

Gerald Rogan, MD

John Paul Aboubechara, MS III

Board Briefs

BOOK REVIEW Health Care Crisis or More Misinformation?

Welcome New Members

Classified Advertising

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 The cover image by John Loofbourow, MD, is of beautiful carved fruit in a Brazilian roadside fast food restaurant called Bob’s Burgers. Space here is limited, but other scalable photos are viewable at nwalmanac.wordpress.com. Dr. Loofbourow traveled to Brazil this Spring to volunteer at a home for invalids. He shares his experience on page 18.

July/August 2015

Volume 66/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2015 Officers & Board of Directors Jason Bynum, MD, President Thomas Ormiston, MD, President-Elect José A. Arévalo, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Laurie Gregg, MD Vijay Khatri, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD

District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Kieu-Loan Luc, DO

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 Maynard Johnston, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Adam Dougherty, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Thomas Ormiston, MD Richard Pan, MD, Senator Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD

District 1 Kevin Elliott, MD District 2 Don Wreden, MD District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Sean Deane, MD Kevin Jones, DO Thomas Kaniff, MD Olivia Kasirye, MD Vijay Khatri, MD Sandra Mendez, MD Patricia Samuelson, MD Armine Sarchisian, MD Vacant Vacant Vacant Vacant Vacant Vacant

CMA Trustees District XI Barbara Arnold, MD

Douglas Brosnan, MD

Richard Thorp, MD

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS III George Meyer, MD Sean Deane, MD John Ostrich, MD Adam Doughtery, 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 Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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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.

CMA Imm. Past President Richard Thorp, MD AMA Delegation Barbara Arnold, MD

Membership Has Its Benefits!

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

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. ©2015 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

Recruiting for Next Year’s Leaders By Jason Bynum, MD FOR THOSE OF YOU WHO read my President’s Message in the last edition, a brief update is in order. Things are better, and I’ve been able to return to work full steam. As one may guess, however, when dealing with an ill child for several months, I have returned with a different view of my profession, my advocacy and my personal life. And, I have returned with renewed vigor on the Board and in organized medicine, in general, as I see this as an opportunity to express my views as a physician in a much broader sense than in my own office or practice. With that in mind, we recently had our Board of Directors meeting in May, and one of the agenda items was approval of the 2015 Nominating Committee (Drs. José Arévalo, Chair; Barbara Arnold, Katherine Gillogley, Marcia Gollober, Ruth Haskins, Ulrich Hacker, Richard Jones, Steven Kelly-Reif, and Pat Samuelson). The committee’s task is to nominate members to fill vacancies in 2016-2017 on the SSVMS Board of Directors and the Delegation to the CMA House of Delegates, where policy from the statewide medical community is heard and debated. I would strongly encourage you to consider becoming involved by seeking nomination to one of these vacancies. In the course of the last year, SSVMS and CMA played a major, if not key, role in defeating Proposition 46 (MICRA overhaul), which would have affected us all on a very real level. This year, issues in the legislature include the hotly-debated vaccination bill, brought by our distinguished SSVMS Past President and State Senator, Richard Pan, MD, as well as various scope-of-practice bills, SB 128, the Death With

Dignity bill, and continued implementation issues with the Affordable Care Act. I am sure we all have opinions around the dinner table or department meetings on all of these issues, and I encourage you to bring those opinions to an organization which can amplify your voice. What I have always been amazed at by SSVMS and CMA is their receptivity to new ideas and new trails to advocate, all in an atmosphere where the stereotypical “doctor attitude” is left behind. Please join us in expressing our individual views and concerns by adding your own to continue the route of policy advocacy. Lastly, I returned not only with ideas on how to implement change in the medical community, but also with a renewed interest in my own well-being, both physically and mentally. In psychiatry training, much time is spent in reflection on concepts such as countertransference (your own feelings about a patient based on your own history), limits on provision of care in emotionally fragile patients so you yourself don’t burn out, and monitoring yourself for signs of anxiety or mood disorders. As a result, I’ve returned, at least as much as I can, to my personal outlet of woodworking. Sitting in a chair holding a baby with respiratory issues and reflux vertically for weeks on end has given me a lot of time with my iPad. I’ve decided to “de-evolve” my wood shop and move into more hand-tool techniques. While I have yet to actually produce any wood products due to time limitations, I have been able to move out of my small shop and into our two-car garage (with a little bribing of my wife). continued on next page July/August 2015

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 picked up a set of hollows and round planes from an 18th century London plane maker, a kit to make a handmade panel saw for cutting my own veneers, and a turn-of-thecentury vintage Stanley 55, often referred to as a “planing mill in itself.” It’s kind of like a transformer of hand planes, and can cut various profiles. My plan is to start with pine and make picture frames for our numerous baby pictures, which are currently strewn about. Then, who knows, maybe I’ll move on to that coffee table in my mind with ogee-profiled edges and vine carved corner medallions. Why am I blabbering on about physician advocacy in the same article as woodworking? Because for me, these have been filtered down into two of a handful of passions which are clearer to me after the past few months. I think it’s important for all of us to provide care for our patients, do our part in the greater good, and also keep ourselves healthy.

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I saw a television show called “Craftsman’s Legacy” where a man said, “I left corporate America to work with my hands in order to feed my soul.” While I won’t be leaving my profession, I personally have found it helpful to have a tangible object after hard work, as compared to our service industry with endless need. I also think that as physicians with limited time, networking in your local Sierra Sacramento Valley Medical Society (here’s the point) can not only bring you closer to your political views, but also to collaboration with peers on a personal level you may never otherwise have. And after that shameless plug, I would end this article with a final word to join SSVMS in a more involved manner for your own passions, whatever they may be. jbynum23@me.com

Editor’s Message

Oh, The Places We Will Go By Nathan Hitzeman, MD THE SACRAMENTO BEE RECENTLY changed its format. Their editors’ pictures show affable, but more haggard, visages. Constant deadlines will do that. Well, I’m not updating my SSVMS photo anytime soon, and we were a bit behind schedule this issue partly due to travels. I’m thumbing this message from a layover on the way to Nicaragua with UC Davis MEDICOS program. Docs like to travel, but detaching ourselves from our practices seems increasingly hard to do. “I only want to leave for eight days. Just let me leave in peace. Don’t have a crisis now! “Don’t tell me you didn’t get the report for the admin work I loathe, but tolerate. “Why is my computer slow? I’m calling my own doc for Xanax!” In this issue, you will enjoy Dr. John Loofbourow’s exhalation of his trip to Brazil. Being open to new interactions and having a flexible itinerary are key. Why do docs enjoy travel? We specialize in keen observation and dealing with a large swathe of the public. We notice the anxiety spectrum of patients on the plane. We note the general health and habits of people at our destinations − how many kids they have, gender roles, religion, tolerance, hygiene. Some things are so different − I remember a trip to Nepal where I was awakened the first morning by the whole town clearing phlegm from their throats. Sometimes things are eerily similar. Dr. Loofbourow practically stumbled upon our SSVMS’ curator’s long lost brother, Juan Carlos LaPerriere in Sao Paulo. I don’t make it to as many exotic places as I did in the B.C. era − before children − but I always enjoy travelling vicariously through our SSVMS contributors. Perhaps you would like to share your travel story?

Also, in this issue, Liliana Loofbourow reflects on workers’ comp. We can learn from travelling back in time as well. My family and I recently visited the Hoover Dam outside Las Vegas. An engineering feat in the Great Depression era and even now, it was built in four years (two years ahead of schedule − take note CalTrans!). Thousands of men gladly worked year-round with their only holidays being July 4th and Christmas. They bored huge tunnels and swung down rock faces with jack jammers. As far as I could tell at the exhibit, there were no fatalities. In this era of OSHA and workers’ comp, I wonder if such a physical feat could be done? Horrors that they didn’t have urine drug testing, titer checks, and sensitivity training back then. We are becoming an increasingly disabled society − both physically and mentally. We can choose to allow a future of depression, substance abuse, fibromyalgia, and bulging discs. Alternatively, we can strive for social wellness, community identity, and grand achievements that honor those who have worked so hard before us. With that, I’m turning off this electronic device for eight days. Adios! hitzemn@sutterhealth.org

Workers on the Hoover Dam project during the Great Depression were not protected by the numerous safety regulations we have today.

