Pulse Magazine Winter/Spring 2014 by Western Communications, Inc.

WINTER/SPRING 2014

H I G H . D E S E R T

Healthy Living in Central Oregon

No longer a death sentence, but still a stigma

Autism:

Milk: Pour

How changing treatment has

yourself a glass of something

changed lives

different

Earbuds: These buds can make a workout a little more upbeat

H I G H

D E S E R T

Healthy Living in Central Oregon

WINTER/ SPRING 2014 VOLUME 6, NO. 1

How to reach us Julie Johnson IEditor 541-383-0308 or jjohnsonClbendbulletin.com

• Reporting Tara Bannow 541-383-0304or tbannow@bendbulletin.com •

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Marielle Gallagher 541-383-0361 or mgallagherCfbendbulletin.com

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Markian Hawryluk 541-617-7814 or mhawrylukerbendbulletin.com • •

David Jasper 541-383-0349 or djasperofbendbulletin.com

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Alandra Johnson 541-617-7860 or ajohnsonCfbendbulletin.com •

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• Design/Production Greg Cross David Wray

Tim Gallivan Andy Zeigert

• Photography Ryan Brennecke JoeKline

RobKerr Andy Tullis

• Corrections High Desert Pulse's primary concern is that all stories are accurate. Ifyou know ofan error in a story, call us at 541-383-0308 or email pulse@bendbulletin.com. •

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• On the Weh: www.bendbulletin.com/pulse

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PEDIATRICS CARDIOLOGY FAMILY MED IC IN E OPTICAL URG ENT CARE ONCOLOGY NUTRITION NEPHROLOGY DERMATOLOGY OPHTHALMOLOGY ENDOCRINOLOGY NEUROLOGY PULMONARY INFEcTIQUsDlsEAsESURGERY INTERNAL MEDICINE ALLERGY RHEUMATOLOGY IMAGING

GASTROENTEROLOGY BREAST HEALTH VEIN CLINIC LAB From office visits to x-rays, lab tests to ife-saving t~eatments, we b~ing it a t o g e t he~ for you. Whether you're sick, hea thy, or everything in-between, we're here. Every day.

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Contents ~HIGH DEsERT PULsE

COVER STORY

10 HIV Infections and deaths are down overall. But things are getting worse for those most at riskof HIV/AIDS.

7:.

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22 AUTISM Behavioral therapy helps some patients, but it isn't always covered. In Oregon, that's about to change.

UPDATES News on synesthesia, mountain bikes and more.

•

FEATURES

DEPARTMEMTS

JOB Art therapy: breakthroughs achieved through the creative process. EATING 20 HEALTHY Soy, seeds, rice, almonds, hemp — which milk alternative is right for you? GEAR 28 your W hen standard headphones don'tworkoutfor workout, keep the music thumping with these earbuds designed for exercise. READY Do you ski? Or snowboard? Why not try the other 33 GET for a day? Here's what we learned. QUIZ 50 POP Is James Bond a boozer?Are flu shots more likely on hot days? Iseither of those research questions real?

51 PROFILE A local mom finds solace in CrossFit. W hen and how to seekasecond opinion. 54 TIPS ESSAY blood test may have saved a father's life. 55 ABut15 years later, a son's doubt lingers. COVER DESIGN: ANDY ZEIGERT/PHOTO FROM THINKSTOCK CONTENTS PHOTOS,FROM TOP: RYANBRENNECKE, ROBKERR, THINKSTOCK, RYANBRENNECKE

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Updates(NEW SINCE WELAST REPORTED Synesthesia morecommonwith autism Shortly after publication of "When hearing is believing" (Fall/Winter 2013), research published in the journal Molecular Autism found that synesthesia, a blending of two senses, was more common in individuals with autism. Scientists from Cambridge University found that synesthesia occurred in 7 percent of the general population and in 19 percent of those with autism. — Markian Hawryluk

Compromise in 29-26 debate The Summer/Fall 2012 issue featured the great wheel debate,n29 n vs. 26, in which two avid mountain bikers squared off to argue about the best wheel size. Now there's a compromise. According to Mountain Bike magazine, at least 10 bike manufacturers in 2013 released mountain bikes with 27.5-inch tires. The tweener tires are supposed to maneuver with the agility of 26ers but handle obstacles as easily as 29ers, according to the publication. — Markian Hawryluk

Trans law changes In "Gender in transition" (Spring/Summer 2013), we reported on issues faced bytransgender individuals, including requirements for changing gender on official documents. Since our reporting, several changes have taken place in neighboring California. In September, AB 1121 passed in the California Assembly. The law helps facili-

Genderin

transition

tate legal name changes for transgender people. The first part of the law went into effect in January and allows people born in California to change the gender marker on their birth certificates through an administrative procedure rather than through a time-consuming and expensive court order. The second part of the law streamlines the process for transgender individuals obtaining a legal name change. Meanwhile, another California law dealing with trans issues is being challenged. In August, the California Assembly passed AB 1266, which allows students to use the bathrooms and participate on the sports teams of the gender they identify as, rather than the gender assigned at birth. A coalition of churches and religious groups has launched an effort to repeal the law, which went into effect Jan. 1. The state has until Feb. 24 to count petition signatures. If enough are collected, a statewide referendum would take place in November. —JulieJohnson

Clinical trials go unpublished We reported on the high rate of medical studies that have been overturned in our Summer/Fall 2012 story, "When science gets it wrong." In October 2013, researchers from Rowan University in Camden, NJ., looked at 585 clinical trials ggl that had been registered with the Ciin- g F re ~ t gwe t gr icalTrials.gov website. They found 171, or 29 percent, had never published their results. Many researchers warn that such studies go unpublished primarily because they show negative results, skewing the medical literature and giving patients and their doctors a false impression of treatments' efficacy. The analysis also found that 150 of the 171 unpublished clinical trails had been funded by the pharmaceutical industry. — Markian Hawryluk

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compositeimageofartwork ~ â&#x20AC;&#x17E;' drawn by Beth De Young, a patient .. ofart therapistKristinaziegler. JOE KLIILIE

"-.~ Using an artist's tools from paint, paper -,- nd crayon to clay can helP PeoPle eXpreSS themSelVeS during art therapy L

On thejob I ARTTHE RAPY 5»

BY ALANDRA JOHNSON

eth De Young walked into her therapist's office in Bend feeling intense rage. She felt she had been unfairly fired from a job she was good at. And that firing had spiraled her back into bulimia, an eating disorder she had been overcoming with the help of therapy. Instead of talking about her feelings, De Young, now 26, remembers drawing with pastelson a piece of paper.De Young remembers her therapist, Kristina Ziegler, asking her to draw her innermost feeling first, slowly spreading outward, and to use the color that best represented each feeling. De Young assumed the paper would be a solid black, filled with her anger. But instead she found herself coloring with red and blue and other colors. When she was done, she sat back and looked at the paper and discoveredshehad many more emotions going on inside than she realized. "I'm sad and I'm confused and I'm lost," said De Young. "I have all these other feelings, not just this rage. It was pretty eye-opening." De Young says art therapy has helped her in many ways over three years, opening her up to her emotions, helping her develop healthy relationships and helping her overcome her bulimia. "It's been such a great thing for my life. (I've made) so many improvements. Honestly I don't know where I

would be today without the help art therapy has provided me," she said. Ziegler is an art therapist with a private practice in Bend. She works with individuals of all ages and helps with a wide range of is- QW More photos atbendbulletin.com/pulse sues, including depression, anxiety, trauma and family issues. ever, simply a tool she uses to get people to talk. The art in itself can be sufficient for What is art therapy? people to change. Ziegler worked for many years as a clinical Starting off, Ziegler usually offers people social worker, in particular in youth wilder- basic choices — paper with colored pencils, ness programs.She took a weekend semi- markers or pastels. Most people work in nar about art therapy and decided to make a those mediums, but some people gravitate change. Ziegler returned to school, first tak- toward oil paint or sculpture. ing studio art classes in Bend and then travSometimes Ziegler suggests a certain meeling to Marylhurst University near Portland dium based on the individual's needs. She each week to obtain her master's degree in might try to get someone who is obsessive art therapy. In 1998, she started her own compulsive, for instance, to use paint and be practice. Ziegler says her practice is unusual. more free-flowing. Or if someone is manic, Most art therapists work in institutionsshe might suggest using a small piece of paschools, hospitals or mental health centers. per to force the person to be more contained. Ziegler sees patients privately in her office. Clients Art therapy, she explains, is a practice in which "clients express themselves through Ziegler says many people assume art theraart as a way of working through feelings." py is only for children, but kids make up only Ziegler says this approach works well for about one-third ofher clients. It's true, however, some people as it can integrate their right that many children are well suited for art therand left brains — the creative and analytical apy. Ziegler said their eyes light up when they sides. Ziegler incorporates art into more tra- see all ofher art supplies, a wall of paints, markditional talk therapy — the mix of talk and ers, colored paper, glitter glue, felt and clay. Her artdepends on eachclient(and she does see favorite client group, however, is teens. "They're some clients who only talk). Art is not, how- never boring," she said.

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On thejob(ARTTHERAPY

Some clients come to Ziegler after her life story or to recreate a parhaving hit a block in regular talk therticular moment. Kids and adults as apy. Others are attracted to the idea of well can have very strong responsart and creativity. She says people don't es to this method. "I've had people need to have art training or experience, sob over their scenes," she said. but they do need to be open. Ziegler says the training she reZiegler said some people "don't seem ceived in art is essential. She unto be engaged" in the art and respond derstands the materials, how they JQEKLINE work and how people respond to better to more traditional talk therapy. Skill level doesn't matter, but a willing- Kristina Ziegleris an art therapist basedin Bend them. She is technically proficient ness to try does. in all of the media her clients work One art exercise Ziegler often starts with is asking patients to draw six with. Personally, she likes to paint and also works in ceramics. "It feelings. The feelings people choose to draw can be revealing. Further helps me stay grounded," she said. Ziegler said many of the people into therapy, Ziegler might ask a client to draw her relationship with her she sees work on art in their spare time. husband. Or she might ask a child to draw an animal familyat home (this Results can be easier than asking the child to draw his or her own family). Sometimes, Ziegler said, people feel embarrassed or self-conBefore her training, Ziegler tended to think art depicting dark imscious about their art because it isn't perfect. Or, they feel "uncom- ages might be the most helpful for therapy purposes — that peofortable with you watching them do art," said Ziegler. She typically ple creating dark art were excising demons and healing trauma. But sits beside the person as they work. exploring positive images is actually more helpful, particularly for Sometimes the art is literal, and other times it is abstract. depressed individuals. When she looks at a patient's art, Ziegler is looking at a host of Ziegler keeps most of the art her patients produce. Some people things. She is paying attention to the space on the page, the type of take it home with them, in particular pieces they find meaningful. line, the color, the patterns and how the art evolves over time. Some De Youngtook home a collage she made of magazine pictures images may symbolize something — a tree with a hole in it, for in- representing her feelings. "It turned out beautiful," she said. "It's kind stance, can be a symbol of a trauma, although it mayjust be a place of a reminder that I am a complex person. I don't have to keep evfor an owl family to live. erything in. There are other avenues to releasing those big feelings "Never make a diagnosis from one piece of art," Ziegler said. that I have." Another technique she uses involves small figurines. In her office, Other times, Ziegler said, clients want to destroy the art work. She Ziegler has floor-to-ceiling shelves lined with small figures — ani- says that can be therapeutic, too, if done in the right way. mals and people as well as props, furniture and settings. During this Ziegler finds beauty in a lot of the work her clients make. "I tend therapy, Ziegler places a tub filled with sand on the table and asks to find a lot of things beautiful," she said. "Transformation, I always the patient to depict a scene. She might ask someone to create his or think that's beautiful. It happens fairly often."• 4

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Page9

CoverstoryiLIvINGwITH Hlv

Though HIV infection and AIDS death rates are down overall, rates among high-risk groups are actually on the rise BY MARKIAN HAWRYLUK

wo years ago, Susan McCreedy stood before a small crowd at the World AIDS Day event in Bend, addressing those who had gathered to mark the 30th anniversary of the deadly disease. "I'm so sad that year after year, I'm standing up here as a proxy for people living with HIV in this community," McCreedy, the HIV program coordinator for Deschutes County for the past 13 years, lamented. "Because no one has felt comfortable — and I would never ask them — to speak publicly." Then to her surprise, a man rose from his seat. "I'm positive and I'm happy to speak," he said, and he approached the podium. Zachary Richard, now 36, had moved to Central Oregon only five months earlier. He had been diagnosed with HIV in 2000 while living in San Francisco, where he felt a great deal of comfort and support from a community that had dealt with the epidemic longer than any other. But in Bend, for the first time, Richard felt isolated and alone. If there were others with

Page 10

HIV in the area, they simply weren't ready to talk about it. It would take an outsider, somebody who learned to be comfortable talking about his condition elsewhere. It was only that morning that he learned there would be an AIDS Day event in Bend. "If the community is going to bother to do this, then I need to be part of that," he recalls thinking. At the podium, Richard spoke about living with HIV and the terrible toll of the AIDS epidemic.He expressed how he wanted people to talk about HIV, educate the public and help support those affected. "It was an opportunity to be a voice for others who couldn't do that," he said. "It was also an opportunity for me to let others know they weren't alone." As she listened to him talk, McCreedy thought to herself, "Wow, 10 years into it, finally things are changing." In fact, there has been no group of patients whose fate has changed as dramatically over the past three decades as that of individuals infected with HIV.

It has been transformed from a nearly certain death sentence to a chronic condition that can often be managed with just a single daily pill. Yet for all those scientific and medical gains, HIV experts say we've made much less progress on the social conditions that continue to drive the epidemic. There remains a deep-rooted stigma associated with HIV that has stymied attempts to make further headway against the disease. "AIDS has devolved into the swamp of intractable problems of poverty and addiction and racismand homelessness and mental illness, that are all kind of intertwined and linked. To deal with any of those, we need to be addressing all of those things in a holistic manner," said Sean Strub, an HIV activist and editor of POZ,a magazine for people affected by HIV. "We're never going to treat our way out of this epidemic. You can't do it." Moreover, the medical advances seem to have distracted the public at large from the tenacity of the epidemic, overshadowing the social drivers of HIV. While the overall rates of new infections in the U.S. have plateaued,

WINTER/SPRING2014•HIGH DESERTPULSE

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IMAGECOURTESYCENTERS FORDISEASECONTROLAND PREVENTION

An electron microscopeimage shows HIV-1 budding (in green) from a cultured lymphocyte. Researchers have madegreat progressin understanding the science of HIV, but less progressin combating the stigma that drivesit.

a closer look at the data reveals some disturbing trends among its various subgroups and components. The rates of transmission among men who have sex with men, and particularly young gay men, have risen dramatically over the past several years. Among gay and bisexual men, there was a 12 percent increase in the number of new infections from 2008 to 2010, even as infection rates for heterosexual men and women dropped. The number ofnew infections among males age 13 to 24 having sex with males increased 22 percent, from 7,200 infections in 2008 to 8,800 in 2010.And young black males accounted for 55 percent of those infections. Much of the progress made with prevention and education from the height of the epidemic may be slipping away. "The bottom line is every month 1,000 youth are becoming infected with HIV," said Dr. Tom Frieden, director of the Centers for Disease Control and Prevention. "Given everything we know about HIV and how to prevent it after more than 30 years of fight-

WINTER/SPRING2014•HIGH DESERTPULSE

Life expectancy A study published in December found that individuals living with HIV can now expect to live into their early 70s. The researchers indicated that in 2007, patients had access to antiretroviral drugs as effective asthose on the market today.