July/August 2015

Executive Director’s Message

Make the Most of Your Membership By Aileen Wetzel, Executive Director WHETHER YOU ARE A longtime member of SSVMS/CMA or have recently joined, these three steps will guide you in maximizing the value of your dues investment.

GET STARTED Visit www.ssvms.org and www.cmanet.org to get acquainted with our offerings and dive right in: LOGIN and complete or update your member profile. ACCESS members-only resources, such as sample letters and toolkits, practice management tips and medical-legal resources. FIND a complete listing of upcoming educational and social events.

GET CONNECTED Visit www.ssvms.org and get linked to the programs and resources: CONNECT with other members as well as SSVMS and CMA on Facebook and Twitter. FIND the educational program – in person or online – that’s right for you. STAY INFORMED on the latest legislative issues affecting the practice of medicine by reading SSV Medicine, SSV Medical Society News, CMA Alert, or CMA Practice Resources (CPR).

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.

GET INVOLVED

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Visit www.ssvms.org to discover volunteer leadership opportunities that will increase your visibility and influence in the community, and find ways to give back to the profession: VOLUNTEER with a council or committee.

GIVE BACK by donating medical services to our region’s uninsured through our SPIRIT program. HELP with a tax-deductible donation to the programs and initiatives of SSVMS’ Community Service, Education and Research Fund (CSERF). At SSVMS, it is our goal to empower you with the tools and resources you need to increase practice viability, eliminate administrative burdens, and give back to the medical profession. We’re glad you’ve joined us, and we look forward to serving you. awetzel@ssvms.org

e.Letters to SSV Medicine Medical Student Die-In, May-June 2015 issue For each alleged case of abuse based on race or sex, there is some possible justification. Therefore, it is foolish to make any conclusion based on a single episode. On the other hand, when the allegations, evidence, and video evidence of abuse are so frequent, so common, and so credible, the conclusion is unavoidable. It happens. It happens often. There is no need to enumerate the cases that have come to light in the past few years. It suffices to state that action and reaction are essential. That is why I admire and support the UC Davis medical students who demonstrated their position so graphically by their recent

“die in” as portrayed on the May-June cover of SSV Medicine. I, unreservedly, admire their courage, sensitivity, and willingness to act personally, peacefully, and dramatically. −John Loofbourow, MD

Drought 2015: A Public Health Report, May-June 2015 issue NICE article, Dr. Lyman: well written, concise, applicable. A good overview of the concerns apparent during this drought in 2015. You did a great job identifying health concerns and tying those to the medical society’s efforts to advance the public’s health in the advocacy arena. You are the right pick for Chair of the Public and Environmental Health Committee. −Jeff Clayton, MD

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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.

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July/August 2015

A Small Heart Transplant Program That Thrives 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.

THE NATIONAL QUALITY Rating Database, maintained by CareChex, a division of Comparion, rated Sutter’s Heart Transplant and Specialty Services Program #1 in California for the second year in a row. CareChex compares all programs that do heart transplant and/or mechanical circulatory support (which is why there are hospitals rated in the top 10 that do not do transplant) and rate them according to complications, inpatient quality, mortality and patient safety. Sutter’s Sacramento program consistently does extremely well, better than the well-known university-based programs. We’re the best little heart transplant program that you’ve never heard of. Michael Ingram, MD, our longest-serving transplant surgeon, attributes our success to two things: teamwork and follow up. First, he credits the whole transplant team, including the phenomenal nurse coordinators, dietitian, pharmacist, social service team, financial manager and doctors, as well as the hospital staff and the very helpful people at BloodSource. Most of the team has stayed with the program long enough to know both good transplant care and our patients, thus providing real continuity for them. Second, he values the fact that we closely monitor and “mother” our patients for the duration. Unlike some of the big programs, we don’t hand off transplant care to outside caregivers who may know little about the medications and potential complications. Sutter does not do a large number of heart transplants. The volume distinction goes to Cedars Sinai Medical Center Los Angeles, which

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performs well over 100 per year. They set the national record last year at 124. Since doctors Doug Schuch, Mike Ingram and Paul Kelly performed Sutter’s first heart transplant on February 16, 1989, we’ve transplanted only 171. Three of the first 10 are still alive and thriving. Our program’s strength has always been quality, not quantity. We are the exception that disproves the pervasive, but irritating, rule that volume equals quality. In 1997, we were the first heart transplant program in the country to be certified by Medicare, based on quality alone. They had volume criteria that we hadn’t met, but Sutter argued effectively that our one-, three- and fiveyear survival rates, as well as outstanding general cardiothoracic surgical volume and outcomes, were so good that Medicare patients deserved access to our services. Occasionally, Medicare questions our volume, and the newspaper makes it sound like the program has closed, but we continue to maintain our certification, transplanting about 10 patients per year. In 1989, Dr. Kelly created a heart transplant team consisting of surgeons, cardiologists, and internist/nephrologist Dr. Jane O’Green Koenig. They were relatively conservative, choosing patients with few co-morbidities who were motivated to take care of themselves afterwards. Cardiologist Dr. John Chin’s patient was our first transplant. He suffered a cardiac arrest in the OR while waiting for the donor heart to arrive, but was successfully transplanted and is shown in the picture, at right, with his surgeons. With that success, Dr. Chin was sold on heart transplant and is now the program’s medical director.

Sutter Hospitalâ&#x20AC;&#x2122;s Heart Transplant Team in 2014.

The surgical team was smart enough to know that post-transplant survival depended on more than surgical technique. I was hired in 1990 to help with nutrition, exercise and disease prevention, long before the big programs paid any attention to those issues. When Dr. Koenig shifted her focus entirely to kidney transplants, I shared the fact that I had done immunology graduate work and post-liver transplant care, and gradually assumed the medical aspect of post-heart transplant care. We remain conservative in our approach, but aggressive in keeping patients alive and rejection-free. In 2005, Robert Kincade, MD, started Sutterâ&#x20AC;&#x2122;s VAD (ventricular assist device) program. With mechanical circulatory support, we can keep qualified heart failure patients alive long enough to find a donor for transplant. The VAD program has become one of the most active in California. It has earned awards for quality every year since 2010, in no small part due to hiring experienced nurse practitioners and Jeffry Jones, MD, becoming our dedicated intensive care doctor. Doctors Chin and Kincade helped UC Davis and Mercy General Hospitals set up their own VAD programs, extending availability of advanced heart services to others in the community. Sometimes great things come in small packages, but we are growing as

we transplant more patients who live a relatively long time, and we assume post-transplant care of patients from CPMCâ&#x20AC;&#x2122;s program. Regardless of size, the staff continues the comprehensive and attentive care we have always given to our patients. algerhardt@sbcglobal.net

July/August 2015

Call for Awards Nominations Nominations are being sought for the Societyâ&#x20AC;&#x2122;s most prestigious awards to be presented to the recipients at the annual meeting in January 2016. The Golden Stethoscope Award, the Societyâ&#x20AC;&#x2122;s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El Dorado-

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Sacramento-Yolo region. The candidate must be an SSVMS member for at least 5 years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship and Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, cstincelli@ssvms.org. Deadline: November 1, 2015.

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July/August 2015

Phoenix From the Fire Learning Tools to Cope With Mental Illness

By Laura Bemis MY LIFE IS ONE OF REBIRTH. After years of struggling with multiple suicide attempts, three years of electroconvulsive therapy and more psychiatrists, psychologists, doctors, hospitalizations and therapists than one can ever imagine, I have been lifted from the fire to where I am able to move to a new relationship with my mental illness. Don’t get me wrong − I still struggle daily to function effectively, but unlike now, my mental illness was a blazing fire in the late 1980s through the early 2000s. I fought through psychosis, schizophrenia, major depression, PTSD, dissociative identity disorder, and numerous other diagnoses. I am now stabilized, and am becoming less ashamed to be “labeled” mentally ill, which now allows me to help others. I am one of the first speakers trained through the organization called, Stop Stigma Sacramento Speakers Bureau. Now, all those dark tunnels of horrifying situations that I call “my fire,” are the backdrop for being able to relate to, comfort,

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.

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and assist others in finding help so they can rise from the flames. The Speakers Bureau gives me the opportunity to share my story with others in hopes of eliminating the stigma around mental illness, and to help those who may find themselves entering the fire. Not only do I speak for the Sacramento Speakers Bureau, I also help others to write their stories. I talk to groups from high school age on up, basically anyone who might be receptive to the organizations tagline that, “Mental Illness is Not Always What You Think.” To promote “Mental Illness is Not Always What You Think,” my picture is on three billboards and my story is told in the group’s literature. All emphasize that I am a functioning partner and photographer living with depression. Agreeing to be so visible was a great achievement in my self-awareness. Sometimes I don’t believe that I have any mental illness, yet I do. The advertising is a way of reaffirming to myself, and to others, that it is

okay to be “labeled” as mentally ill and still be of value to society. I am not sure when my mental illness began; however, at age 18 I was raped and it left the first major internal scar. After the rape, I never sought treatment and I blamed myself for being in the wrong place at the wrong time with a person who took advantage of my naive, trusting soul. I truly believe this was the “trigger” that lit my personal fire. From that day forward, I was not the same person I used to know. After I developed Anorexia Nervosa and was hospitalized for six months, away from family and friends, I began getting help, yet I never spoke about the trigger. I learned self-mutilation from another patient while in group therapy at the hospital. I lost a lot of friends, as well as the husband I had married just six months prior to my hospitalization. From there, my story evolved into a horror story of self-destruction, disassociation, despair, depression, and more. I tried to take my life several times, with at least four episodes landing me in the ICU. To this day, I do not know why I lived through my fire, except for the exceptional care from my doctor and the medical staff, and a deep desire to live. I do not know if I will ever “recover” from my

Samples of Laura Bemis’ photography include a self-portrait, at lower left, and this image, truly expressing that sometimes “time hangs heavy.” The billboard at far left was one of four that appeared in the area from March to May of this year.

mental illness, but I have learned many tools throughout the years to help me cope with the disorder that challenges my daily living. I came from the bottom to a place where I can proudly say, I am more confident, and I am the Phoenix risen from the fire. Presently, I hold two paying part-time jobs. I am a photographer for a local newspaper and the Coordinator for “In Our Own Voice” (IOOV) with the National Alliance on Mental Illness (NAMI) of Sacramento. I have been trained as a speaker for NAMI and will be in charge of the NAMI Sacramento “Crisis Intervention Training” (CIT) speakers who share their stories to law enforcement. I volunteer on the Sacramento County Mental Health Board, and currently hold the position of secretary. The Mental Health Board makes recommendations to the Sacramento County Supervisors concerning Mental Health Services (MHS) budget adjustments, new policies, contractors, and present services in the county. I enjoy taking tours of new and existing programs and seeing, first-hand, how the distribution of services is affecting our community. continued on page 15

July/August 2015

Promise in the Battle Against Schizophrenia By John Paul Aboubechara, MS III

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

MENTAL ILLNESS IS A CRUCIALLY important challenge facing our society. Probably each of us can identify a loved one who has been affected by some form of mental illness. The impact is not limited to the emotional well-being of the individual inflicted; it has far reaching effects on all those with whom they interact, and even on the broader economy. Unfortunately, there remain insufficient resources to care for all those who suffer from mental illness — but this is a topic for another discussion. As a medical student, I have cared for many patients with mental illness. The most frustrating among them to treat were those who suffered from schizophrenia, largely because of how disabling and refractory the disease proves to be. Schizophrenia is a heterogeneous disorder with patients experiencing any of a number of symptoms. It may consist of positive symptoms such as hallucinations, delusions, or disorganized speech, or negative symptoms of a flat affect or poverty of speech, and impairments in cognition including attention, memory, or executive functions. The World Health Organization has ranked schizophrenia as one of the most globallyburdening illnesses because of how disabling and economically catastrophic it proves to be. In fact, schizophrenia afflicts about one percent of the world. Other than a slight preponderance in men, it is equally prevalent in people of all demographics. Treatment of schizophrenia can involve any of a number of antipsychotic medications, as well as psychosocial interventions. Antipsychotics act primarily by decreasing the

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effect of dopamine in the brain. However, these medications can cause a number of serious side effects because dopamine is important for a number of unrelated neurological processes, including voluntary movement. The finding that all antipsychotic medications block dopamine receptors in the brain led to the hypothesis that schizophrenia is due to some aberration in dopamine signaling. What exactly caused this dysfunction has remained unknown. Recent research has implicated immune mechanisms in the development of schizophrenia. It is believed that the disease begins when a child is still in its mother’s womb. If the mother suffers from some sort of infectious process, it is believed that the mother’s immune system may inadvertently penetrate the brain and damage the developing neural circuitry — a phenomenon dubbed “maternal immune activation” or MIA. Research on this hypothesis is being led by scientists at UC Davis. In fact, the UC Davis Center for Neuroscience was recently awarded a prestigious grant to establish a Silvio O. Conte Center for Basic and Translational Mental Health Research, making UC Davis one of only 15 such institutions nationally to receive this honor. The center has developed a multi-pronged approach to study the effects of MIA on brain development. At last, there is hope to potentially understand schizophrenia, and to develop new preventative and treatment approaches. The timing of this grant award lines up nicely with my own training aspirations. I am a student in the Physician Scientist Training Program at UC Davis, wherein I am pursuing both MD and PhD degrees. I recently finished

my second year of medical school, and took the anxiety-provoking Step 1 board exam. Starting this fall, I will begin to work toward my PhD in Neuroscience, and I hope to join the team at the Conte Center. As a future physician-scientist, I am in awe of the exponential growth of biomedical research. In particular, I am inspired by the potential to finally have treatments for those afflicted with diseases that were long deemed untreatable. Neuroscience is particularly appealing because it allows me to simultaneously study

human disease and to address my philosophical needs to understand the nature of the mind and our existence. In fact, ever since I was introduced to neuroscience, I have been dumbfounded by its potential. How awesome is it to think that the mind, my mind, my entire being, my beliefs, memories, dreams, and aspirations, are the sum of an incredibly complex network of neurons? With all of the problems facing our health care system, it is easy to be pessimistic. But I, for one, am extremely optimistic for the future. jjaboube@gmail.com

Phoenix continued from page 13 I wish my story of hope, determination, and perseverance will give you a new perspective on severe mental illness. It is not hopeless: Proper treatment and perseverance can lead not only to

existing in society, but also to being a productive member giving back to others in need. mycameras64@yahoo.com

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July/August 2015

Book Review

Health Care Crisis or More Misinformation? Two Days That Ruined Your Health Care, by William C. Waters III, MD, Publisher Logikon, ISBN-13: 978-0977128839

Reviewed By Lee O. Welter, MD

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

THIS IS A BRIEF REVIEW of an article and a book, but first let’s put it in perspective. In an interview 35 days before his presidential term ended, President William Clinton referred to the lack of a prescription drug benefit as “a fatal flaw in American health care.” Ironically, “A Fatal Flaw in American Health Care” is the title of an article by James G. Knight, MD, President, San Diego County Medical Society, published in the CSA (California Society of Anesthesiologists) Bulletin, July-September 2003 issue, page 76. Dr. Knight referred to the disconnect of patients from personal responsibility for their medical expenses, promoted by federal legislation during, and shortly after, World War II. He also mentioned a relevant study, The Health Insurance Experiment, conducted in the 1970s and early 1980s. See the RAND website www.rand.org/health/projects/hie/ about the study which addressed “two key questions in health care financing.” How much more medical care will people use if it is provided free of charge? What are the consequences for their health? The RAND Health Insurance Experiment Study “…showed that modest cost sharing reduces use of services with negligible effects on health for the average person.” Dr. Knight reported that a cost disconnect had increased outpatient costs by 67 percent and inpatient costs by 30 percent. And, “…there was no evidence of any increased health benefit