Ufe expectancyatage20 56

'00-'02 Source: PlosOne.org

'03-'05

'06-'07 ANDYZEIGERT

of color will have HIV by the time they're 35. "These are astonishing statistics, and it is always risky projecting numbers way out into the future, but in terms of (infection) rates over that kind of time frame, it's never looked this bad since we've been measuring it." Strub said. Those same trends are in play locally. In 2011, for example, Deschutes County public health officials identified a cluster of five HIV cases among young gay men. All were under the age of 28, and health officials were able to connect the cases, tracking the spread of the infection through a mostly closeted gay community in the region. For McCreedy, every single new infection seems like a failure of the system. To have five new infections occur so closely together was almost unthinkable. "What? You got infected? How did you miss this?" she recalls thinking.

ing the disease, it's just unacceptable that young people are becoming infected atsuch high rates." Research suggests that at the current rate Changed attitudes of infection, about half of college-age gay men today will have HIV by the time they're Both nationally and locally the answer is 50, and half of today's college-age gay men complex.Many believe thatyoung gay men

Page11

HIV/AIDS timeline 1981

June 5,1981:Centers for DiseaseControl publishes report of a rare lung infection, Pneumocystis carinii pneumonia, in five young, previously healthy gay men in Los Angeles, marking the first official reporting of what will become known as the AIDSepidemic. Byyear-end, there are 270 reported cases of severe immune deficiency among gay men,and 121of those individuals have died.

no longer fear AIDS the way the previous generation of gay men did. In part, that's because individuals who have tested positive and are taking antiretroviral medications can reduce the amount of virus in their bodies to undetectable levels, which can nearly eliminate the risk of transmission. But the unintended side effect of effective treatment is that many men may be becoming less diligent about protecting themselves. "There is a myth that AIDS is an old gay guy's disease, and I'm not going to get it," McCreedy said. "And then there's medicines if I get it, so what's the big deal?" Ads forHIV drugs in gay magazines feature healthy, vibrant men carrying kayaks or riding bikes, enjoying full and active lives. Newspaper articles focus on the breakthroughs of medicine or the prospects for a vaccine. There's even talk of a cure. It's a far cry from the days when the nation feared a "gay plague." "In recent years we have seen a decline in the sense of urgency around HIV. The headlines have disappeared, and complicated issues for many men have been oversimplified. But the threat is no less real," said Dr. Jonathan Mermin, director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the CDC. "HIV is again on the rise in gay and bisexual men." Moreover, the Deschutes County cluster appearedtobrush offthe odds and the consequences of contracting HIV. "There's a lot of denial around it. 'My partner has it but I don't, and I love that person, so who cares?,"' McCreedy said. "Drive-related behaviors like eating, smoking, sex — things that are human drives — they're not just in your brain, they're in your body, they're instincts. It's very hard to mediate those." Many gay men, sheexplained, take a "don't ask, don't tell" approach to disclosure.

Page 12

1982

January1982:The first American AIDS clinic is established in San Francisco, and the first community-based AIDSservice provider is founded in New York.

1983

Sept. 24, 1982: CDC uses the term AIDS (acquired immune deficien-

cy syndrome) for thefirst time and releases the first case definition.

Dec.10,1982: CDC reports a case of AIDS in an infant who received blood transfusions, and the following week reports 22 casesininfants.

January, 1983:CDC reports cases of AIDS in female sexual partners of males with AIDS.

Jan.4,1983:CDC hosts a national conference to determine blood

bank policy for testing for HIV, but participants fail to

reach consensus.

RYAN BRENNECKE

Susan McCreedy, an HIV specialist with Deschutes County Health Services, makes some opening comments during the World AIDS Day event at the Central Oregon Justice Centerin December.

New infections

ners already assume they are HIV-positive, and so don't tell. "I tell them, if you're having unprotected sex with other gay men in this community, Intravenous MSMandIV I'm very concerned because there's a high drug Use drug use positivity rate and there's a low disclosure 8% 3% Menhavlng rate," McCreedy said. Heterosexual sexwith Richard, who now does HIV outreach as 25% men a volunteer with the Deschutes County De(MSM) partment of Health, said it often just comes 63% down toyoung men making poor choices, Source: whether under the influence of drugs or alNote: Percentages Centers for do not add up to Disease cohol or out of desperation. 100 due to Controland rounding Prevention "Some ofthese young folksare working in the sex trade for their housing or food or ANDYZEIGERT shelter. Sometimes they're not able to say, Uninfected individuals may assume their Yes,you have to put on a condom.' Otherpartners will tell them if they are positive, wise, they're going to be sleeping out on the and so don't ask. HIV-positive individuals, on street," he said. "I think that folks don't rethe other hand, may believe that their part- alize that that's in every city. That happens Estimated new HIV infections by route of transmission in 2010:

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1984

1985

March 4,1983:CDC notes that most

cases of AIDS have been reported among homosexual men with multiple sexual partners, injection drug users, Haitians and hemophiliacs. The report suggests that AIDSmay be transmitted sexuallyor through exposure to blood or blood products.

Sept.9,1983:CDC identifies all major routes of HIVtransmission and rules out transmission by casual contact, food, water, air or environ-

mental surfaces.

April23,1984:Health and Human Services Secretary Margaret Hecklerannounces that Dr. Robert Gallo at the National Cancer Institute has found the cause of AIDS, the retrovirus HTLV-III. InJune, Gallo and Professor Luc Montagnier from the Pasteur Institute in France announce that they have found the same virus, and it is likely the cause of AIDS.

July 13, 1984: CDC advises that avoiding

IVdrug useand needle-sharing will help prevent transmission ofthe virus.

1985: FDA licenses the first commercial HIV blood test, and

blood banks begin screening the U.S. blood supply.

June 1985:Ryan White, an Indiana teenager who contracted AIDS through contaminated blood products used to treat his hemophilia, is refused entry to his middle school. He goes on to speak publiclyagainst AIDS stigma and discrimination.

2010 HIV rates in Oregon and U.S. counties per 100,000 In counties where either the total population or the HIV-positive population fall below a specific threshold, the rates have been suppressed to protect privacy.

Legei1d

No data available

Rates suppressed •

0 -15

1 6 - 7 5 7 6 - 30 0 3 01 -1,000

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1,00 1 -5,000

Hawaii

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Alaska Source: AIDSVu

here." Carl Siciliano, who founded the Ali Forney Center for homeless lesbian, gay, bisexual and transgender youth in New York City, has called adolescents and young men thrown out of their homes for being gay "ground zero" for HIV risk. Young gay men are being encouraged to come out, and then find their families and their communities are not ready to support them when they do. "The experience of being driven from your home and told that being gay makes you unworthy of being loved is a devastating experience. Compound it with hundreds of thousands of kids out on the street trying to find beds, they get the message from larger society that they don't matter. These kids really struggle with hopelessness," he said during a CDC roundtable on HIV. "If we find homes for these kids, we will watch

WINTER/SPRING2014•HIGH DESERTPULSE

these HIV numbers go way down."

Prevention andmanagement Health officials now refer to a concept known asthe care cascade to measure the effectiveness of HIV prevention and management. The cascade tracks individuals on the progression from testing and diagnosis to treatment and suppression of the virus. On a national level, for example, for every 100 individuals living with HIV in the U.S., it is estimated that 80 are aware of their status, 62 have been linked to HIV care, 41 stay in care, 36 get antiretrorival therapy and 28 are able to adhere to their treatment and achieve undetectable viral loads. That means nearly three out of every four people living with HIV aren't able to successfully get the disease under control. Dr. Sean Schafer, medical director for the

ANDYZEIGERT

HIV program at the Oregon Public Health Division, said in Oregon the most recent estimate shows more than 80 percent of people who know they are HIV-positive have undetectable viral loads, more than twice the national average. "The vast majority of them are in care and are getting care that's sufficient to suppress their levels to almost unmeasurable," he salcl. As long as they continue to take their medications, they can keep the virus from multiplying, keep immune systems intact and keep from infecting others. Schafer attributes that success mainly to a decision state officials made 10 years ago. While other states took federal dollars provided through the Ryan White HIV/AIDS program to pay for expensive HIV medications, Oregon was one of the first states to

Page 13

Cover storyi LIVING WITH HIV 1986

T i m eline, cont'd

1986:AIDS activist Cleve Jones creates the first panel of the AIDS Memorial Quilt.

May1986:International Committee on the Taxonomy of Viruses declares that the virusthatcauses AIDS will officially be known

as Human Immunodeficiency Virus (HIV).

March19,1987: FDA approves the first antiretroviral drug, zidovudine (AZT). The U.S.Congressapproves S30million in emergency funding to states for AZT.

use the funds to purchase health insurance for uninsured HIV patients, and to help with premiums and copays for those who had coverage. "That practice is relatively widespread now across the country, but Oregon was one of the innovators," Shafer said."So as a consequence, while a lot of states had waiting lists of people who wanted their drugs paid for, Oregon's never had a waiting list." With more HIV individuals insured, there are fewer gaps in coverage and more individuals are able to stick with their treatment. But the implementation of the Affordable Care Act has thrown much of that stability into chaos. Many HIV-positive individuals were concerned about possible disruptions in care, as they are shifted to private insurance or new plans. Nonetheless, funding for HIV care is stressed. The Ryan White dollars are never enough, McCreedy said, particularly as patients are living longer. Recently federal funding has been reallocated to shift resources toward states with higher numbers of HIV infections. While undoubtedly the need is great in those states, it also penalizes the states that have been effective in preventing new HIV infections. "That'scatch-22," McCreedy said."The better you do, the less money you get.n Fundingfor needle exchange programs, which have been shown to reduce HIV transmission rates, has been cut as well. DeschutesCounty's needle exchange program is limping along, relying solely on donated needles. Meanwhile, prevention funding isn't being targeted toward high-risk groups. Strub said only about 5 percent of HIV prevention funding nationally is aimed specifically at gay men, who account for two-thirds of new infections. And federal funding for HIV pre-

Page 14

1988

1987

May31, 1987: President Reagan makes his first publicspeech about AIDSand establishes a Presidential Commission on HIV.

1989

July1987:Congress adopts the Helms Amendment, banning the use of Federal funds for AIDS education materials that "promote or encourage, directly or indirectly, homosexual activities."

December numberof 1988: World reported Health OrganiAIDS cases zation declares in the Unit- Dec. I to be ed States the first World reaches AIDS Day.

April 1988:The first

1989:The

comprehensive needle-exchange program (NEP) in North America is established in Tacoma,Wash. San Francisco then establishes what becomesthe largest NEP in the nation.

100,000.

Care cascade HIV experts refer to the care continuum to track how many individuals living with HIV are able to get the virus under control.

Outof allindividualswith HIV... 82% knowthey're infected 66% are linked tocare 37% stay in HIVcare 33%are receiving treatment 23% have undetectable viral loads Source: Centersfor DiseaseControland Prevention

RYAN BRENNECKE

Zachary Richard, whois HIV-positive and works as a volunteer for the county health department, often speaks with groups about HIV.

vention and treatment is largely centralized in a few programs with strict guidelines. That limits the ability of local community organizations to tailor messages and outreach. Public health officials are now trying to affect each step of the care cascade to try to minimize the drop-off. CDC has long had a recommendation that people at higher risk for HIV get tested annually, and in 2006, recommended routine testing for all individuals. That effort got a boost last year, when the U.S. Preventive Health Services Task Force recommended that everyone 15 to 65 be tested for HIV at least once. Oregon still has a long way to go, as health officials estimate that only 43 percent of Oregonians in that age group have ever been tested. In 2011, Oregon legislators passed a law

AND Y ZEIGERT

allowing doctors to order HIV testing without going through the informed consent process, which required doctors to discuss the procedures, risks and alternatives. Now doctors can order an HIV test the same way they would a cholesterol or blood sugar test. "People are a bit surprised, but I explain it, this is routine. It's covered by your health insurance. It's recommended," said Dr. Laurie D'Avignon, an HIV specialist at Bend Memorial Clinic. "I just don't think it's become common practice, especially with older populations." Universal testing could not only identify more of the 20 percent of HIV-positive individuals who don't know they are infected, it could also help to remove some of the stigma of HIV. "We're trying to get away from that, 'I'm not gay, I don't use intravenous drugs, I don't need testing,"' said Michael Anderson-Nathe of the Cascade AIDS Project, a Portland-based HIV advocacy and support group. "There are a lot of people at risk out-

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1990

1992

1991

April 8, 1990: Ryan White dies of AIDS-related illness at the age of18.

August1990:U.S. Congress enactsthe Ryan White Comprehensive AIDSResources Emergency (CARE) Act of1990, which provides S220.5million in Federal funds for HIVcommunity-based care and treatment services in its first year.

1991:The Visual AIDS Artists Caucus launchesthe RedRibbon Project to create a visual symbol to demonstrate compassion for people living with AIDSand their caregivers. The red ribbon becomes the international symbol of AIDS awareness.

side of those factors." Moreover, researchers have discovered that treating HIV is one of the best ways to prevent HIV infection. In 2011, a National Institutes of Health study of couples of mixed HIV status found that when the infected individual was treated with antiretroviral therapy immediately, rather than waiting for T-cell counts to drop or AIDS symptoms to appear, infection rates dropped by 96 percent. "If you can get people living with HIV to know their status, and linked into HIV-spe-

1993

Nov. 7, 1991: American basketball star Earvin

Nov. 24, 1991:

Freddie Mercury, lead singer/song"Magic" Johnson writer of the rock announces that he band Queen, dies is HIV-positive. ofbronchial pneumonia resulting from AIDS.

cific care and onto medication, and if they adhere to those medications, you can lower the risk of ongoing transmission by 96 percent," Anderson-Nathe said. "Absent a cure or a vaccine, the best way we're going to end HIV is getting everybody who's living with HIV on treatment." That study has also contributed to a shift in clinical practice as doctors no longer wait for signs that a person's immune system has weakened. Those who test positive are now generally offered antiretroviral medications immediately.