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for those with free or nearly free care versus those with high-deductible coverage… [$1,000 maximum out-of-pocket].” This vital issue is even better addressed in a book: Two Days That Ruined Your Health Care, by William C. Waters III, MD, ISBN-13: 978-0977128839. The first phase of problem-solving is to define the problem. Those who cannot learn from history are doomed to repeat it, said philosopher and essayist George Santayana. Do we really have a “health care crisis”? It must be so, even if politicians only use this claim to gain more power. Do we really need to read thick history books with yellowed pages in order to understand our predicament? NO! The history in Dr. Waters’ book begins on the First Day, October 2, 1942, with the Stabilization Act of 1942. The Second Day was April 10, 1965, when the Mills Bill, HR 6675, aka Medicare, was enacted. Despite the book’s political overtones, Dr. Waters claims his only political affiliation is the small, unpopular Realist Party, for which he is a recruiter. Terse and entertaining, the blend of lively dialogue and often amusing anecdotes makes the book hard to put down. It’s ideal for a two-hour (uneventful commercial) airline flight or a few treadmill sessions. Dr. Waters explained details of HIPAA to a Senator who appeared nonplussed and responded, “This is like Nazi Germany, not

America. How in the world did this get passed?” When Dr. Waters asked, “You were one of the 100 Senators who voted for passage, weren’t you Senator?” the Senator looked worse than nonplussed. Despite Waters’ initial downplay of politics, he cannot ignore threats of further political meddling in addition to our current government burdens created by the Two Days. Published in September, prior to the 2008 presidential election, the author considers health care proposals of two prominent candidates. Which program is like “pouring kerosene on what is already a lively blaze”? Online reader reviews of the book are very positive:

“Positively the best and the most readable analysis that I have ever read about what goes on at the ‘Healthcare Laundry’ and how to fix it...” −Jane M. Orient, MD, Executive Director of the Association of American Physicians and Surgeons. “This book should be required reading for all the politicians in Washington who are largely responsible for the mess we’re in.” −S. Robert Lathan, MD. To his credit, Dr. Waters offers hope and suggestions for a constructive solution, as well as six+ pages of End Notes. lwelter916@att.net

These Words, Our Work, Your Worth By Caroline Giroux, MD Our fingers touch the chalk You are the story, stark Your voice flows, Yet you don’t glow

Since the knights of time You have been stuck in your legend But every ordinary being Deep inside, hides a hero in the end

Your locked up words Never uttered before Paths to unfolding scars To my innocent ears, feel like swords

Stone after stone You can erect a new shrine Where the vine Grows with dreams you own

Still, it is not you Who hurts me so fast But those who hurt you In a forgotten past

Lift your chin Nothing can spoil your riches Nobody can steal what lies within Learning from you we must!

Together we visit this dark land Together we can stand Dusty ruins we find A new light must shine

Your hand holds the chalk There is no more fear of the dark You rewrite the story This tale of glory cgiroux@ucdavis.edu

July/August 2015

Mission to Brazil This article is excerpted from seven Brazil and Chile letters written in Feb-Mar 2015. The originals, with many scalable photos, can found at nwalmanac.wordpress.com.

By John Loofbourow, MD

Monday Feb. 16, 2015

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 am a Methodist by virtue of family, and inclination, who has participated in several Volunteers in Mission (VIM) projects; I find the people who do this sort of thing are unusual and outstanding in the best sense of the words. We are six people, middle-aged or retired, who meet at the São Paulo Airport. We split up into two rented vans and drive four hours north to a small town in Minas Gerais. The drive is fraught with adventure and misadventure; yet we arrive. All other logistical details have been arranged by VIM. Frank, who drives our van, is from Oregon and has never been out of the USA. He spent his career in electronics, is retired, now trying to develop a practical small hydrogen generator to split water into its gasses, set them on fire, making energy and water again for another cycle. His workshop has only blown up twice. The guiding spirit of the project is a Brazilian expatriate living in California. Our trip leader − let’s call him Ted – is from Silicon Valley, compulsive and aggressive. Probably that’s essential there. But he is also a gourmet cook who prepares our meals in a rented farmhouse. He constantly speaks of herding cats; yet he, himself, is an extraordinary cat who has led many other VIM missions. Two other volunteers are, one way or another, associated with prominent high-tech families. We spend the next 10 days working on an asilo, a home for the old and handicapped. It has been a long-term project, the resurrection of a large residential building abandoned several decades ago. Yet, it is now reaching a state of

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viability, with increasing support from the town people, who, at first, were quite dubious, if not scornful. We prepare and paint the interior and exterior of the second of three buildings. This time some people from town, and residents of the asilo, join us. The experience is extraordinary. That is also the perfect word for people who leave their comfortable homes and pay their own way to a remote part of the world in order to try doing something that might be illusory or idealistic, but takes them to a place that is new and renewing, where there is much to be done. I find that missionaries, whether secular or religious, are the same people wearing different clothes who live both within and beyond their own lives. After our work is complete, Carnaval begins. It lasts about four days, shorter and lower-key by comparison with cities. It is less crowded than I remember last time, less beer, more friendly; maybe that’s because the country – indeed the world – is more reflective than it was then. Everywhere government is unpopular, corrupt, bungling, and worse: powerless. Brazil is no exception. Some things like this annual celebration endure, because they spring from societal angst. On a Saturday afternoon, I watch a Samba school band practice for their competition. Maybe 40 people. A leader starts to conduct from the front, then moves around constantly into the band, urging them on with rhythmic jumping, shouting instructions, arms pumping up and down for emphasis, blowing on a police whistle to signal certain changes or rhythms. Toward the rear are 10 or 15 teen boys and

At far left, volunteers paint and tidy up a facility for invalids in Brazil. At near left is Dr. John Loofbourow in the futbol stadium.

girls; they beat small metal-rimmed plates, with varying metallic sounds. I visit Nana, a 90-year-old matriarch, who occasionally lends me her Wi-Fi connection; she is in her kitchen, on her own computer, copying verses from the Bible in huge text. After writing for an hour, I relent. She loves to talk, is in the last years of a long difficult life, quite alert, and lonely at times. We speak together for hours, almost understanding one another. We talk of everything and nothing. Once she says, “a mea mae estaba en cadeira de roda por seis anos.” I am challenged by the consonants and 16 variable vowel sounds; and by the miscues I get from both Spanish and English. After a time, she makes clear she means wheelchair … cadera means hip in Spanish, while in Portuguese, cadeira is chair; roda begins with the sound of h. (My mother was in a wheelchair for six years). I break out my hearing aids. She’s somewhat hard of hearing, too, so I pass her one. We continue, each one-eared. Nana had tried some hearing aids before, but my Costco’s seemed much better, so she plans to get a pair. Out of that decent, healthy countryside, I venture into rough, tough, raucous São Paulo. If Rio de Janeiro is the beautiful painted lady of Brazil, São Paulo is its body and soul: Futbol, Samba, and industry. I often go to a corner restaurant – Segredos de Minas (www. segredosdeminas.com). I like the name – Secrets of Miners. It reminds me of the 13 little mining towns of my childhood, even though the restaurant has nothing to do with mines, except history, and an extract from a poem by Frei

Betto on the back of the menu: Segredos de Minas. Minas and mineros remain a treasured part of the national lore. When there is a chill breeze at night, I order hot soups. They come boiling in big clay pots with a ladle in the middle, accompanied by buttered garlic bread. I order water sem gas (no gas). And possibly an espresso later, but not too late. Yes, I’m an old man. One reason I stay on in São Paulo is a disease: xenophilia, love of the other. Besides, I have a conceit about being an American; one living in both our continents; an America with three major languages. Brazilian is the one I most lack. What better way to learn than immersion? This is my third São Paulo trip, but the others were touristic and short. I did study some before coming; the overlap between both English and Spanish, and Brazilian, is sometimes helpful, sometimes very misleading! Even so, I can now read almost everything. I can make myself understood fairly well because, when totally lost, I revert to gestures and to Spanish. Nonetheless, I can hear almost nada, except when the subject is quite clear, as on TV news about assault, murder, robbery, ads, erudite art, news… etc. Of course, teenagers talk in strange tongues in Brazil, as they do everywhere. It seems to me Brazilians are reliably tolerant, and considerate, even in crowds. On July/August 2015

have to go elsewhere for water, as in some San Joaquin Valley towns. But at least so far, these 15 or 20 million Paulistas have water; the parks and rural fields are green and the São Paulo faucets put out clean, chlorinated water, with only occasionally a slight musty smell. Everyone who can, continues to choose bottled water in a determined effort to fill the ocean with plastic garbage, which is, of course, oil.

Monday Feb. 23, 2015

Above is a view of the Brazilian countryside.

the subway escalators, people politely, almost always, move to the right (like the sign says!) To allow those in a hurry to pass. Drivers are courteous, even in this city of perhaps 15 to 20 million. People are almost always ready to answer questions, even when they aren’t clear about the question or the answer! There is a rather ordinary Brazilian machismo; it’s reflected in the Futbol museum, a multi-million dollar homage to maleness. Yet, Brazilians are very attuned to the USA, and there are prominent informational items everywhere on the social, sexual, environmental and nutritional matters we dote on in the USA. There is a general tolerance of the other, with some exceptions: the homeless and the drug-addicted are ignored almost completely. I suppose people assume they don’t vote, or contribute much in any other way. In that sense, this is a harsh or practical reality. Is it tough love? I suspect it is. That of a country on the move. Street sleepers are usually gone by 10 am. In my upscale Paulista area, they are…where? The “millennials,” young, educated adults, are, it seems to me, like their peers all over the world. The world is, says CNN, concerned about the closing down and evacuation of many millions in São Paulo due to lack of water. There is here, yes, a drought; much like ours in California. It may last several years. In some small towns, the water infrastructure is inadequate and people

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I want to stay on in the same hotel, so I ask to extend. But I’m told the room rate now is 45 percent higher; the clerk explains that when the hotel is full, that happens. And even though I have been here now for a week, they cannot allow me a three-hour late checkout when I leave; not without another hefty charge. The people are very pleasant, and proper, but the rules are set somewhere in non-personal space; since I don’t want to devote my time to arguing or moving, I accept this abuse as inherent in a non-consumer sensitive society. I go to the Museu do Futebol – the soccer museum. Brazil is, at least nominally, Samba, song, and Futbol. The museum is much more than a huge monument to maleness, or the sport. It is a cultural resume of history and peoples. Brazil is a melting pot like the USA. They have won the World Football Cup five times, tied with Argentina. They failed in 2014, such a national disaster that it is not yet included in the displays devoted to each World Cup. I doubt it will be there before the next cup! São Paulo is a huge and labyrinthine metropolis. I travel by metro, bus and taxi when necessary. I am often lost. There is always the question of safety with respect to foreign travel. In the USA, our media is salted with reports of what sells: assault, theft, extortion, etc. Yet, at home, we know where and how those things are most likely to happen. On the other hand, in a foreign environment, that is not so clear. My trip from the airport bus station to downtown São Paulo is an example of what to do and not to do. I live in the mind of a child of the Great Depression of the thirties: waste not, want not. So, after asking at the airport, instead

of a cab or transfer van, I take a bus directly to the upscale Paulista section of the city. During the half-hour drive, the bus attendant asks each passenger what stop they want. I ask about hotels; he explains they are too expensive near my stop, the last. He suggests a cab to a different nearby sector. He hails a cab and scratches a name and address on a card. (Ooops! I notice he takes a commission! My second mistake is to ignore that.) The driver has trouble finding the hotel; it is in one of the most filthy, run-down and fearsome, drug toxic, inner area of any city I have ever seen. When I make that sort of stupid mistake, I try to react immediately. Without getting out, or paying the fare, I tell the embarrassed driver I’ll give him an extra half fare to take me immediately back to where we started; this time, directly. I think we are both pleased to get there; he, with his undeserved fares, and me with my immediate future.

Wednesday Feb. 25, 2015 I have often found it most interesting and informative to explore a new place free of appointments and guides; whether in mountain or city, that leaves me open to the unexpected, to personal discovery. The most insignificant person, or remote corner, can be a more open doorway to an inner sanctum than an accredited official or guide. The local São Paulo Medical Society, Asociación Paulista de Medicina, offices are at Brigadeiro 278, 8th floor, in a modern office building. There is strict security, yet my California driver’s license and avuncular “walking white man” appearance are adequate documentation. The guard speaks at some length with the museum receptionist. I am issued a visitor tag and assigned a pleasant guide; perhaps she is also my keeper – to keep me from being lost or making trouble. The museum receptionist is formal and pleasant, indicating I’m free to roam the place, in company of my keeper. There are medical students reading medical journals, mostly those familiar to us in the U.S. After wandering through and taking photos, I venture to ask

some questions of a young man I see cloistered in a small office. He is a pre-med student, working as a library docent. After a few minutes, he dismisses my guide, and spends the next two hours taking me through the other sections of the association offices. Though he is not in, the museum has a curator and mentor. So, I log his secretary on to the SSVMS site and web page with Dr. Bob LaPerriere’s fine online tour of our museum. Outside, dark thunder clouds loom and begin to speak and leak. I thank everyone, ask that they visit me or SSVMS whenever possible, and leave for my next stop. I just make it to the museum, Pinoteca, before the rains hit. Oldsters are admitted free; it is not crowded, and I stay for five hours while outside the storm rages. At about hour three, I am the only person on a guided tour provided by the museum; perhaps others, wiser than I, have fled the storm. During a short lull, I dash across the four-lane road to the Luz Metro Station. It is still raining heavily when the train reaches my station, a few big blocks from my hotel. I wait about 20 minutes, but finally just go, arriving completely soaked. I strip and dry myself gratefully, and turn on the TV. I videotape live coverage of extensive flooding, cars piled up by the roiling brown water, metro stations closed with people walking the rails to escape fallen trees, and a man electrocuted when he leaves his flooded car as a wire carrying 15,000 volts falls. This storm drops more water in less time than any on record. It seems clear that reports of people fleeing São Paulo because of the drought were premature; but some actually are leaving because of flooding. I hope to leave tomorrow, despite weather and an independent trucker strike. The greve, (strike or grievance), results when diesel prices are raised 30 percent to pay for a huge loss by state-owned Petrobras (oil). Independent truckers are blocking freeways without warning. Can I make it to the airport tomorrow?

I have often found it most interesting and informative to explore a new place free of appointments and guides…

John@loofbourow.com

July/August 2015

All physicians and their families are invited to join SSVMS for a free, fun, family-friendly summer social at the

Aerospace Museum of California Saturday, August 22, 2015, 5:30â&#x20AC;&#x201C;8:00pm Hors dâ&#x20AC;&#x2122;oeuvres and beverages will be served. RSVPs required as space is limited. RSVP to Shannon at (916) 452-2671 or sbuchan@ssvms.org Deadline: Wednesday, August 19, 2015 Special Appreciation to Our Sponsors BloodSource and NORCAL Mutual Insurance Company

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Guest Commentary

Objections to Workers’ Comp Proposed Changes By Liliana Loofbourow LEGISLATION IS RARELY RIVETING. Bring up in conversation that the Department of Industrial Relations’ Division of Workers’ Compensation recently proposed a number of changes to Chapter 4.5, Subchapter 1, Article 11 of the Labor Code, and your friends will start looking for the nearest exit. So let’s put it another way: Legislation has been proposed that would, if implemented, drastically degrade the quality of communication between non-English-speaking injured workers and their doctors. And it would leave non-English speaking patients and their physicians at a serious disadvantage − legally and medically. The regulations in question are numerous, opaque, dull, and complex. Among other things, they require physicians to fill out additional paperwork listing the exact duration of each medical appointment − door to door − with a non-English speaking patient, and change the fee structure for professional interpreters like myself, for whom billing has already metastasized into a labyrinth of liens. Most gravely, however, these regulations compromise the integrity of a system intended to ensure that patients and doctors communicate accurately and efficiently. In California, non-English speaking patients have the right to a professional interpreter. The proposed regulations would nominally maintain that requirement, but circumvent it in practice by allowing anyone present to be temporarily “pronounced” a professional interpreter by (for example) judges, physicians, or insurance adjusters. Their professional duties would extend to evaluating a third party’s linguistic competence in languages they

themselves do not speak! The legal risks here are clear. Under the proposed changes, then, professional, certified interpreters, trained in legal and medical terminology, could be replaced by anyone a claims adjuster elects to “temporarily certify” as an interpreter. The proposed changes effectively mean that physicians and non-English speaking injured workers are uniquely vulnerable to the many legal and medical misunderstandings that will likely arise as a result of garbled or inaccurate translations. The regulations would, in addition, require physicians to stipulate precisely how long an interpreter was present in his or her office − including the time each patient waited before being seen. The effects, for doctors, interpreters, and patients alike, are troubling. Interested and concerned parties were invited to comment on the proposed changes through May 18, 2015. As of that date, there were well over 200 pages of comments detailing risks, disadvantages, and potential for discrimination. As a State Certified Interpreter who has spent the last 25 years becoming all too familiar with our state’s flawed, but critically important, workers’ compensation system (and the sometimes pernicious behavior it encourages), I had a lot to say. My comments are below: “Interpreters are highly trained professionals who have studied languages for years. They have mastered complex legal and medical terminology, and they have passed an extremely rigorous certification process. That process exists to protect the non-English speaking injured worker. It exists — and professional interpreters exist — to guarantee that an injured worker, who happens not to speak English, will not receive

July/August 2015

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.