December 1993: The film "Philadelphia," starring Tom Hanks asa lawyer with AIDS,opens in theaters. Based on atrue story, it is the first major Hollywood film on AIDS.

1992:AIDS becomes the No. 1 cause ofdeath

for U.S.men ages 25 to 44.

Universal testing might also help identify earlier a group that has become known as late testers. About 40 percent of individuals with HIV in Oregon are diagnosed within 12 months of progressing to full-blown AIDS, with viral counts through the roof and T-cells virtually nonexistent. Those cases are harder to treat but still have good outcomes with today's antiretroviral medications. But late testers have also lived longer with their infection, increasing thechance they've passed iton to someone else.

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Page 15

Cover story ~LIVING WITH HIV 1994

T i m eline, cont'd

Aug. 5, 1994:U.S.Public Health Service recommends that HIV-positive pregnant women be given the antiretroviraI drug AZTto reducethe risk of perinatal transmission of HIV.

Feb.23, 1995:Greg Louganis, Olympicgold medal diver, discloses thatheis HIV-positive.

1995

1996

1996:The numberofnew AIDS cases diagnosed in the U.S,declines for the first time since the beginning ofthe epidemic. HIV/AIDSresearcher Dr. David Ho advocates for a new strategy for treating HIV- "hit early, hit hard." He issubsequently named TIME Magazine's "Man of the Year."

June1995:U.S. Food and Drug Administration approves the first protease inhibitor. This ushers in a newera ofhighly active antiretroviral therapy. Bythe end oftheyear, 500,000 cases of AIDShave been reported in the U.S.

1998

1997

1997:CDC reports the first substantial decline in AIDSdeaths in the U.S. Worldwide HIV infections reach 30 million with 6,000 people newly infect-

ed each day.

April20,1998:Health and Human Services Secretary Donna Shalala determines that needle-exchange programs are effective and do not encourage the use ofillegal drugs, but the Clinton Administration does not lift the ban on use offederal funds for needle exchanges.

Transmission, stigma andparadox New HIV infections and AIDS deaths Prevention efforts have driven down the annual rate of new infections from a peak of 130,000 in the 1980s, but haven't been able to put a dent in the 50,000 new HIV infections a year in the U.S. over the past decade. That casts doubt on whether the U.S. will meet the Obama administration's stated goal of getting down to a level of 38,000 new infections by 201 5. Oregon sees about 250 to 270 new cases each year, contributing to the estimated 6,000 to 7,000 people living with HIV in the state. Of those, about 1,000 don't know their status. An estimated 200 to 300 people are living with HIV in Central Oregon, although about a fifth of those do not know it. "Thosepeoplewho don'tknow they're infected are unwittingly transmitting 60 to 70 percent of those new infections every year," said Schafer. CDC estimates that for every 100 persons who learn they're infected with HIV, another eight transmissions would be prevented through HIV treatment and risk-reduction behaviors. Now public health officials, who for years worked diligently to broaden the scope of HIV prevention efforts beyond gay men, find themselves refocusing on that high-risk group, trying to regain the ground lost over the past decade. In November, CDC reported a nearly 20 percent increase in the number of men reporting unprotected sex with men from 2005 to 2011, from 48 percent in 2005 to 57 percent in 2011. Unprotected sex was twice as likely among those who didn't know their HIV status. Offici als suggested some of those men having unprotected sex might be trying to limit their risk by serosorting, or having

Page 16

The number of Americans infected with HIV and the number of AIDS-related deaths both peaked in the 1990s. While rates have declined since 2000, prevention efforts have not been able to keep new infections below the 45,000-per-year level.

HIVinddence inU.S. Years through 2006 are estimates of the average annual number of infections for a multi-year period. The methodology for calculating HIV incidence changed in 2007. 150,000120,000 -

60,000 -

30,000 -

'77- '80- '82- '84'79 '81 '83 '85

'86- '88- '91- '94- '97- '00- '03'87 '90 '93 '96 '99 '02 '06

'07

III '08

'09

'10

AIDSdeaths Figures account for individuals that diedwith AIDSand not from AlDS. 60,00050,00040nnn I 30,00020,000-

10,000-

iiiiil~itlli

'85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Source: Centersfor Disease Control and Prevention

sex only with men who share the same HIV status. The percentage of men reporting unprotected sex with someone of discordant statuswas unchanged from 2005. But serosorting is still considered risky because some partners may not know or disclose their status. And even individuals who are already infected with HIV face risks from unprotected sex. "That too is not risk-free," BMC physician D'Avignon warned."There's a risk of acquir-

ANDYZERSERT

ing other sexually transmitted diseases. There's a risk of acquiring a new drug-resistant strain of HIV." An estimated 10 percent of HIV infections involve strains that are resistant to one or more antiretroviral medications, much like bacteria can become resistant to antibiotics. Schafer explained that HIV makes a lot of mistakes when it replicates. "That turns out to be an advantage for HIV,because some of those mistakes are

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1999

2000

March1999:VaxGen, a San Francisco-based biotechnology company, begins conducting the first human vaccine trials in a developing country, Thailand.

July 2000:UNAIDS, WHO and other global health groups announce a joint initiative with five major drug companies to negotiate reduced prices for HIV/AIDSdrugs in developing countries.

2001

2001:After generic-drug makers offer to produce discounted, generic forms of HIV/AIDSdrugs for developing countries, several major pharmaceutical companies agree to further reduce drug prices to those countries.

2002

Nov.14,2001:World Trade Organization announces the Doha Declaration, which affirmsthe rights ofdeveloping countries to buy or manufacture generic medications to meet public health crises such as HIV/AIDS.

•

January 2002:Global

July2002:UNAIDS reports that HIV/AIDS is now byfar the leading cause ofdeath in sub-Saharan Africa, and the fourth biggest global killer. Average life expectancy in sub-Saharan Africa falls from 62 years to 47years. Side effects and increasing evidence ofdrug resistance call into question the "hit early, hit hard" strategy.

Fund to

Fight AIDS, Tuberculosis and Malaria is established.

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useful," he said. "So if I don't take my medicine and I only have a little bit around when my virus is replicating, from time to time it makes a mistake that gives it resistance to the drug I'm supposed to be taking." Clinicians treat HIV with a cocktail of antiretroviral drugs, so that if a strain is resistant to one of them, it can be eliminated by another. "If you only have one drug on board, and the mistake ends up being useful, then you end up having a whole bunch of viruses that have the capacity to grow in the presence of that (drug)," Schafer said. To some extent, there is a divide within the gay community about how to approach the seemingindifference young gay men

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have toward HIV. Many older gay men feel frustrated by the attitudes of their younger counterparts "You hear this from gay men of my generation, who lived through a horrific loss, saw the cruelty of this epidemic up close, and now are very frustrated when they see young gay men putting themselves at risk," Strub said. "And you want to just knock them upside their head. What did we die for?" But at the same time, Strub, who has had a front row seat to the AIDS epidemic since being infected sometime in the early 1980s, argues that those tragic events don't represent the current reality of HIV. "The consequencesof HIV transmission are very different today than they were be-

fore," he said. "The problem is that so much of the message that people hear is, 'It's no big deal I'll just pop a pill and not worry about it,' or 'Oh my gosh, your life is over and it is the most horrible thing that can happen to a person.' And the truth is somewhere in between." Strub believes the message should be that HIV is a life-changing event. Yes, you can still live a full and vibrant life, but an HIV infection will add complexity and burden. While treatments are effective and generally well tolerated, they can be expensive and come with side effects. Some will experience nausea, vomiting or bone loss, and no one yet knows what it means to take these drugs for 20 years or longer.

Page 17

Cover storyi LIVING WITH HIV 2003

Ti m eline, cont'd

2004

2005

2006

• 00 0 00 0 00 Jan. 28, 2003: President George W. Bush announces

Feb. 24,2003: Biotech firm VaxGen announces that its a 515 billion,5-year AIDSVAX vaccine trial plan to combat AIDS, failed to reduce overall primarily in countries HIV infection rates with a high burden among those who ofinfections. were vaccinated.

December 2006: A studyfinds medical circumcision of men reduces their risk ofacquiring HIV during heterosexual intercourse by 53 percent.

Oct. 23, 2003: William I Clinton Foundation secures price reductions for HIV/AIDS drugs from generic manufacturers to benefit developing nations.

"In some ways, it's day and night. People who acquire HIV today, if they have access to quality medical care, can expect to live literally within a few months of the same life span," Strub said. "In other ways, though, we'venot made as much progress.Stigma remains the biggest impediment to dealing with the disease." Stigma, he says, is the reason people are reluctant to be tested and find out their HIV status. It is the reason why they are reluctant to access treatment. It's the reason why people with HIV are reluctant to disclose their status to others.

2007

2008

• 00 0 00 0 00 0

"And the reason is because the consequences of being associated with the virus or being suspected or people knowing that you have it are very substantial," he said. "I say that stigma is worse today than it was in years past." Increasingly such men get little sympathy from the broader public, which seeks to distance itself from the risk of HIV infection by blaming those infected for their actions. "The first half of the epidemic, say from the beginning to mid-90s — regardless of what people thought about homosexuality or drug use or whatever level of blame, or

•

2007: CDC

2008: Timothy Brown, aka the Berlin Patient, becomes the first person to

reports over 565,000 people have died ofAIDS in the U.S. since

be cured of AIDS, through a bone marrowtransplant.

1981.

morality or religious stuff, or God's judgment, whatever anybody wanted to impose on it — most people believed that most people with AIDS were going to die, and very possibly a very horrific death," Strub said. "Therewas some measure of compassion around that, that kind of transcended the judgment." Once combination therapy became available in the mid-90s and the public realized that people were going to live, the perception of people with HIV changed. "The sympathy largely went away, and instead ofbeing seen through the prism of our

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"LOCAL SERVICE - LOCAL KNOWLEDGE"

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2009

2010

2012

2011

• 00 0 00 00 0 00 0 February 2009: Health officials report that Washington, D.C.,hasa higher rate of HIV (3 percent of the population) than West Africa.

ed population.

March 2012: International AIDS Conference in Washington, D.C., is first AIDS conference in the U.S. since travel ban was lifted.

ending possibly in horrific death, we were being seen through the prism of our potential to infect others," he said. That has led to the criminalization of HIV, with more than 1,000 individuals prosecuted under HIV-specific statutes, for potentially exposing others to HIV through intercourse, biting or spitting. Those indivi duals have been punished with harsh sentences even when no actual transmission of HIV occurred. "But it isn't even the impact on those people, which is horrific and it's destroyed lots of lives," Strub said. "But it's how this drives

stigma, because all this gets covered in the media, and that is very powerful and persuasive with the public." Many gay men, sometimes advised to do so by lawyers, have resisted testing, knowing they face potential criminal liability if they know they're HIV-positive, but not if they are unaware of their status. "We know most new infections don't come from people who know that they have it, they come from people who have it and don't know it," Strub said. "Once someone gets tested and tests positive, they're vastly more responsible in their sexual behaviors

Oct.6, 2010: National Institutes of Health 2009:FDA reports study showing that a daily approves dose of HIVdrugs reduced the risk of the 100th HIV infection among HIV-negative antiretrovi- m en whohavesexw ith men by44 ral drug. percent, supporting the concept of pre-exposure prophylaxis in a target-

2013

•0 Jan.4,2010:

Obama administration

officially lifts the HIV travel and immigration ban.

July16, 2012: FDA approves Truvada medication forthe prevention of HIV infection.

2013: President

Obama signs HOPE Act, overturning ban on HIV-positive organ donations to HIV-positive patients.

Source:

Alos.gov

than people who don't know it, yet we're punishing the responsible behavior, and privileging the irresponsible behavior. It just doesn't make sense." HIV criminalization belies the reality of what living with HIV is today. For individuals who know their status and take their medications, their viral loads can be undetectable and the risk of transmission of HIV is almost nonexistent. "Therehas notbeen asingledocumented, provencase of someone with an undetectable viral load transmitting the virus sexualContinued on page 30

COP ING SP ECIALIST ")ust a little guidance can make all the difference. That's my specialty — Ifocus on my patients'emotional needs and helpguide them through the challenges they face. It might be helping facilitate family discussions, or providing some much-needed counseling, or just offering coping ideas. Sharing in the journey is a real privilege for Partners ln Care."

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Page 19

Healthy eatingi MILK

BY ALANDRA JOHNSON •PHOTO BY ROB KERR

eruse most supermarkets today and you will find an abundance of milk that doesn't come from a cow. There's milk made from soy, almonds, hemp seed, rice, coconut, sunflower seeds and other ingredients. People search for alternatives to traditional milk for a variety of reasons. Some people are lactose intolerant, some are vegan or fol-

lowing a dairy-free diet and others simply don't like the flavor. But with so many nondairy choices available, picking the right milk alternative can be confusing. Julie Hood Gonsalves, a registered dietitian and an associate professor of human biology at Central Oregon Community College, helped us sort through the options. In general, she said, milk alterna-

Hemp

Soy

Coconut (not canned)

Nutrition per 8-ounce serving: 80 calories, 7 g fat, 2 g protein,300-400 mg calcium (iffortified),1 g sugar (14 g if sweetened), 0 g fiber Pros:The fat in hemp milk (which is made from legal hemp seed) is primarily unsaturated and contains a large amount ofomega 3, good forinflammation and heart disease. Unsweetened versions contain little sugar. Cons:Not a good source of protein. In general, this can be an expensive choice. Taste: Rich and creamy.

Nutrition per 8-ounce serving:70 calories,4 g fat, 8 g protein, 300-550 mg calcium (iffortified),3 g sugar(12 g ifsweetened),2 g fiber Pros:Soy is one of the rare nondairy choices that is high in protein. The fat in soy milk is also good, as it is primarily unsaturated and also contains some omega 3 fatty acids. Cons:The protein is not nearly as complete as cow's milk. Taste:Thick and creamy consistency, similar to whole milk. Nutty flavor. Can be substituted for milk in most savory recipes, although since it adds some soy flavor, not a best pick for desserts.

Nutrition per 8-ounce serving:45 calories, 4.5 g fat, 0 g protein, 300-400 mg caIcium (if fortified), 7 g sugar Pros:Relatively low in sugar. The fat is saturated, but new evidence suggests it is not unhealthy like other saturated fats. Cons:No protein. Taste:Creamy and rich with a bit ofcoconut flavor. Good in coffee or tea as well as by the glass. Substitutes well in baking, but adds a sweet coconut flavor.