Doctors, in addition to the responsibilities they already face, will now have to serve as timekeepers…

differential treatment under a labyrinthine workers’ compensation system which (though it all too frequently fails) aspires to be accurate, thorough, and just. This legislation is a disaster, not just for professional interpreters who deserve better than to be subject to what amounts to a form of discrimination, but for the injured workers, who stand to have their lives adversely and irrevocably affected by the changes proposed. “Professional interpreters exist to ensure that non-English speakers will be ably and accurately represented. The role professional interpreters play is crucial, and I emphasize ‘professional’ because there is simply no way to overstate the extent to which the legal and medical terminology that goes into a workers’ compensation case is available to the average person, even if they’re fully bilingual. These are specialized fields, with specialized vocabularies, and those vocabularies matter. Cases are decided on that basis. “It is essential that injured workers be empowered to both receive and transmit information that is thorough and correct. The proposed legislation would enable parties, who have no qualifications to evaluate an interpreter’s skills, to ‘designate’ a random party and provisionally certify them. Perhaps it’s a son, or an administrative assistant, or someone who happens to be in the waiting room who speaks the language in question. An adjuster — or doctor, or judge — could, according to these changes, point to that person and say, ‘you are now a certified interpreter.’ “To demonstrate how deeply inappropriate and irresponsible this is, it might be instructive to ask the average person on the street to translate a deposition, or to explain a complex surgical procedure to a passerby. “This is an effort to completely undermine the rights of injured workers. It is an insult to professional interpreters, who take their responsibilities toward the population they serve extremely seriously and train for years in order to be able to do it well. It absurdly overestimates the discriminatory powers doctors and judges have, who are neither magical nor omniscient,

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and who are no more qualified to ‘certify’ interpreters than they are to ‘certify’ someone as a banker for a day, or a lawyer, or a nurse. This is not a game. People’s lives are in the balance. If this goes through, the following can be expected to take place: 1) The health and recovery of non-Englishspeaking Injured workers will be jeopardized by the State of California — to the benefit of the insurance companies, who are quite literally the only beneficiaries of these changes. 2) Injured workers will, in fact, lose their right to due process. 3) Doctors will be at far greater risk for malpractice or poor treatment. If effectively forced by the State of California to treat patients with the misunderstandings poor translations frequently produce, they will be writing opinions and reports based on inadequate or erroneous information. 4) Doctors, in addition to the responsibilities they already face, will now have to serve as timekeepers, recording the amount of time the interpreter spent with the injured worker. Here, too, doctors are credited with an omniscience they simply do not have. Anyone who has ever attended a medical appointment knows that the time spent with the doctor is a small fraction of the time spent in his office. An injured worker does not have the right to an interpreter during his or her time with the doctor; he or she has a right to an interpreter whenever asked to provide or receive medical information. He has a legal right to an interpreter when he has to fill out forms he cannot understand, follow instructions, schedule a next appointment, collect prescriptions. There are three choices, then: a. If the proposed legislation sincerely proposes that the doctor personally supervise and document all these transactions, the system will be broken in weeks, not months. b. If the proposed legislation proposes to deny the patient the right to an interpreter while filling out all the forms the doctor will ultimately use when writing his/her report, that’s a flagrant violation of the law and demonstrates the extent to which injured workers have become ancillary to the system intended to serve them.

c. If the proposed legislation proposes that interpreters simply attend the doctor’s appointment with the injured worker for however long it takes (frequently upwards of an hour), but only get paid for the few minutes spent with the doctor, then interpreters, who must make a living too, will have no choice but to schedule many more appointments per day. If a doctor happens to run late (and I suggest you take a survey of how many medical offices actually run on time), the interpreter will have to abandon the injured, because another appointment is scheduled elsewhere. “No part of these revisions serves the injured worker. None. These changes do serve the insurance companies, who would certainly prefer to pay as little as possible — for one hour instead of two, and at hourly rates that were fixed in the 90s. An insurance carrier will have full control over every step of the process, up to, and including, the appointment of an interpreter. Insurance companies will be able to have fully

private conferences with their attorneys, while injured workers are forced to communicate with their lawyers through an interpreter appointed by an insurance company employee. “It’s not the State of California’s job to care for the pocketbooks of the insurance companies; the State of California is answerable to the injured workers, the huge population of non-English speakers who make this great state run, and to justice, which cannot be served if an adversarial system is replaced by one in which the insurance companies hold all the cards. Under these revisions, claims examiners — insurance companies again — will have the authority to pay lower rates to Spanish-English interpreters than they would to other languages. This is discriminatory. Is the injured Spanish speaker less deserving? Obviously not. One can only hope the proposed changes are changed again with the injured worker in mind.“ liliana@loofbourow.com

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July/August 2015

The Art of Commenting to Government Agencies By Gerald Rogan, MD

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to e.LetterSSV Medicine@gmail. com.

IF YOU HAPPEN TO FEEL disenfranchised, or that our government does not listen to your thoughtful comments, you may benefit from my experience with the process of commenting to our governmental agencies. I was a recipient of comments whilst serving the Medicare Program as a Medicare B Carrier Medical Director. Many physicians and others would comment about our proposed Medicare local coverage decisions. Our policy team read every comment. We posted a summary of each or group of similar comments and responded to each. In some cases, commenters shared relevant insights we had not considered. Some comments changed the policy and some did not. Based on this experience, here are my recommendations to improve your art of commenting: Determine whether you are commenting to a proposed piece of legislation or a proposed rule (aka regulation). Legislation is proposed to the public by the legislature, not by an agency of the executive branch of government. Once a law is enacted, it is interpreted by the government agency which administers it. For example, Congress enacted the Patient Protection and Affordable Care Act (PPACA, aka Obamacare) which affects Medicare and Medicaid. PPACA is a law, not a regulation. Centers for Medicare and Medicaid Services (CMS), under Health and Human Services, administers portions of the PPACA that are relevant to Medicare and Medicaid. One can sign up with CMS to receive proposed rules on a variety of topics. The California Department of Health Care Services and the

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California Department of Industrial Relations issue regulations for Medi-Cal and Workers Compensation, respectively. You may comment on most of them. 1. Do not comment on whether you agree or disagree with the underlying legislation. That ship has left the harbor. Address concerns about legislation to your legislator, not to the lawâ&#x20AC;&#x2122;s administrator. Contact the California Medical Association for guidance. 2. Be sure your comment arrives prior to the end date of the comment period. If it arrives late, again the ship has left the harbor. You have disenfranchised yourself. 3. Address your comment to a proposed rule to the person or department listed to receive the comments. 4. State the name of the rule to which you are commenting. 5. Summarize or quote the portion of the rule to which you are commenting. 6. Be sure you understand what the rule proposes. If you are not sure, do more research to find out. If you misunderstand the proposal, your comment is worthless. 7. State whether you support or do not support the proposal. 8. If you support the proposal, stating same may be sufficient. If you are concerned that others may comment against the proposal, you may wish to explain your reasoning. 9. If you do not support the proposal, provide an alternative solution, if you

have one. Be as specific as you wish. Recognize the agency is attempting to implement a law and is compelled to do so. Comments such as “the law is silly” or “the law does not protect the rights of XYZ group” are a waste of time for a regulator. Address the proposed regulation rather than proposing changes to the statue. 10. Explain your rationale for your opinion, clearly, succinctly, and cogently. 11. Be polite. You are writing to a human being who will judge your respect, wisdom, intelligence, relevance, knowledge base, and politeness. A cogent comment to a proposal, correctly understood, gains respect and may be actionable. 12. Assume the reader of your comment is working in good faith. 13. Cite appropriate references, if available. 14. Cite relevant similar precedents that have been effective. 15. Do not insult the reader. Pretend you are writing to a friend whom you like. 16. Shorter is better − it shows mastery of the subject and respect for the reader. 17. Anything longer than two pages is too long. 18. Do not repeat yourself. 19. Use as few words as possible. 20. Use a thesaurus, when needed, for verbal precision. 21. Do not use references to unknown persons, such as “they.” Pronouns without reference cause confusion. 22. Keep your political philosophy to yourself. 23. Avoid extrapolating the proposal into gloom and doom predictions. For example, if the policy proposes to restrict access to a medication, do not assume innocent people will die and the Medicare Program will self-destruct. 24. Sometimes a proposal that is not exactly on target will be considered when compiling a subsequent rule. Not every innovative idea is internally generated.