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tives "have come a long way" in terms of taste and selection. When selecting a nondairy option, Hood Gonsalves suggests people consider what role milk plays in their diets. elt depends on the person and what they need," she said. Are you using a glug of milk in your morning coffee or does milk account for a large proportion of your daily protein and calcium intake? Children, in particular, tend to fall into the latter category. "Since calcium and protein are the most important nutrients we'd be expecting to find in this food group, those are what we would be looking for in substitutes," Hood Gonsalves said. (Whole cow's milk has 148 calories, 7 g fat, 8 g protein, 300 mg calcium and 12 g sugar per 8-ounce serving.) While many nondairy choices are fortified with calcium and vita-

min D, many do not have as much protein as milk. She also cautions individuals to watch for sugar, which is often added to improve flavor. Hood Gonsalves also points out individuals can try to make their own nondairy milk. eyou can make substitutes with about anything ... add water, let it soak, blend and strain. The taste, the texture, the nutrient availability are all dependent on what you start with and whether it is fortified," she said. Nutrition values among milk alternatives vary depending on the particular manufacturer; many of these nondairy drinks are also fortified with additional nutrients and vitamins. The following information is a basic guide. •

Almond

Rice

Flax milk

Nutrition per 8-ounce serving:40 calories, 3 g fat,1 g protein, 300-400 mg calcium (iffortified),1 g sugar (15 g ifsweetened),1 g fiber Pros:The fat is primarily unsaturated. Ifunsweetened, almond milk is a very low-sugar choice. Cons:Protein levels are very low and the protein is not complete. Taste:Sweet and nutty. Goes well in tea or coffee as well as in cereal. Also a good baking substitute, although it will add a hint of almond.

Nutrition per 8-ounce serving:70 calories, 2 g fat,1 g protein, 300-400 mg calcium (iffortified),13 g sugar,0 g fiber Pros:Low in fat; relatively inexpensive for a milk alternative. Cons:Very high in sugar and very low in protein. Taste:Sweet and rather thin — almost wateryand light — in consistency. Some people think this is the best milkfor replicating a glass of milk. Works well as a milk substitute in desserts, but is too sweet for most savory preparations.

Nutrition per 8-ounce serving:30 calories,2.5 g fat,0 g protein, 300-400 mg calcium (if fortified), 0 g sugar (8 g if sweetened), 3 g fiber Pros:Contains Omega 3s. High in fiber. Cons:Very little protein. Taste: Neutral flavor with some body.

Source: Nutrition information provided by Iulie Hood GonsaIves, the USDA and manufacturers' information

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Page21

Feature AUTlsM THERA PY

BY TARA BANNOW

rose from hispew, made hiswayto the front ofhis

congregation and began hisspeech. The churchgoers vvere nervous. •

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What's chang ng?

< Derek Sauter,21, has received a form ofautism therapy ca ed app ied behavior ana ysis s nce he was 3 years o d. His parents say the therapy has imp~oved his communication ski s and e iminated vio ent outbursts.

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public schoo students is identified as autistic. That is one of the highest rates in the nation.

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behavior ana ysis must be covered by a nsurance po ic es in O~egon but it won't be an easy shift.

AUTISM IN OREGON

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Feature IAUTISM THERAPY

• About 1 in 88 children in the U.S. hasbeen identified as having autism, according to 2008 data from '. the Centers for Disease Control and Prevention. That'supfrom1 in150when the CDC performed the same research in 2000.

it will extend to low-income Oregonians. Derek underwent up to 30 hours per week of ABA therapy, starting with learning simple prompts and words and progressing to life skills like identifying dangerous situations. "What you're trying to do is rewire the brain," said Derek's father, Bob. "You know how stroke victims will need to learn to walk and talk again? ABA works similar to that in that it reprograms the mind to do things."

'A finger-pointing game' • Autism occurs among all racial, ethnic and socioeconomic groups. • Autism is almostfive times more common among boys (1 in 54) than among girls (1 in 252). • A growing number ofchildren are being diagnosed at increasingly earlier ages —18 percent are diagnosed by age 3. •Themedical expenses of autistic individuals exceeded that of those without autism by 54,110 to 56,200 per year. • In 2005, the average annual medical costs for autistic children on Medicaid was$10,709 per child — about six times that of children without autism.

WHAT CAUSES AUTISM> • Researchers stilldo not knowexactly. Science has, however, identified environmental, biologic and genetic factors that may make some more prone to autism than others. • Research has shown that parents who haveone child with autism have an increased risk ofhaving asecond child with autism. Studies have also found that both identical twins in a pair are more likely to have autism than both nonidentical twins. •Autism also tends to show up inpeople with other geneticconditions,such as Down syndrome, fragile X syndrome or tuberous sclerosis. Also, children bornprematurelyor with low birth weightare at greater risk. •A 2008 study linkedstates with higher precipitation, including Oregon, California and Washington, with higher autism rates. Researchers theorized the connections could include more time in front of7/s, less vitamin D or more exposure to household cleaners, or the rain itselfcould contain chemicals such as pesticides. • If taken during pregnancy, prescription drugsvalproic acid and thalidomidehave been linked to higher autism risk. • Many studies have investigated a link betweenautism and vaccines. The research continues to show that vaccines do not cause autism. Sources: U.S. Centers for Disease Control and Prevention, Archives of Pediatrics & Adolescent Medicine GRAPHIC: TARA BANNOW, DAVIDWRAY

See video interview with Derek Sauter and his family atbendbulletin.com/autism

Research has found ABA to be most effective when initiated as early as possible — ideally before age 4 — through an intensive form of the therapy. Currently, though, few autistic children in Oregon are getting ABA, whichcan costroughly $20,000 to $50,000 ormore. The financial barrier drives many families with autistic children to rely on special education in public schools, which autism advocates say places an unfair burden on schools and results in inadequate intervention for kids with autism at a crucial period in their development. Others accept the minimal autism therapy their private insurance covers, although that's generally not ABA. "It's been a finger-pointing game," said Paul Terdal, policy chair for the Oregon chapter of Autism Speaks, an autism advocacy organization. "Insurance companies say, 'Go to your schools.' Schools say, 'Go to the insurance companies,' or 'Families, you should deal with this yourselves. Why can't your kid behave?'And nothing really gets solved." Or families fight for coverage. Several families have found success in obtaining coverage for ABA by taking their insurance companies through the administrative appeals process or — when that doesn't work — filing lawsuits. Autism advocates have argued for years that Oregon's laws already mandate ABA coverage under the state's mental health parity act and a law that requires coverage of treatments for children with developmental disorders, including autism. The new law, they say, simply serves to remove the loopholes and establishes Oregon's own licensing system for ABA providers. "Parents and families shouldn't have to be bankrupting themselves to provide this," said Tobi Rates, executive director of the Autism Society of Oregon, an organization that supports and advocates for individuals and families with autism."They shouldn't have to be going through administrative appeals or court cases, lawsuits, in order to get this coverage."

ABA in action On a recent weekday afternoon, ABA provider Jenny Fischer files into a classroom at the School of Enrichment in Bend, which provides early childhood education. There, a tiny, chatty girl waits for her atop a stuffed dog two times her size.

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"Jenny! Pet him!," the preschooler, whose parents asked that she not be identified, shouts in halted speech. Fischer obliges, asks a few questions about the girl's new friend and her troll doll sitting nearby and then gently coaxes her to a round rug near the center of the room where they begin their session. First, the girl creates her schedule by choosing activities denoted on pictures and attaches them to a Velcro board. "Do you want to sit on the giraffe or the alligator?" Fischer asks. Fischer is the only board-certified behavior analyst (BCBA) in Central Oregon. Currently, the Florida-based Behavior Analyst Certification Board certifies university- and college-based training programs and credentials those who have taken them as well as completed supervised experience and passed an exam. That doesn't mean she's the only one providing ABA therapy, though. BCBAs like Fischer work with trusted teams of so-called interventionists who do most of the in-the-trenches work with the kids. Fischer brings together reams of research to design treatment protocols for her clients, and the interventionists follow those plans as they work with the clients.

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Every other week — like today, for example — she sits in on the sessionsand makes sure they're going as planned. ABA's interventions are based on a number of different learning principles designed to improve behaviors and increase communication skills. Positive reinforcement is an important component of the therapy. The girl, who has autism, is receiving the intensive form of ABA therapy, which Fischer said can go for up to 40 hours per week. Depending on the child's skill level, the sessions can take place in a home, at a day care or preschool or elsewhere in the community where the student can observe his or her peers interacting. Intensive ABA therapy relies strongly on parents to continue the training even when the therapy is not in session, Fischer said. She also collaborates with other professionals like speech therapists and teachers in schools. "One of the critical features of behavioral analysis is that it's really focused on the needs of that individual and seeing each individual's situation as very unique," Fischer said. "What would be more beneficial to make meaningful change for that person?" The girl's session includes periods of structured learning sandwiched between periods of play. To begin, the girl, Fischer and in-

Page25

Feature IAUTISM THERAPY

RESSURE ISON FOR MORE PROVIDERS Oregon will likely need significantly more applied behavior analysis providers to meet the demand for the therapy once the law takes effect in 2015 for public insurance plans and 2016 for private plans. Jenny Fischer said she is the only board-certified behavioral analyst in Central Oregon, and she estimates there are about 30 in the state of Oregon, although not all of them are practicing. "We do have fairly low numbers compared to other states," she said. "That will be an issue. We really have to focus on building capacity over the next couple ofyears as this law rolls out." There are currently about 15,000 ABA providers certified through the Behavior Analysts Certification Board in the world, said Eric Larsson, executive director of clinical services for the Lovaas Institute Midwest in Minneapolis. That's a "very small bump on the horizon" compared with other health professions, he said. "It's just a very brand-new, cutting-edge practice," said Larsson, who serves on an international behavior analysis certification board. The Oregon Institute ofTechnology announced in September 2013 it would ramp up its ABA course offerings to help meet the anticipated demand for providers in Oregon. The University ofOregon also offers ABA courses.

terventionist Ashlee Partridge each hold an object. The girl is tasked with identifying the objects based on who is holding them. "Who has the ball?" Partridge asks. The girl answers correctly. "Very smart! So smart!" Partridge praises enthusiastically, then puts on an inquisitive expression, "And who has the giraffe?" "I do!" the girl says. The instructors speak slowly and clearly, and each correct answer the girl gives is met with repeated, enthusiastic praise. Sometimes, amid the stream of questions, the girl seems to lose interest. Her eyes leave the circle and she twists her body to gaze around the room, not focusing on anything particular. When this happens, Fischer gets up and positions herself squarely in front of the child. She makes eye contact and touches the girl's arm in an effort to draw her back to the activity. Finally, Fischer dangles the bait she hopes will entice her student to keep at it: a game of hide-and-seek if she just finishes the task at hand first. It works. Rates, of the Autism Society of Oregon, has two sons on the autism spectrum. Her older son has a milder form that did not require ABA therapy. Her 9-year-old, Jacob, however, is much more severely affected, and can'tspeak.He began ABA atage 3. ABA is like a gateway that addresses foundational behavioral issues that prevent the child from progressing and learning, Rates said. Once those behaviors are overcome, the child can benefit more from things like occupational therapy, speech therapy and physical therapy, she said. Jacob's first hurdle, for example, was simply his inability to sit in a classroom and learn. "The first thing they worked with my son on was getting him to sit in a seat, and to sit there," Rates said. "It started at 2 seconds and

Page26

then 5 seconds and on and on to where he could sit and learn." Fischer, who also works with children with other special needs and behavioral issues in addition to autism, said her current clients are either lucky enough to have ABA covered through their insurance or they're paying for it out-of-pocket. More often than not, though, potential clients are referred to her by their doctors but ultimately learn they can't afford the therapy, even if she offers it on a sliding fee scale. "Oftentimes, right now, I get the calls but it's not able to become a reality," she said. "It's very hard."

Wrangling for coverage Paul Terdal's years-long battle for ABA coverage in Oregon is at once personal and professional.His two sons, ages 6 and 8, both have autism, and he's watched both of them benefit from the therapy. The younger son — whose name Terdal, of Portland, declined to provide — was diagnosed at age 2 with a form of regressive autism in which he seemed to develop normally, but would then lose skills. His sensory processing also was out of whack. Blood tests that involved poking his fingers with needles didn't spur reactions. "Most kids, you poke them with a needle, they're going to cry," tcare because his sensory processing was so Terdal said. "He didn' far out of line that he just didn't feel the needle." Now, following four years of roughly 20-hour-per-week ABA therapy,his son'sIQ hasgone from 86 to around 137,and hiscommunication skills — once the occasional grunt or cry — have progressed such that he can understand people and express himself clearly through speech, Terdal said. "I can tell that he has autism," he said. "I can see that the characteristics he has are still consistent with it. But if you didn't know, it would never occur to you. He's bright, he's social, he's energetic." But getting his insurance company to cover that treatment was a nightmare, one that inspired Terdal to dedicate the past four years to helping families like his get their insurance providers to cover ABA therapy, a service he argues Oregon's laws already required. His battle started with his own family. In June 2011 — confident in his interpretation of the law and prepared to defend it — Terdal formally disputed his denial letter from Kaiser Permanente to cover his sons' ABA therapy. "I simply said, 'I know you don't think you cover this treatment; I want you to process a referral for it anyway, and if you think you have a basis for denying coverage, you can deny it in writing and we'll go through that appeals process,'" he said. Kaiser, which last summer agreed to pay $9.3 billion to families who were denied coverage for ABA therapy to settle a class-action lawsuit, told Terdal that the providers he had chosen were not properly licensed. He remedied the problem by finding a licensed provider. Then Kaiser retorted that even though its doctors recommended ABA therapy, it still Continued on Page 35

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Page29

Coi/erstory IHIV

' a Q' r'r

RYAN BRENNECKE

Red ribbons were created for participants during the World AIDS Day event held at the CentralOregon Justice Centerin December.

Continued from page19

ly," Strub said. "We've neglected to recognize the extent to which a person who is undetectable is rendered not infectious." The Swiss Federal AIDS Commission recently said that having an undetectable viral load carries a lower risk of transmission than usinga condom, which has up to an 8 percent failure rate. It is the new reality of HIV infection today: a functional cure if not an actual one. Strub, who is 6 feet I i nch and 165 pounds, said 16 years ago at the height of his HIV infection, he weighed a mere 124 pounds. He had a viral load of 3.3 million and his CD-4 T-cell count, a measure of his remaining immune system, was down to 1. Normal individuals have a count over 500 to 1,000. Anything under 200 meets the clinical definition of AIDS. He was covered in Kaposi's sarcomas, cancerous tumors of connective tissue that were once the telltale sign someone had

Page30

are," McCreedy said. progressed from HIV infection to AIDS. "Compared to that I consider myself pretMany of them left Central Oregon for ty cured," he said. Portland, San Francisco or other big cities, where they could feel free to be themselves Local issues and part of the gay community. Then they In Central Oregon, where despite an in- got HIV and came back home thinking they creased acceptance ofgay, lesbian and were going to die. "So they moved back in with their parents transgender individuals, many still don't feel comfortable telling people about their sexu- who never accepted them in the first place, al orientation or their HIV status. Almost all and now they'r e not dying, of course.And of McCreedy's gay HIV case-management they're caring for their elderly parents," Mcpatients remain in the closet. Creedy said. "It's a really intense dynam"There's definitely an underground feeling ic because a lot of them are still not being to the gay community," she said. "People will accepted." come up tome and say,'Hey,you spoke in When McCreedy counsels HIV-positive climy class,' and then they'll pull me aside and ents, she warns them to think very carefully say, 'I'm a gay man ..."' about who they tell they are infected. She urges them to come to the health deRichard, who speaks to a variety of partment and get an HIV test. But they never groups about HIV, said people in Central Orcome. "We have this old-school thing going egon are accepting of gay and HIV-positive on. I have this whole demographic of peo- individuals, for the most part. Every once in ple that I know feel very ashamed and badly a while, however, someone will say someabout who they are, what they are, how they thing that reminds him how much work still

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needstobe done.When he was preparing to speak to onegroup outdoors, for example, the organizer of the event asked him to wear plenty of mosquito repellent so he wouldn't pass on HIV. "At first it upsets you. You can get sad and angry about it, but then you realize it comes from a place of not being informed," he u said. And you kind of turn it around and realize, that's myjob, to inform people. Nine times out of 10 their intent was not to hurt you. Their intent was to protect themselves." John, a Central Oregon resident who asked to be identified

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only by his first name, was diagnosed with HIV two years ago. He had felt ill for two years prior to being tested for HIV, but doctors had never considered it. He didn't fit the profile. "I've never done IV drugs. I've never smoked pot. I've never snorted coke, never had gay sex," he said. "I've had two partners in my last 35 years, neither one of them have it." Instead his doctors suggested it was fibromyalgia or lupus. Frustrated with a lack of answers and his fading energy, he went to a new doctor outside his plan's network, paying cash and asking her to start from a clean slate. She suggested a complete blood work-up, which included an HIV test. The next day, she called John with the news he was positive. His viral load was more than 600,000 and his CD-4 T-cell count was less than 40. Health officials were incredulous, asking him repeatedly if he hadn't visited a prostitute or done drugs even once. John still doesn't know for sure how he contracted HIV. "I've been a volunteer fireman for 30 years, and I've done emergencymedicine careon people who are so badly damaged, they're covered in blood sometimes," he said. "I've done that all my life as a community member, I don't know where I got it." The infection has had a devastating effect on his life, as he lost his business, his equipment and his home trying to cover all of his medical costs. He now rents a small room, living on $60 a week. His hands shake continuously from the medications. They affect him so strongly that he takes them before going to bed each night so the effect will begin to wane by midday and he can drive safely in the afternoon. When his family found out, the rumor mill went into overdrive, and John found himself having to deny the rampant speculation of his relatives. Other than health providers and his family, he's only told one person, a former co-worker whom he trusts implicitly. "The saddest part is when you read about it or if there are movies about it, it's always a drug user or a gay lifestyle," he said. "It creates a really harsh stereotype." John now regularly meets with other HIV-positive individuals in the area for coffee. Most of the attendees are much younger, men who contracted HIV despite everything that is known about how to prevent transmission. "These men,honestly,could care less about what we know. They got laid or shot up, and they didn't think about the risk," he said."Who cares about what's coming because I'm screwed anyway," they tell him. "We all are." In October, John received a life-changing phone call from his doctor. Some 18 months after being diagnosed with HIV, his viral load, for the first time, was down to zero. Although the HIV virus likely lies dormant in the dark corners of his body, as long as he continues to take his medication, it is unlikely to return to measurable levels. "It was so affirming to believe positively that I could kick its (rear) and to have done so," he said. "I'm lucky to be alive."•

Page32

WINTER/SPRING2014•HIGH DESERTPULSE

Getready

A boarder

A skier

"You OK?" one snowboarder in a small group called over after I almost took a fall. The shame ofit was, I hadn't even hit the slope yet. I was just departing the West Village rental area and had a little trouble negotiating the last step in those cruelly stiffboots. "Myfirst time in ski boots," I explained. I felt more than a little humbled as I moved like some kind of newly birthed Bambi-Frankenstein hybrid. It wasn't just the awkward gait that humbled me. As a skateboarder, snowboarding seemed like the natural way to

I've finally figured out why snowboarders don't have to wear those heavy plastic ski boots: Ifit weren'tfor the comfortable shoes,you might never get past the first dayofboarding. As a lifelong skier, I've gotten to the point where I rarely fall down. At the start of each day, I line up my skis on the snow, plant a pole on each side, elegantly step into my bindings and I' m off. As a snowboarder,you get up close and personal with the snow just to get your board strapped on. And I spent more

on skis

on a board

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Are you a skier who wants to try snowboarding . Or a boarder

f h 2QQ]Q2

Like every snowboarder I know, • 7 ,.~ CurlOUS abOut SkiS. Ijustfounditintrinsicallycooler than skiing. Skiers in clunky .WePorters Markian Hawryluk(alifelong skier Picturedinback) and David JasPer>~ bo o ts vocallycomplaining ' (adedimedsnowboard« in +ont) deci«d «switch dis«P»nes f~a day with,~ abouLarid ma!Igning snow '

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a slope. That's why I'm convinced things are so easy in the rental shop. Theygiveyou a pair of marshmallow soft boots that

. •

ia ce up)jke proper footwear

P o~aMt:~a~~@ lorsk arrd sn'cvv@ oitrd +~ttuctor. R

..w@yg„ltgjgdcross-countr:::,;.J '. ws Ik(rj'g fer t4'efirst time last ye ar, and I was booked. (Those p boots are like w'earing a pair ofcushyslippers!) I ended up going to Virginia Meissner Snopark more than I snowboarded last season,and Iconfessthat when I did snowboard I began looking at skis — at least the wider ones that resemble snowboards in shape, replete with raised tips in the front and back — with curiosity. Nevertheless, I did not foresee myselfdonning a pair of them and taking a lesson. Yet+

''''~.ingfourseparatepiecesofgear;:-.-.-

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you have only the one board, leaving a hand free for a cup of coffee or a water bottle. My instructor, Nate Edgell, ofthe Mt. Bachelor Ski School, told me he made the switch from skiing to snowboarding years ago. Now he does both, often choosing the board for deep powder days and skis for firmer snow. It's somewhat easier to switch from one discipline to the other, he told me, because you already understand things like the fall line, how the lift

(C eQ

"4' I

•

Page33

HIGH DESERTPULSE JOE KLINE

r-'~

Getready SKI AND BOARDSWAP

„>4

+ here I was standing on skis

+ works and howto properly

on a late December afternoon. Cross-country skiing gave me at least one advantage for my first-ever alpine skiing lesson. I could sort ofsnowplow, which is when you turn your toes inward, dig in the inside edge ofthe ski and pray that, along

engage in apres-ski activities. But any illusions that this would be easy were dispelled w hen coul I dn'teven buckle my boots. I'm long on leg and short on flexibility, and just reaching down to the buckles was hard. Edgell helped me out the first

JOE KLINE

Snowboardiskiinstructor Nate Edgell, right, talks Markian Hawryluk through going down the hill during a lesson at Mt. Bachelor ski area.

torture and slow you down, That, too, was easier said than maybe even bring you to a stop.. done. Once you get your boots Screaming isn't necessary, but that's how I do it. strapped in, you must engage in an acrobatic maneuver to get yourselfupA second slight advantage over switching from skis to snowboarding: right on the board, a move probably better suited for those younger than According to snowboard and ski instructor Nate Edgell, as well as a few 45. The technique involves bending your knees and positioning your rear other Mt. Bachelor employees, snowboarders generally have an easier close to the edge ofthe board. Then you launch yourself upward so that time migrating to skiing than skiers do moving to a snowboard. A comyour center of gravity lunges forward over the top ofyour feet, making sure forting notion that I clung to it like a security blanket as I clicked in. to halt your forward progress so as not to fall face-first onto the snow. It's not nearly as simple as I've made that sound. Edgell gave me great tips about keeping an athletic, bent-kneed stance and my upper body inclined forward, keeping pressure on the front of Eventually Edgell took pity on me and helped me up onto my feet. Failing my boots at all times, and my poles in front of me. I skeptically tried it, and to passthe most rudimentary oftests didn't bode well for the day's lesson. sure enough, I did notfall. At least, notyet. We started out on nearlyflat snow withjust a hint ofincline. As I shimmie d forward, the board began to slide slowly. It was rather easy to stay cj Neither of the supposed advantages I had as a newbie made'me feel -+ ' ~~ t c .cveryconfidentwhen thetime<ametoturn. I still don't thinkI understand b~'~ balanced andeven to cometo a relativelysmooth stop. the physics ofhow one can turn on%i+sirriplybywhifting weightrari' , Inf a ct, I had done so well Edgell.decide'd to take me up to one ofthe r'-;~;, n ges — at least not without:fallirig — 'ag'jet j,"rnanaged to'ma e ~".~ j~-' most'fe'aorecI slo thetun that evokes more-screams, .-':,"".,' +s cln dthsce'mountain, ww y S n v hmuor'eegosthan anyotyierstopi'on the- ',"-.~"-',- ;:-'-":;-;.' : causes morefalls and b'tuis "threiyMjggdt~ s h g r'tstrgtrchtjfrtreBundy w ithoutfaytling —: '' iv + ps w -',ence There was'stoppegand th@6'Ayardly plowing I do but nofalllng. I ' -. mountain'It should probably beenamed Devil's Cliff or ER Fast Track but I "'".'-:-'-== .

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though I wasfollowing Edgell's advice and it was working. I was merelyalong for the ride. This feeling was confirmed when, on my last run, I headed toward a small orangefence, leaned back, panicked and tooka dive. Edgell slid over, plopped down on the snow and showed me how to return from my sprawled position to a standing one. Once again, it worked well. And then I was back down at the bottom, and it was Markian's turn to snowboard. I ran to the car, gleefully shed the concrete blocks — er, ski boots — and fetched my board. Wisely, I think, I paid close attention to the snowboard lesson Edgell gave my colleague. I'd never taken a snowboard lesson before, and as he explained snowboarding to Markian, I realized I'd forgotten as much as I'd never learned. The next day at work, a coworker asked if I'd liked alpine skiing. I had to think about it for a minute. I did. But still, I think I'll stick with the snow devil I know. — David Jasper

Page34

"~ thinkformally it's called the Bunny Slope. N . *+ki . Unlikeskring,whereyoudirectyourskisbyshifdngweightfromone foot to another, boarding involves more ofa rocking motion from heel to toe. It's a game ofbalance and a game I was rapidly losing. Edgell consoled me, telling me the learning curve for snowboarding is harder. Ifyou can persevere through the first three days, you can get good quickly. Skiing might be easier on day one, but it takes more time to progress to higher levels. aYou know the difference between a snowboard instructor and his student?" Edgell asked."About three days." I had a few runs down the slope that didn't involve falling down, but they were the exception rather than rule. I never did quite get the hang of getting up on my own or controlling my speed on the board. Eventually, my weight would shift too far forward or backward, and I'd go down hard. I suppose with another couple of days oftrying, I'd get better and maybe figure this thing out. It just seemed like a high price to pay for comfortable shoes. — Markian Hawryluk

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Feature IAUTISM THERAPY

Continued from Page 26

wasn't medically necessary. So Terdal had the Oregon Insurance Division appoint an outside expert to determine whether ABA was necessary. It was. Michael Foley, communications manager for Kaiser Permanente, said the company's criteria for considering a treatment a medical necessity are that the patient exhibit "significant, measurable and sustainable improvement as a result of receiving services" and that a treatment plan be developed. By December 2011, Terdal said, he had a binding order to Kaiser to pay for ABA therapy for both of his boys. "My assertion, then, is that this has really been required all along," he said. The biggest roadblock to coverage â&#x20AC;&#x201D; one that the new law is designed to alleviate â&#x20AC;&#x201D; is credentialing. Because Oregon doesn't have its own licensing board for ABA providers, insurancecompanies have denied coverage on the basis that the providers, BCBAs and interventionists, are not licensed in Oregon. "We have licenses in Oregon for everything," Rates said. "You need one to braid hair professionally. Not having a license in Oregon creates a number of problems." The new law calls for the creation of a behavioral analysis regulatory board in 2014 that will license ABA providers in Oregon. It also requires licensing for the interventionists who work with BCBAs like Fischer. Autism advocates argue that two Oregon laws mandated ABA coverage prior to the 2013 law. The first: the state's mental healthy parity act. Passed in 2005, that law requires that insurers cover treatment of mental or nervous conditions at the same level and with no more restrictions than other medical conditions. The second is a 2007 law that requires coverage of medically necessary services for children with pervasive developmental disorders, including autism. Since getting his own situation worked out, Terdal has helped more than 100 Oregon families navigate the maze of loopholes that had prevented them from getting coverage for their childrens' ABA therapy. In some cases, that means guiding them through the insurance company's internal and external

WINTER/SPRING2014â&#x20AC;˘HIGH DESERTPULSE

appeals processes. In others, it's lawsuits. He's helped some families get their names attached to an ongoing class-action lawsuit filed in May 2013 against Providence Health Plan for refusing to cover ABA therapy. When Iamilies don't get ABA coverage, many of them turn to the public school system. Terdal estimates that public schools in Oregon spend $200 million per biennium on special education and community services for adults and children with autism, a burden he says would likely be reduced if kids are able to get necessary treatment earlier in life. In Rates' case, when her son Jacob was eligible for special education services through the Clackamas Education Services District, the then-4-year-old was getting 10 hours per week, a number she said has since been about halved. Rates estimates roughly 2 hours per month of that was ABA therapy, far less than the 20 to 40 hours per week of ABA that's recommended for kids at his age and level of severity, Rates said. "To try and say 'Well the schools need to provide that, but we're not going to give them the resources to do it' is giving the schools an impossible task," she said, "and our kids are the ones who are suffering because of it."

lists of essential health benefits, some of which differ from the federal government's list. Those lists were basically locked in on Dec. 31, 2011. If a state mandates any condition after that point, that state must pony up the money to pay for the additional cost of covering that treatment under insurance policies. Here is where the question of whether Oregon'sABA mandate isa new one becomes crucial. It's impossible to know how much money is at stake, but it's enough to make state officials nervous. The Oregon Insurance Division, unsure of how exactly to interpret the state laws as they pertain to ABA coverage, has called upon the U.S. Department of Justice to make a final call on whether insurance companies were legally obligated to cover ABA therapy prior to the 2013 law, said Berri Leslie, deputy administrator of the state Insurance Division. "They're interpreting, really, whether or not ABA was part of the essential health benefits package," she said, "and so their guidance will help us come to an opinion about a lot of outstanding complaints in cases we have." Julie Kornack, public policy analyst for the Center for Autism and Related Disorders, an organization that provides ABA therapy, said Affordable Care Act caveat in her view, Oregon's mental health parity The Affordable Care Act outlined what's law already required coverage for ABA becalled essential health benefits, a list that in- fore the 2013 law was passed. But even if the cludes 10 categories of conditions that insur- DOJ interprets otherwise, she said the cost ance plans must cover. States have their own difference between providing a policy that

Page35

Feature IAUTISM THERAPY

covers ABA and one that doesn't is negligible. In other states that have implemented laws requiring ABA coverage, the additional cost has worked out to about 33 cents per policy member per month, Rates said. "So, something that's going to cost a family $25,000 or more per year, you spread that risk out among the policy pool, it's 33 cents per month," she said, "If you don't get these treatments, you're overburdening the schools, and in time, (those with autism are) not living productive and meaningful lives, which is the goal."