25. Use active tense verbs. Example: August 27, 2012 VIA Electronic Mail to: glenn.mcguirk@cms.hhs.gov Marilyn Tavenner Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 RE: Medicare Program; Public Meeting in Calendar Year 2012 for New Clinical Laboratory Tests Payment Determinations [CMS-1441-N] Dear Ms. Tavenner: Please consider my comment as part of the above public meeting. I propose the following: CMS administer Molecular Diagnostic (MolDx) tests in the same manner as it does for DME equipment by using: (1) A PDAC-like contractor to assign a unique code to each unique test or set of same tests from a unique category of HCPCS codes; (2) A laboratory specialty contractor to determine medical necessity for each test based on scientific evidence, with notice and comment, just like the four DMEPOS MACs do now for DME items. Rationale: CMS and its contractors cannot consistently identify each laboratory-developed test provided because some may be billed with a stack of process CPT codes that are not test specific. AMA refuses to provide brand-specific CPT codes. Most MolDx tests are unique. To determine medical necessity under the statue 1862(a)(1)(A), each test and its purpose must be identifiable. Brand-specific coding, and generic bundling when appropriate, may better enforce the law. Unique codes will allow for faster electronic processing and proper payment determination. Thank you for the opportunity to comment. Respectfully− continued on next page

July/August 2015

Note that this comment was not in response to a proposed rule, but to a public meeting on a relevant topic. The person responsible for the meeting received the E-mail. My proposal had been discussed with the HCPCS team. The team did not have the authority to implement my proposal, so I chose to write to the then current CMS Administrator. The problem of improper payment and inability to enforce the statute were well known to CMS and need not be repeated. Summary: Thoughtful comments to proposed regulations have impact. Use your freedom of speech to improve our collective self-rule. Good ideas must start somewhere, perhaps with you. jerryroganmd@sbcglobal.net

The Day I Caught Up By Nathan Hitzeman, MD I woke up this morning, Without any warning, Cured my breath, And all the rest. Stretched my legs, Cooked some eggs, Finished the paper, And my Prozac taper. At work I gave passes, To all of the masses. Medicines – quite a lot, And scans just nonstop. Endless forms completed, My lunch was reheated. Finished my JAMA. Deleted my Spam … Ah! Submitted my CME. Donated a tree. Wrote a politician, About primary care attrition. Volunteered at a clinic, A paper I finished. Peer review – just did it, Even drove home the speed limit. In an empty house that still stands, With drink and pen in hand, I sign away my kids and land. This job is too much, But today I’ve caught up. hitzemn@sutterhealth.org

—William Nakashima, MD

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A Posit Addressing Scribes “Healthcare organizations should provide medical scribes for their physicians.”

Background: In an April 6, 2014 article in the Wall Street Journal, a Minnesota cardiologist, Dr. Alan J. Bank, describes the benefits of having a medical scribe to offload the amount of data input and busy work that the physician has to do. The cost of the scribe was made up for by the increased productivity of the physician. Physicians spent more time looking at the patient instead of the computer screen. Patient satisfaction was not diminished. View the article at https://drive.google.com/ file/d/0By-WBPzYZRaBNU5QRnpIUFVuOHM/ view?usp=sharing. Note: Posits are aggressive statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 40/Agree – 9/Disagree. Commentary follows:

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 agree. They should be provided when they add value and efficiency to the physician work flow. They should not be provided if that doesn’t happen. Not all specialties would benefit from a scribe. The issues that arise are confidential conversations (they are well accepted by patients, but for some issues the scribe should leave the room), dependence by the physician and disruption caused by turnover, productivity (enough to justify the cost) and logistics/overhead (another work station etc.). Like most things “it depends.” − Thomas Atkins, MD Yes, of course, they should provide scribes. This would greatly enhance (“restore”) the quality of the “face-to-face” physician-patient encounter which used to be, and once again should be, a central tenet in the practice of medicine. −Scott Wigginton, MD I disagree. They should increase

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reimbursement to cover the costs of a scribe. They could not provide scribes that would practically fit into anyone’s practice. −Andrea Willey, MD Great idea! Ever since the Kramerica Industries episode of Seinfeld, I’ve wanted a dutiful personal assistant. EHR has made certain things easier like e-prescribing and trending labs, but the amount of navigation, clicks, pop-ups, health maintenance, and “meaningful use” tasks tends to derail the human aspect of the visit. A scribe would help us return to “meaningful medicine.” −Nathan Hitzeman, MD It has been my experience that much of the important issues are gleaned from direct faceto-face contact with the patient; the diverted glance, the raised eyebrow, etc. −Harold Renollet, MD I disagree. Remember the days of transcriptionists and transcribers? Remember those screamingly-funny transcriptions that you had to sometimes read out in court? Providing “medical scribes” is just bringing back the same process under “a new and improved” name! Now instead of being in an office away from you, they will be at your elbow (what happens to privacy laws?) and in your way. Although they would create jobs, the cost and waste of time involved in every aspect of the making of a final report is phenomenal. Providers still have to read through the notes to make sure that the information transcribed is accurate, etc. (an additional delay). With the computer era, the Dragon has been a very valuable tool in writing notes; whatever the note may be, in the direct care of the patient. Like everything, learning to use the Dragon takes some personal time and effort, but once mastered, it is a great little tool that is lighter than the stethoscope, and

there should be a Dragon port that a personal Dragon can be plugged into, on all providers’ computers. −Elisabeth Mathew, MD I agree. Were I still a gladiator in the medical arena today, I’d want to use scribes. I think that would make me a better doc, more effective, and efficient, make my e-record more accurate, and make billing less haphazard and tedious. I would want my scribes to be people I train in person, and know well, who know my practice. I would employ at least two scribes, or three; to stay with my patient as I move on, go over the visit record and instructions with the patient, have the patient sign the record, give them a copy of the visit record, and call the patient the next day for follow-up in certain cases. In many places, at least one of my scribes would be English-Spanish, bilingual, (probably certified − another whole subject). I think scribes could make rural, solo, and small partnership practice attractive again. On the other hand, scribes would surely not be as cheap as the article’s author suggests, except maybe during training; but a known and trusted scribe could become so critical to the practice as to cost at least as much as a nurse. Or be a nurse. Many questions would have to be addressed: patient privacy, malpractice coverage, Obama-nation and other insurance provider reactions. −John Loofbourow, MD I did not go to Medical School to become a clerk or typist. I have used a scribe since 1984, where I learned in residency to do so. With EHR, it is even more necessary than ever. EHR contributes to neck and back problems, carpel tunnel and arthritis. I’ve been through two EHR systems, six figures of expenses and unplugged two systems. EHRs do not contribute to patient care in their present form. It is impossible to attest they do sincerely. −Richard Meister, MD [Agree.]Whether we like it or not, and no matter how much we decry a loss of medicine as an “art,” I think that the organizations that can deliver care efficiently will probably enjoy commercial success, make greater profits, and maybe even foster happier employees, including happily employed physicians. − Alfredo Czerwinski, MD