Medicaid coverage in question Among the questions about the law still waiting to be answered is whether it will apply to older kids with autism. A clause in the 2013 law directs the group that decides what's covered under Oregon's Medicaid program to consider adding ABA therapy to its list of covered treatments. (Medicaid is not among the public plans required to cover ABA under the new law.) An earlier incarnation of the Health Evidence Review Commission first considered covering ABA therapy for autism under the Oregon Health Plan in 2008 but decided there wasn't enough evidence proving its effectiveness. This time around, the HERC appears poised to approve the therapy, at least for some OHP beneficiaries. A HERCsubcommittee last September reviewed a number of studies on ABA and issued a draft recommendation that OHP cover up to 40 hours of ABA per week for children ages 2 through 12 years. The subcommittee did not recommend covering the therapy for people over the age of 12, however, citing insufficient evidence of its effectiveness among older children and adults. (The subcommittee could change its recommendation to the commission at a meeting in February.) The recommendation provides initial coverage for a six-month period, with ongoing coverage provided based on demonstrated progress. Since the recommendations came out, many autism advocates as well as experts brought in to advise the subcommittee have spoken out against them, arguing there shouldn't be an age limit to receiving ABA therapy. Bob Joondeph, executive director of Disability Rights Oregon and the only subcommittee member who voted against the age limit, said one of the challenges of autism is that it's a highly individualized disorder, and each person responds to therapies differently. "Saying 'This makes sense for an 11-year-old as opposed to a 12-year-old as opposed to a 13-year-old' doesn't make sense to me," he said. "It seems to me that if you have a person who is on the autism spectrum, and they have certain behaviors that indicate ABA may be an effective treatment for them, they should have the ability to get a trial of that treatment to see if it is helpful or not." Some have criticized the subcommittee's methodology for arriving at the recommendation, arguing that the group wasn't following its own guidelines, didn't review the strongest research available and didn't heed the advice of experts called upon to weigh in.

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The main area of disagreement concerns the type of research that can be used to evaluate a treatment's effectiveness. The HERC staff abides by strict standards that govern which studies it can use, with randomized controlled trials (RCTs) being the most coveted form of evidence. In RCTs, participants are randomly assigned to different groups, with some receiving the treatment being tested and others, the control group, not receiving that treatment. Autism advocates argue that ABA therapy doesn't lend itself to the RCT format, because those who can benefit the most from the therapy would ideally be receiving it during their early, formative years. They say that enrolling in a study in which subjects may not be receiving the therapy could have detrimental effects. "My child needs help now; I'm not going to participate in a study where they may or may not get help and lose that time," Rates said. "There's just no parent who would do it, and I don't think it's ethical for a researcher to ask them to do it." They also argue that ABA is too individualized a therapy to compare groups in a study. The subcommittee's review did include six small RCTs, but the study results were mixed on whether the ABA therapy improved functioning in the test subjects, especially among kids older than 12. While HERC staff members say those studies prove the RCT framework can be applied to ABA, critics say there are better studies to choose from that would have yielded far different results, they're just not RCTs. "There's tons of data with children, adolescents and adults in general on this general issue," said Eric Larsson, executive director of clinical services for the Lovaas Institute Midwest in Minneapolis, which provides behavioral intervention programs like ABA, "but when you narrow it down to a highly restricted data set, it appears as if the opposite conclusion is warranted." The other forms of studies included in the HERC's review did report positive results of the ABA therapy, but the HERC places less weight on studies that are not RCTs. Larsson, who has been providing ABA therapy since the late 1970s, was among the experts the HERC brought in to advise the subcommittee in making its recommendation. The best way to study ABA's effectiveness, he said, is through single-subject studies, in which the effects of a treatment are observed on a single subject. But Alison Little, director of clinical affairs for the Center for Evidence-based Policy at Oregon Health & Science University, said single-subject studies carry a high likelihood of bias. Little and her colleagues at the Center are responsible for gathering the studies that the HERC uses to evaluate treatments. "It is possible to do them very well, but most of them are not done well and without good controls," she said. Larsson, by contrast, said there are many issues â&#x20AC;&#x201D; global warming, for example â&#x20AC;&#x201D; that can't be studied using RCTs, but that doesn't mean scientists aren't studying them. "In our case, the kind of study they're talking about would cost about $10 million and would only answer one of about 100 ques-

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The ABA therapy coverage recommendation will go before a different HERC subcommittee in March, and before the full HERC for an official vote in May. Any new coverage guidelines the HERCvotes on would take effect between October 2014 and April 2015. While the public discussion about covering ABA has focused on the evidence, Joondeph said he thinks the underlying issue is simply the fact that it's expensive. "Whether it's articulated or not, the impediment to ABA coverage has been the thought that the costs would override the efficacy," he said. "In other words, it's so expensive that it would be asking either the public or ... other people who are paying for insurance policies to pay for this service."

'Innocence around us everyday'

tions that are open as not having been studied by randomized controlled studies," he said. "Nobody's going to spend $10 million doing a study. They may as well be treating the kid." Three experts were called upon to provide their opinions on the matter for the subcommittee: Larsson, Katharine Zuckerman, assistant professor of pediatrics at OHSU, and Eric Fombonne, director of OHSU's Autism Research Center. The age limit of 12 would disproportionately affect blacks and Latinos, as the average age of diagnosis is later in those groups compared with whites, Zuckerman said. Terdal, the parent and autism advocate, said he feels the subcommittee disregarded testimony from "top-notch, world-class experts." Some have questioned whether Little herself is biased on the topic, having served as an expert witness for the state of Florida when it was sued for refusing to pay for ABA therapy under its Medicaid program. Florida ultimately lost that case. Joondeph, the subcommittee member, said the materials Little presented to the group in this case were comparable to data she's gathered for other cases. "That said, the fact that she acted as an expert witness in Florida is troubling because it gives the appearance of bias," he said. Little — who was paid $200 per hour by the state of Florida, according to court documents — said she was simply discussing what the evidence showed. Likewise, in the current case, she said her job is simply to interpret evidence.

WINTER/SPRING2014•HIGH DESERTPULSE

When Derek Sauter was just 4 years old, an autism specialist with the Bend-La Pine School District told his parents that their son would need to be institutionalized by the time he reached his teens. The specialist also recommended that Jill and Bob Sauter start teaching Derek sign language, as he hadn't yet begun to form words. And if he couldn't speak, they were told, he couldn't be potty trained. "It was pretty sad," Jill said. "I was just like, 'This is going to be our future: never going anywhere because he's going to be out of control."' It was 1995 and the Sauters had just moved to the area. Derek lasted just days in the Bend-La Pine School District before his parents pulled him out. The first sign that it wasn't going to work was when they learned the then-head of the special education program had taken just one chapter of one college course worth of education in autism. "She said, 'I'll have to read up about that,"'Jill said. "We felt like they were really behind the times. I couldn't be just putting him in school waiting for them to figure out what ABA was." Initially, a family friend traveled periodically from California to oversee Derek's ABA program. Because he still was not speaking or writing, it started with 20 to 30 hours per week of pointing to pictures and the instructor placing his or her hand over Derek's to teach him to perform simple tasks. Derek was not an easy kid to work with at the time. He had taken to ripping up any paper he came across, enjoying the sound it made. The family could have no pictures on the walls, because he'd throw them down to hear the glass shatter. The tutors had to wear long-sleeved shirts to protect their skin from the inevitable scratching. And the work was so intense they could

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Featurei AUTISM THERAPY

only work two-hour shifts at a time. "One of the girls had to take off a month before her wedding because she said, 'I can't have these scratches all over my hands in the pictures,"'Jill said. The lessons eventually progressed to include photos of Derek's tutors making facial expressions and instructions such as "show m e a surpr ised face"or"show me a sad face." The lessons also included pictures of objects — an apple, for instance — that he would have to identify. Derek was taught to count and to read, the lessons always placing a heavy emphasis on repetition. There were also lessons in everyday life skills that Derek lacked,such as dressing himself.And he had to learn about danger, and who is a stranger and who's not. "Autistic kids have no sense of fear," Bob said. "They have no sense of distrust. You walk up to one and say,'Come with me,'and they'll go."

Getting the therapy paid for, however, required countless letters back and forth with the insurance company. Bob, a retired FBI agent, remains insured through Special Agents Mutual Benefit Association, which contracts with different insurance companies who handle the claims. Initially, the company decided ABA wouldn't be covered, as it was considered a mental health issue. Bob sent them articles, studies and court cases in which autistic clients won against their insurance companies. Finally, the company gave in, with the caveat that Bob provide semi-annual progress reports written by a board-certified professional. Fast forward more than a decade and a grown-up Derek greets visitors to his family's home on the outskirts of Bend in rehearsed, halted speech. A wide smile on his face, he responds to his parents' questions politely, with an air of obedience. He heads upstairs to watch TV and runs back

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down when Jill calls him. She requests he playasong on thepiano.He nods,and sits on the bench without hesitation, breaking into slow but accurate renditions of "Mary Had a Little Lamb" and "Twinkle Twinkle Little Star." When he's finished, he turns to face his clapping audience. Once the applause ceases, Derek gets up promptly and makes his way back upstairs. Derek will always be autistic, but he can do a number of things his parents say he wouldn't have been able to without his ABA therapy. Not only have his violent outbursts ceased and he speaks clearly, he takestaekwondo classes,goes to the library, plays cards, does chores and can read just about anything, his parents say. And he keeps track of it all on a large calendar that allows him to place Velcro activity cards next to certain hours of the day. But Derek's disconnect still reveals itself in small moments. The other day, Jill said, she was joking around with her friends. She laughed so hard, tears rolled down her cheeks. "Derek said to me, 'Sad? Crying?"' Jill said. "He was confused. 'Why are you sad, Mom?' It was like, 'Wow, he recognized that I'm laughing but I'm crying.' That must have been really confusing." Derek's parents say he'll probably never be able to live alone, and they've learned to be OK with that. After all, Jill said, life with Derek is simpler in some ways than it was with their other kids, ages 27, 31 and 33. At 16, they wanted cars. Derek wanted a Thomas the Tank Engine book. "With them, too, we always worried about who they were with, who they were driving with and stuff, what they were eating and drinking," she said. "With Derek, we pretty much know what he's about." Derek is a blessing, said Bob, his eyes welling with tears. "I mean, we have innocence around us every day," he said. "No guile, no hate — justinnocence. And, gee, how many 21-year-olds do you know that would love to go for a drive with their dad just to get a root beer?"•

WINTER/SPRING2014•HIGH DESERTPULSE

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Kylie Vige la nd, A c c o un t E x e c u t iv e ( H e a lt h 8c Medical) • 5 4 1 . 6 1 7 . 7 8 5 5 •

s•

•

ADULT FOSTERCARE

AbsoluteSerenity Adult FosterCare

AESTHETIC SERVICES

DermaSpa atBend Dermatology

ALLERGY gr,ASTHMA

Bend Memorial Clinic

ALZHEIMERS ADEMENTIA

Clar e Bridge Brookdale Senior Living

ASSISTED LIVING

Brookside Place

AUDIOLOGY

Central OregonAudiology AHearing AidClinic

BEHAVIORAL HEALTH

St. Charles Behavioral Health

CANCERCARE

St. Charles Cancer Center

CARDIOLOGY

Bend Memorial Clinic

CARDIOLOGY

St. Charles Heart gt Lung Center

COSMETIC SERVICES

Bend Memorial Clinic

DENTURISTS

119 N Rope Street• Sisters

541-588-G119

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541-382-4900

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161 E Cascade• Sisters

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Bend Dermatology Clinic

2747 NE Conners Drive• Bend

541-382-5712

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Bend D ermatology Clinic

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Bend Memorial Clinic

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541-382-4900

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ENDOCRINOLOGY

Bend Memorial Clinic

1501 NE Medical Center Drive• Ben

541-382-4900

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ENDOCRINOLOGY

EndocrinologyServices NW

929 SWSimpson Ave,Ste 220 • Bend

541-317-5600

FAMILY MEDICINE

Bend Memorial Clinic

Locations in Bend, Redmond tk Sisters 541-382-4900

FAMILY MEDICINE

Central Oregon Family Medidne

www .stcharleshealthcare.org

www.bendderm.com www.bendderm.com

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www.cofm.com

645 NW 4th St.• Redmond

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FAMILY MEDICINE

St. Charles Family Care

2965NEConners Ave,Suite 127 • Bend

541-706-4800

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St. Charles Family Care

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541-447-G2G3

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211 NW Larch Avenue• Redmond

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St. Charles Family Care

630 Arrowleaf Trail• Sisters

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High Lakes Health Care

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GASTROENTEROLOGY

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

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541-728-0535

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541-923-7633

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GRRR RRLSIIGBRY, RIBBRTRIGSAVRIRGRRR Advanced Spedalty Care

1247NE Medical Center Drive • Bend

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GENERALSURGERY A BAEIATRICS St. Charles SurgicalSpedalists

1245 NW 4th Street, Ste 101 • Redmond

541-548-7761

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Serving Deschutes County

877-SG7-1437

GASTROENTEROLOGY

Gastroenterology of Central Oregon

GENERAL DENTISTRY

Coombe and Jones Dentistry

GERIATRIC CAREMANAGEMENT Paul Battle Associates

[ [ [

www.PaulBattle.com

HOME HEALTH SERVICES

St. C harles Home Health

2500 NE Neff Road• Bend

541-706-7796

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HOSPICE/HOME HEALTH

Hosp i ce of Redmond

732 SW 23rd St• Redmond

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Partners In Care

2075 NE Wyatt Ct. • Bend

541-382-5882

HOSPITAL

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1201 NE Elm St• Prineville

541-447-6254

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541-70G-7796

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HYBERBARICOXYGENTHERAPY Bend Memorial Clinic

IMAGING SERVICES

Bend Memorial Clinic

IMMEDIATE CARE

High Desert Family Atedidne At Immediate Care

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1501 NE Medical Center Drive• Bend

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Locations in Bend 8t Redmond

541-382-4900

www . bendmemorialdinic.com

570 67 Beaver Dr. • Sunriver

541-593-5400

n/a

INFECTIOUS DISEASE

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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INFECTIOUS DISEASE

St. Charles Infectious Disease

2965 NE ConnersAve., Suite 127 • Bend

541-706-4878

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INTEGRATED MEDICINE

Centerfor Integrated Medidne

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Nine Locations in Central Oregon

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Bend Memorial Clinic

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Redmond Medical Clinic

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St.Charles Laboratory Services

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1501 NE Medical Center Drive• Bend 2400 NE Neff Road, Ste A• Bend

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The Center: ouhopedicrtt NeurosurgicalCarest Research Locations in Bend 8t Redmond

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Bend Memorial Clinic

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Bend Memorial Clinic

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The Center:ouhopedic stNeurosurgical Carest Research Locations in Bend 8t Redmond

541-382-3344

OSTEOPOROSIS

Deschutes Osteoporosis Center

2200 NENeffRoad,Suite302 • Bend

541-388-3978

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St. Charles Advanced Illness Management

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541-706-5880

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PEDIATRIC DENTISTRY

Deschutes Pediatric Dentistry

1475 SW Chandler Ave, Ste 202• Bend

541-389-3073

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Bend Memorial Clinic

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St. Charles Family Care

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Desert Orthopedics

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Healing Bridge Physical Therapy

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Offices in Bend, Redmond 8sMadras

541-388-2861

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PULMONOLOGY

Bend Memorial Clinic

Locations in Bend 8t Redmond

541-382-4900

PULMONOLOGY

St. Charles Heart AtLung Center

Locations in Bend 8t Redmond

541-706-7715

RADIOLOGY

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend

541-382-9383

REHABILITATION

St. Charles Rehabilitation Center

Locations in Bend 8t Redmond

541-706-7725

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RHEUMATOLOGY

Bend Memorial Clinic

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541-382-4900

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www.corapc.com

ADVEGTISINGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY A

•

2200 NENeffRoad,Suite302 • Send

541-388-3978

Bend Memorial Clinic

Locations in Bend gt Redmond

541-382-4900

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SLEEP MEDICINE

St. Charles Sleep Center

Locations in Bend BI Redmond

541-706-6905

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SURGICAL SPECIALIST

St. Charles Surgical Spedalists

1245 NW 4th SL Ste 101• Redmond

541-548-77G1

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SURGICAL SPECIALIST

Bend Memorial Clinic

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Locations inBend(East AWest) A Redmond 541-382-4900

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RHEUMATOLOGY

Deschutes Rheumatology

SLEEP MEDICINE

URGENT CARE

Bend Memorial Clinic

URGENT CARE

St. Charles Immediate Care

UROLOGY

Bend Urology Assodates

UROLOGY

UrologySpedalistsofOregon

VASCULARSURGERY

Bend Memorial Clinic

VEIN SPECIALISTS

InoviaVein Spedalty Center

VEIN SPECIALISTS

Bend Memorial Clinic •

ADAM WILLIAMS, MD

• o •

Bend Memorial Clinic

STEPHEN ARCHER, MD, FACS Advanced Spedalty Care NGOCTHUY HUGHES, DO, PC St . Charles Surgical Spedalists

www,bendarthritis,com

2600 NE Neff Road• Bend

541-706-3700

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Locations in Bend gI Redmond

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1501 NEMedical Center Drive • Bend

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2200 NE Neff Road, Ste 204• Bend

541-382-834G

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www . bendmemorialdinic.com

541-3 8 2 -4900

ww w .bendmemorialdinic,com

•

www.bendvein.com

•

Send Eastside A Redmond

1247 NE Medical Center Dr• Send 54 1 -322-5753 w 1245NW4thStreet, Ste101• Redmond 541-548-7761 w

w w .advancedspecialtycare.com ww. stcharleshealthcare,org

KAREN CAMPBELL, PHD

St. Charles Behavioral Health

2542 NE Courtney Dr• Send

541-70G-7730

www.stcharleshealthcare,org

BRIAN T. EVANS, PSYD

St. Charles Behavioral Health

2542 NE Courtney Dr• Send

541-706-7730

www.stcharleshealthcare,org

JANET FOLIANO-KEMP, PSYD

St .Charles Behavioral Health

2542 NE Courtney Dr• Send

541-70G-7730

www.stcharleshealthcare,org

EUGENE KRANZ, PHD

St. Charles Behavioral Health

2542 NE Courtney Dr• Send

541-706-7730

www.stcharleshealthcare,org

WENDY LYONS, PSYD

St. Charles Family Care

211 NW Larch Ave• Redmond

541-548-2164

www.stcharleshealthcare,org www.stcharleshealthcare,org

SONDRA MARSHALL, PHD

St. C harles Behavioral Health

2542 NE Courtney Dr• Send

541-706-7730

MIKALA SACCOMAN, PHD

S t. Ch arles Behavioral Health

2542 NE Courtney Dr• Send

541-70G-7730

www.stcharleshealthcare,org

2542 NE Courtney Dr• Send

541-706-7730

www.stcharleshealthcare,org

2965 NE ConnersAve, Suite 127 • Bend

541-70G-7730

www.stcharleshealthcare,org

REBECCASCRAFFORD, PSYD St. Charles Behavioral Health

SCOTT SAFFORD, PHD

St. Charles Family Care

LAURA SHENK, PSYD

St. Charles Behavioral Health

2542 NE Courtney Dr• Send

541-706-7730

www.stcharleshealthcare,org

KIMBERLY SWANSON, PHD

St. Charles Family Care

211 NW Larch Ave• Redmond

541-548-2164

www.stcharleshealthcare,org

HUGH ADAIR III, DO

St. Charles Heart 8I Lung Center

2500 NE Neff Road• Bend

541-388-4333

www .stcharleshealthcare,org

CATHERINE BLACK, PA-C

Ben d Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www ,bendmemorialdinic. com

JEANBROWN, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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NABEL FARRAJ, DO

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

RICK KOCH, MD

Bend Memorial Clinic

Send Eastside A Redmond

541-382-4900

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JAMES LAUGHLIN,MD

St. Charles Heart 8I Lung Center

2500 NE Neff Road• Bend

541-388-4333

www .stcharleshealthcare,org

BRUCE MCLELLAN, MD

St. Charles Heart 8I Lung Center

2500 NE Neff Road• Bend

541-388-4333

www .stcharleshealthcare,org

GAVIN L.NOBLE, MD

Bend Memorial Clinic

Send Eastside gt Redmond

541-382-4900

www . bendmemorialdinic,com

STEPHANIE SCOTT, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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JASONWEST, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialdinic,com

MICHAEL WIDMER, MD

St. Charles Heart 8I Lung Center

2500 NE Neff Road• Bend

541-388-4333

www .stcharleshealthcare,org

JASON IL WOLLMUTH, MD

Ben d Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialdinic,com

ADVEGTISINGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY I

EDDY YOUNG, MD

St. Charles Heart t)t Lung Center

2500 NE Neff Road• Bend

54 1-3 8 8 -4333 w

JOHN D. BLIZZARD, MD

St. Charles Heart t)t Lung Center

2500 NE Neff Road• Bend

541-388-1636

www.stcharleshealthcare,org

ANGELO A.VLESSIS, MD

St. Charles Heart t)t Lung Center

2500 NE Neff Road• Bend

541-388-1636

www.stcharleshealthcare,org

JORDAN T.DOI,MSC, DC

NorthWest Crossing Chiropracticgt Health

628 NW York Dr, Ste. 104• Bend

541-388-2429

www,nwxhealth.com

THERESA M.RUBADUE,DC,CCSP NorthWest Crossing Chiropractic gt Health

628 NW York Dr, Ste. 104• Bend

541-388-2429

1345 NW Wall St, Ste 202• Bend

541-318- 1000

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JASON M.KREMER, DC,CCSP,CSCS Wellness Doctor

www,nwxhealth.com

MICHAEL IL HALL, DDS

Central Oregon Dental Center

1563 NW Newport Ave• Bend

541-389-0300

www,centraloregondentalcenter,net

BRADLEY E.JOHNSON,DMD

Co n t emporary Family Dentistry

101 6 NW Newport Ave• Bend

541-389-1107

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2600 NE Neff Road• Bend

541-382-4900

www . bendmemorialdinic,com

Bend A Redmond

541-382-4900

www.bendmemorialdinic,com

2747 NE Conners Drive• Bend

541-382-5712

www.bendderm.com

388 SW BluffDr • Bend

541-678-0020

www,centraloregondermatology.com

2600 NE Neff Road• Bend

541-382-4900

www.bendmemorialdinic,com www.bendderm.com

ALYSSA ABBEY, PA-C

Bend Memorial Clinic

ANGELA COVINGTON, MD

Ben d Memorial Clinic

WILLIAM DELGADO, MD, (MOHS) Bend Dermatology Clinic MARK HALL, MD,

Central Oregon Dermatology

JAMES M. HOESLY, MD

Bend Memorial Clinic

JOSHUA MAY, MD

Bend Dermatology Clinic

2747 NE Conners Drive• Bend

541-382-5712

KRISTIN NEUHAUS, MD

Bend Dermatology Clinic

2747 NE Conners Drive• Bend

541-382-5712

www.bendderm.com

GERALD E. PETERS,MD, DS(MOBS) Bend Memorial Clinic

2600 NE Neff Road• Bend

541-382-4900

www.bendmemorialdinic,com

ANN M. REITAN, PA-C OttOHS) Bend Memorial Clinic

2600 NE Neff Road• Bend

541-382-4900

www . bendmemorialdinic,com

2747 NE Conners Drive• Bend

541-382-5712

www.bendderm.com

STEPHANIE TRAUTMAN, MD Bend Dermatology Clinic

2747 NE Conners Drive• Bend

541-382-5712

www.bendderm.com

LARRY WEBER, PA-C

2747 NE Conners Drive• Bend

541-382-5712

www.bendderm.com

LISON ROBERTS, PA-C

I I

Ben d Dermatology Clinic

Bend Dermatology Clinic

MARY F. GLRROLL, MD

Bend Memorial Clinic

1501 NE h4edical Center Drive• Bend

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RICKN.GOLDSTEIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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1501 NE h4edical Center Drive• Bend

541-382-4900

www.bendmemorialdinic,com

929 SWSimpson Ave,Ste 220 • Bend

541-317-5600

n/a

TONYA KOOPMAN, MSN, FNP-BC Bend Memorial Clinic PATRICK MC~

, MD

Endoc r inology Services NW

TRAVIS MONCHAMP, MD

EndocrinologyServices NW

CAREY ALLEN, MD

St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-G2G3

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HEIDI ALLEN, MD

St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-G2G3

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211 NW Larch Avenue• Redmond

541-548-2164

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1501 NE Medical Center Drive• Bend

541-382-4900

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865 SW Veterans Way• Redmond

541-382-4900

www . bendmemorialdinic,com

630 Arrowleaf Trail• Sisters

541-549-1318

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THOMAS L. ALLUMBAUGH, MD St. Charles Family Care KATHLEEN C. ANTOLAK, MD B end Memorial Clinic SADIE ARRINGTON,MD

Bend Memorial Clinic

JOSEPH BACHTOLD, DO

St. Charles Family Care

929 SWSimpson Ave,Ste 220 • Bend 541-317-5600

n/a

1080 SW tvtt. Bachelor Drive• Bend

541-382-4900

BRANDON W. BRASHER, PA-C St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-G2G3

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SHANNON )L BRASHER, PA-C St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-G2G3

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JEFFREY P. BOGGESS, MD

Ben d Memorial Clinic

MEGHAN BRECKE, DO

St. Charles Family Care

2965NEConners Ave,Suite 127 • Bend

541-70G-4800

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NANCY BRENNAN, DO

St. Charles Family Care

2965 NE ConnersAve, Suite 127 • Bend

541-70G-4800

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WILLIAM C. CLARIDGE, MD

S t . Charles Family Care

211 NW Larch Avenue• Redmond

541-548-21G4

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ADVERTISING SUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY MATTHEW CLAUSEN, MD

St. Charles Family Care

AUDREY DAVEY,MD

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www . bendmemorialdinic.com

JAMES K. DETWILER, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www .stcharleshealthcare.org

MAY S. FAN,MD

Bend Memorial Clinic

231 East CascadesAvenue • Sisters

541-549-0303

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929 SW Simpson Avenue• Bend

541-389-7741

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2965 NE ConnersAve,Suite 127 • Bend

541-70G-4800

www .stcharleshealthcare.org

630 Arrowleaf Trail• Sisters

541-549-1318

www .stcharleshealthcare.org

211 NW Larch Avenue• Redmond

541-548-2164

www .stcharleshealthcare.org

645 NW 4th St.• Redmond

541-923-0119

Redmond 8) Sisters

541-382-4900

645 NW 4th St.• Redmond

541-923-0119

211 NW Larch Avenue• Redmond

541-548-21G4

JAMIEFREEMAN, PA-C

High Lakes Health Care Upper Mill

MARK GONSKY,DO

St. Charles Family Care

STEVEN GREER, MD BRIANNA HART, PA-C

St. Charles Family Care

MARGARET"PEGGY" HAYNER ) FNP Central Oregon Family Medidne ALAN C.HILLES, MD

Bend Memorial Clinic

MARKJ. HUGHES, D.O

Central Oregon Family Medidne

SING-WEIHO,MD

2965NEConnersAve,Suite127• Bend 541-70G-4800 w

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PAMELA J.IRBY,MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www . stcharleshealthcare.org

DAVID KELLY, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

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MAGGIE J. KING, MD

St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-62G3

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PETER LEAVITT, MD

St. Charles Family Care

2965 NE Conners Ave,Suite 127 • Bend

541-70G-4800

www .stcharleshealthcare,org

CHARLOTTE LIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialdinic.com

KAE LOVERINK, MD

High Lakes Health Care Redmond

1001 NW Canal Blvd• Redmond

541-504-7635

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STEVE MANN, DO

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

JOE T. MC COOK, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-21G4

G. BRUCE MCELROY,MD

Central Oregon Family Medidne

645 NW 4th St.• Redmond

541-923-0119

www.cofm.net

LORI MCMILLIAN, FNP

Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

n/a

EDEN MILLER, DO

High LakesHealth Care Sisters

354 W Adams Avenue• Sisters

541-549-9G09

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KEVIN MILLER,DO

High LakesHealth Care Sisters

354 W Adams Avenue• Sisters

541-549-9609

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541-389-7741

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JESSICAMORGAN ) MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