Helping doctors be more productive is good. −John Young, MD I disagree. My own medical group is doing this as a pilot project, but I fail to see the advantage compared to using medical transcriptionists, as so many of us did years ago. Now I use a voice recognition dictation system, but it is nowhere near as good (much higher error rate) and does not allow me to speak as quickly as a good transcriptionist. − Francisco Prieto, MD I agree. Institutions have much more to gain from EMR than practitioners. Physician payment structures do not take into account the true costs of EMRs in terms of time and dollars. −Richard Stack, MD I agree. Also, one has a scribe to prevent malpractice claims (sexual assault, etc.). Absolutely needed in our litigious society. − Maynard Johnston, MD I agree. Data input is detrimental to the work flow, and the productivity of physicians. Let’s employ another person who is well trained for this. Scribes with abilities to properly code will save a lot of physician time, and a lot of waste. Let’s get paid more doing the real medical work, and employing other people. − Steven Tran, MD I disagree. It is much easier for the physician to enter any data/information. −For-Shing Lui, MD I disagree. We already have enough people trying to make us more efficient at taking quality care of our patients. An additional person in the room might even create a situation where the patient does not feel as comfortable opening up with their sensitive medical concerns, and patient satisfaction may be diminished. We have to make an effort to always make eye contact and engage the patient and discuss their issues without having our attention focused on a computer screen and still make time, possibly outside the exam room, to document the particulars surrounding the visit. −Jose Cueto, MD

July/August 2015

Remember those screaminglyfunny transcriptions that you had to sometimes read out in court?

Rogan’s Rules of Medicare By Gerald Rogan, MD 1. Just because the patient needs the service does not mean Medicare will cover it.

7. Just because you keep the money does not mean you followed the rules.

2. Just because you provided the service does not mean you will get paid for it.

8. Just because there is a CPT or HCPCS code for the service does not mean it is covered.

3. Just because Medicare has a policy governing the service does not mean the service is covered. 4. Just because Medicare covers the service does not mean Medicare will pay for it.

9. Just because there is a CPT and HCPCS code describing the same procedure does not mean you may bill for the same procedure twice.

5. Just because you got paid for the service does not mean you can keep the money.

10. Medicare is from our government and is here to help you.

6. Just because you were paid for the service once does not mean you will be paid for it again.

jerryroganmd@sbcglobal.net

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916-808-1591 TripleR.org

Locations in Midtown, North Sacramento and Greenhaven Licensed by the State of California, Dept. of Social Services

OLDER ADULT SERVICES

Remember When During World War I, the demand for milk soared when condensed milk was used to fight malnutrition among European conscripts. To support the war effort, President Herbert Hoover asked American civilians to eat less wheat and meat and to consume

more fruit and vegetables. These Milk Ration images are part of many wonderful items of memorabilia that can be seen in the SSVMS Museum of Medical History.

Are you a physician who is near retirement or who has retired? Our museum gladly accepts donations of medical artifacts, equipment and memorabilia. Usable medical tools not appropriate for the museum will be sent overseas to one of several developing hospitals where there is a great need. Contact Dr. Bob LaPerriere, Curator, at xtbob@ surewest.net.

July/August 2015

Jul

2015 ICD-10-CM Code Set Boot Camp 5-1

6•

201

Learn to code for ICD-10-Clinical Modification (ICD-10-CM) and prepare for the ICD-10 Proficiency Assessment. Training is led by a certified AAPC Instructor and is provided onsite in a classroom format. Conducted over two days, attendees will receive 16 hours of intensive general ICD-10 code set training along with hands-on coding exercises.

TRAINING FOCUSES ON:

WHAT’S INCLUDED:

• ICD-10 format and structure

• 16 CEUs

• Complete in-depth ICD-10 guidelines

• AAPC ICD-10-CM Code Set Course Manual

• Nuances found in the new coding system with coding tips

• AAPC ICD-10-CM Code Set Draft Book • AAPC Online ICD-10-CM Proficiency Assessment

PRICING:

(Required for current AAPC CPC’s to maintain their credential)

• $399 for CMA members & members’ staff • $499 for CA-MGMA members • $599 for non-members

• Access to AAPC’s Online ICD-10-CM Assessment Training Course Space through December 31, 2015

*Comparable AAPC ICD-10 Boot Camp Costs $799

is Limite

SACRAMENTO DATES & LOCATION: July 15-16 Sierra Sacramento Valley Medical Society • 5380 Elvas Avenue • Sacramento, CA 95819 8 a.m. - 5 p.m. each day with an hour break from 12 - 1 p.m.

REGISTER: CALL (800) 786-4262 OR VISIT WWW.CMANET.ORG/AAPC-ICD10 INFORMATION: CALL JULI REAVIS AT (916) 551-2046 OR EMAIL JREAVIS@CMANET.ORG In partnership with: For more information about SSVMS please visit: www.ssvms.org 34

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Board Briefs May 11, 2015 The Board: Approved the 2014 Audit Report. Approved the 2015 First Quarter Financial Statements and Investment Reports. Approved the 2015 Nominating Committee members as follows: Chair, José Arévalo, MD, Immediate Past President; District 1, Ruth Haskins, MD; District 2, Patricia Samuelson, MD; District 3, Barbara Arnold, MD; District 4, Ulrich Hacker, MD; District 5, Steven Kelly-Reif, MD; District 6, Marcia Gollober, MD; At-Large Member, Richard Jones, MD; At-Large Member, Katherine Gillogley, MD. The Nominating Committee is charged with nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. Approved the 2015-2016 nominations to the CALPAC Board as follows: Ruth Haskins, MD, representing Senate District 1 and Lee Snook, MD, representing Senate District 6. Approved the Membership Reports for March, April and May 2015 as follows: For Active Membership — Derek A. Ailes, MD; Heather D. Angell, MD; Helen Y. Cheng, MD; Raquel L. Dudderar, MD; Everett Brantley Dyer, III, MD; Michael R. Grazier, MD; Paul G. Hayes, MD; Tiffany G. Heu, DO; Albert D. Hwang, MD; Arthur R. Jey, MD; Kanwaljit S. Kahlon, MD; Richard J. Kaplon, MD; Wendy W. Lin, MD; Dennis M. Liu, MD; Donald A. Miles, MD; Alan S. Morris, MD; Michael S. Morrissey, MD; Rimma A. Pavlova, MD; Timothy S. Plimpton, MD; Robert E. Quadro, MD; Tariq A. Rafiq, MD; Wasim H. Raja, MD; Cecilia Romo Divin, MD; Kapil Sharma, MD; Amardeep Kaur Singh, MD; Natasha N. Smith, MD; Maria C.P. M. Soller, MD; Jason T. Spears, DO; Robert J. Weston, MD; Dao Xiong, MD; Hamed Zamani, MD.

For Reinstatement to Active Membership — David A. Bayne, MD; Marian L. Butcher, MD; John Chin, MD; Robert C. Duncan, DO; Erin E. Forest, MD; Robert P. Kozel, MD; Don Loomer, MD; Katherine Overton, MD. For a Change in Membership Status from Multiple to Active — Rudy Herraiz Paro Zaragoza, MD. For Resident/Fellow Active Membership — Theodore M. Geissler, MD; Melody L. Tran, MD; Jon Yan Zhou, MD. For Retired Membership — Edward W. Hearn, MD; Rodney A. Loeffler, MD; Elisabeth Mathew, MD; Ronald R. Yamada, MD. For Resignation — Lynette Scherer, MD Deceased — John B. Evrigenis, MD (3/22/2015); George A. Hahn, MD (4/23/2015)

Requirements:

Want to lead a Walk with a Doc event? We are planning for one Walk with a Doc event per quarter in 2015. Saturday, August 15, 2015

LOCATION: Valley Hi Community Park, 8185 Center Parkway, Sacramento

An interest in talking to a group of walkers about health and wellness for 10 minutes before the walk. Ability to walk for 30 minutes and chat with walkers.

To volunteer, or for more info., contact Kris Wallach at 916 453-0254 or kwallach@ssvms.org

Saturday, October 10, 2015

LOCATION: Illa Collin Park, 8333 Vintage Park Drive at Calvine, Sacramento