DANIEL J. MURPHY, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond 5 4 1 - 5 48-2164

SHERYL L. NORRIS, MD

St. Charles Family Care

211NWLarchAvenue• Redmond 5 4 1 - 5 48-2164 w

AUBREY PERKINS, FNP

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-21G4

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JANEY PURVIS, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialdinic.com

KEVIN REUTER, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

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DANA M. RHODE, DO

Bend Memorial Clinic

HANS G.RUSSELL, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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ERIC J. SCHNEIDER, MD

Bend Memorial Clinic

1501 NE Medical Center Drives Bend

541-382-4900

www . bendmemorialdinic.com

JEFFERY SCOTT,DO

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

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LINDA C. SELBY, MD

St. Charles Family Care

1103 NE Elm Street• Prineville

541-447-62G3

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CINDYSHUMAN, PA-C

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

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5706 7 Beaver Dr. • Sunriver

541-593-5400

1501 NE Medical Center Drive• Bend

541-382-4900

DAIUEL M. SKOTTE) SR. DO., P.C. High Desert Family t)tedidne AImmediate Care

EDWARDM. TARBET, MD B

JOHN D. TELLER, MD NATHANR. THOMPSON, MD S t . ~

E. T O WLE, MD

end M emorial Clinic Bend Memorial Clinic Charles Family Care Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend 54 1 - 382-4900 w

1501 NE Medical Center Drive• Bend 541-382-4900 w

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n/a ww w.bendmemorialdinic.com ww . bendmemorialdinic.com

211 NW Larch Avenue• Redmond

541-548-2164

www .stcharleshealthcare.org

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialdinic.com

LISA URI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

ww w .highlakeshealthcare.com

MARK A. VALENTI, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www .stcharleshealthcare.org

ADVEGTISttts SUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY 1501 NE Medical Center Drive• Bend

54 1-382-4900 w ww .bendmemorialdinic.com

THOMAS A. WARLICK, MD

Ben d Memorial Clinic

BRUCE N. WILLIAMS, MD

St. C harles Family Care

1103 NE Elm Street• Prineville

541-447-62G3

ww w.stcharleshealthcare.org

B e n d Memorial Clinic

Bend Eastside th Redmond

541-382-4900

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RICHARD H. BOCHNER, MD

ELLEN BORLAND,MS, RN, CFNP Bend Memorial Clinic

ARTHUR S. CANTOR, MD

Bend Memorial Clinic

HEIDI CRUISE, PA-C, MS

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w ww .bendmemorialdinic.com

Bend Eastside th Redmond

541-382-4900

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1501 NE Medical Center Drive• Bend

541-382-4900

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1501 NE Medical Center Drive• Bend

541-382-4900

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SIDNEY E. HENDERSON HI, MD Bend Memorial Clinic

Bend Eastside th Redmond

541 382-4900

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SANDRA K HOLLOWAY,MD

Bend Memorial Clinic

Bend Eastside th Redmond

541-382-4900

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GLENN KOTEEN, MD

Gastroenterology of Central Oregon

2450 Mary Rose Place, Ste 210 • Bend

54 1 -728-0535 w ww .gastrocentraloregon.com

JENIFER TURK, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w ww .bendmemorialdinic.com

MATTHEW WEED, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w ww .bendmemorialdinic.com

JANE BHSCHBACH, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

SUSAN GORMAN, MD

High Lakes Health Care Redmond

1001 NW Canal Blvd.• Redmond

541- 5 04-7635 w ww .highlakeshealthcare.com

CHRISTINA HATARA, MD

Ben d Memorial Clinic

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LAURIE D'AVIGNON,MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 -382-4900 w ww .bendmemoriaidinic.com

JOHN LUTZ, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w

REBECCASHERER, MD

St. Charles Infectious Disease

JENESS CHRISTENSEN, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

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JOHN CORSO,MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

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Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

MICHAEL N.HARRIS, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

ANNE KILLINGBECK,MD

Internal Medidne Assodates of Redmond

23 6 NW Kingwood Ave • Redmond

541-548-7134

ANITA D.KOLISCH, MD

Bend Memorial Clinic

865 SW VeteransWay• Redmond

541-382-4900

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MATTHEW R. LASALA, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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MADELINE LEMEE, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

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MARY MMHKDI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

ww w.highlakeshealthcare.com

KAREN L.OPPENHEIMER, MD

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www.bendmemorialdinic.com

H. DEREK PALMER, MD

Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

n/a

A. WADE PARKER, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemoriaidinic.com

MATTHEW REED, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

M. SEANROGERS, MD

Bend Memorial Clinic

1501 NE htedical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

DAN SULLIVAN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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FRANCENA ABENDROTH, MD Bend Memorial Clinic

1501 NE htedical Center Drive• Bend

54 1-382-4900 w

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GREGORY FERENZ,DO

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w

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CRAIGAN GRIFFIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900 w

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RAY TIEN, MD

The Center:Orthopedic ttt NeurosurgicaiCaretit Research Locations in Bend St Redmond

54 1-3 8 2 - 3 344

www.t h ecenteroregon.com

BRAD WARD, MD

The Center:Orthopedic gtNeurosurgicai CaregtResearch~ Locations in Bend th Redmond

541-382-3344Q

www.thecenteroregon.com

ELSO A.GANGAN, MD

2965 ConnersAve,Ste 127 • Bend 54 1 - 70G-4878

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www.stcharleshealthcare.org

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ADVERTISING SUPPLEMENT

2013 CENTRAL OREGON M E D ICAL DIRECTORY ' ANNIE BAUMANN, RD, LD

Bend Memorial Clinic

ANN-BRIDGETBIRD,MD

St. Charles OB/GYN

Locations in Redmond Ar Prineville

5 4 1 - 52G-GG35

www.stcharleshealthcare,org

BRENDA HINMAN, DO

St. Charles OB/GYN

Locations in Redmond AI Prineville

5 4 1 - 52G-6G35

www.stcharleshealthcare.org

NATALIE HOSHAW,MD

St. Charles OB/GYN

Locations in Redmond gr Prineville

5 4 1 -526-6635

www.stcharleshealthcare.org

AMY B. MCELROY,FHP

St. Charles OB/GYN

Locations in Redmond Ar Prineville

5 4 1 - 526-6635

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CLABE THOMPSON, DNP,CNM St. Charles OB /GYN

Locations in Redmond AI Prineville

5 4 1 - 526-G635

www.stcharleshealthcare,org

1501 NE Medical Center Drive• Bend 541-382-4900 w

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JAMES NELSON,MD

The Center:Orthopedic A NeurosurgicalCaretr Rese arch Locations in Bend Ar Redmond

541-382-3344

www.thecenteroregon.com

LABBY PAULSON, MD

The Center:Orthopedic srNeurosurgical CaresrResearch Locations in Bend AI Redmond

541-382-3344

www.thecenteroregon.com

ROB BOONE,MD

St. Charles Cancer Center

Locations in Bend ArRedmond

541-706-5800

www .stcharleshealthcare.org

CORA CALOMENI,MD

St. Charles Cancer Center

Locations in Bend AI Redmond

541-706-5800

www .stcharleshealthcare,org

SUSIEDOEDYHS, FHP

St. Charles Cancer Center

Locanons In Bend ArRedmond

541-70G-5800

www.stcharleshealthcare.org

BRIAN L.ERICKSON, MD

Bend Memorial Clinic

Send Eastside gi Redmond

541-382-4900

www.bendmemorialdinic.com

St. Charles Cancer Center

locations in Bend gi Redmond

541-70G-5800

www.stcharleshealthcare,org

St. Charles Cancer Center

Locations in Bend AI Redmond

541-706-5800

www.stcharleshealthcare,org

B e nd Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

Bend Memorial Clinic

Bend Eastside A Redmond

541-382-4900

www.bendmemorialdinic.com

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1-382-4900

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MATTHEWN. SIMMONS

UrologySpedalistsofO regon

1247 NE Medical Center Drive• Bend 541-322-5753 w

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BRIAN P. DESMOND, MD

Bend Memorial Clinic

Bend Eastside, Westsidegr Redmond 541-382-4900

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Bend Eastside, Westside ArRedmond

541-382-4900

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Send Eastside, Westside AIRedmond

541-382-4900

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STEVE KOBNFELDr MD

BILL MARTIN,MD

BENJAMINJ. MIRIOVSKY, MD

LAURIE BICE, ACNP WILLIAM SCHMIDT, MD

HEATHERWEST, MD I

' I

THOMAS n. FITgglmOZSr Mn,MPH Bend Memorial Clinic

ROBERT C. MATHEWS, MD

Bend Memorial Clinic

SCOTT T.O'CONHE, MD

Bend Memorial Clinic

Bend Eastside, Westside gr Redmond

541-382-4900

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DARCY C. BALCEB, OD

Bend Memorial Clinic

Bend Eastside AIWestside

541-382-4900

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LOBISSA M. HEMMER, OD

Bend Memorial Clinic

Bend Eastside, Westsideih Redmond 5 4 1-382-4900

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KEITH E. KRUEGER, DMD, PC Keith E. Krneger, DMD, PC I '

1475 SW Chandler, Ste 101• Bend 54 1 - 617-3993 w

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AARONASKEW,MD

Desert Orthopedics

ANTHONY HINZ, MD

The Center:Orthopedic srNeurosurgical CaresrResearch Locations in Bend Ar Redmond

JEFFREY P. HOLMBOE, MD

The Center:Orthopedic A NeurosurgicalCaretr Rese arch Locations in Bend gr Redmond

541-382-3344

www.thecenteroregon.com

JOEL MOORE, MD

The Center:Orthopedic Sr Neurosurgical CareSrResearch Locations in Bend Ar Redmond

541-382-3344

www.thecenteroregon.com

I '

•

Locations in Bend gr Redmond

541-388-2333

www.desertorthopedics.com www.thecenteroregon.com

•

KNUTEBUEHLEB, MD

The Center:Orthopedic I Neurosurgical Care I Research lo c a tions in Bend gi Redmond

541-382-3344

www.thecenteroregon.com

MICHAEL CARAVELLI,MD

The Center:Orthopedic srNeurosurgical CaresrResearch Locations in Bend AI Redmond

541-382-3344

www.thecenteroregon.com

ADVERTISINGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY I '

I '

•

541-388-2333

www. desertorthopedics.com

The Center:Orthopedic a NeurosurgicalCarea Research Locations in Bend Sr Redmond

541-382-3344

www . thecenteroregon.com

Desert Orthopedics

541-388-2333

www .desertorthopedics.com

www.desertorthopedics.com

ERIN FINTE, MD

Desert Orthopedics

JAMES HALL, MD ROBERT SHANNON, MD I

•

Locations in Bend gr Redmond

Locations in Bend gr Redmond I

MICHAEL RYAN, MD

Desert Orthopedics

1303 NE Cushing Dr, Ste 100• Bend

54 1 -388-2333

GREG HA, MD

Desert Orthopedics

1303 NE Cushing Dr, Ste 100• Bend

54 1 -388-2333 w

KATHLEEN MOORE,MD

Desert Orthopedics

1303 NE Cushing Dr, Ste 100• Bend

54 1 -388-2333

www. desertorthopedics.com

I '

ww. desertorthopedics.com

TIMOTHY BOLLOM, MD

The Center:orthopedic a NeurosurgicalCarea Research Locations in Bend gr Redmond

541-382-3344

www.thecenteroregon.com

BRETT GINGOLD,MD

Desert Orthopedics

541-388-2333

www. d esertorthopedics.com

SCOTT T. JACOBSON, MD

The Center:Orthopedic stNeurosurgical Care5Research Locations in Bend gr Redmond

541-382-3344

www.thecenteroregon.com

BLAKE NONWEILER, MD

The Center:orthopedic a NeurosurgicalCareaResearch Locations in Bend 8r Redmond

541-382-3344

www . thecenteroregon.com

Desert Orthopedics

54 1 -388-2333 w

CARA WALTHER, MD I

1315 NW 4th Street• Redmond

1303 NE Cushing Dr, Ste 100• Bend

ww. desertorthopedics.com

MICHAEL COE,MD

The Center:Orthopedic a NeurosurgicalCare5 Research Locations in Bend 8r Redmond

541-382-3344

KENNETH HANINGTONs MD

D e s ert Orthopedics

Locations in Bend gr Redmond

54 1- 3 8 8-2333 w

ww. desertorthopedics.com

AARON HOBLET, MD

Desert Orthopedics

Locations in Bend 8r Redmond 5 4

1 - 3 88-2333 w

ww. desertorthopedics.com

SOMA LILLY, MD

The Center:Orrhopedrc aNeurosurgical Care5 Research Locations in

Bend gr Redmond 5

The Center:orthopedic aNeurosurgicalCarea Researdr Locations in

Bend 8r Redmond 5 4

JAMES VERHEYDEN, MD I

I ' I ' I

www . thecenteroregon.com

41- 3 8 2 -3344

www.t hecenteroregon.com

1- 3 8 2-3344 w

ww. t hecenteroregon.com

MOLLY OMIZOs MD

Deschutes Osteoporosis Center

LISA LEWIS, MD

Partners In Care

RICHARD J. MAUNDER, MD LAURA K. MAVITY, MD

2200 NE Neff Road, Suite 302• Bend

54 1 - 388-3978 ww w.deschutesosteoporosiscenter.com

2075 NEWyattCt • Bend

541-3 82-5882

www.partnersbend.org

St. Charles Advancedlllness Management

2500 NE Neff Road• Bend

541-706-5885

www.stcharleshealthcare.org

St. Charles AdvancedIllness Management

2500NE Neff Road • Bend

541-706-5885

www.stcharleshealthcare.org

STEPHANIE CHRISTENSEN, DMD Deschutes Pediatric Dentistsy

1475 SW Chandler Ave, Ste• Bend

541 - 389-3073

www.deschuteskids.com

STEVE CHRISTENSEN, DMD

Deschutes Pediatric Dentistry

1475 SW Chandler Ave, Ste• Bend

541 - 389-3073

www.deschuteskids.com

KATE L. BROADMAN, MD

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541 - 382-4900

www . bendmemorialdinic.com

THOMAS N ERNST MD

St Charles Family Care

211NWLarchAve• Redmond

541-5 4 8 -2164

www. s tcharleshealthcare.org

JEIIFER GRISWOLD,PNP

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541 - 382-4900

www . bendmemorialdinic.com

MICHELLE MILLS, MD

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541 - 382-4900 w ww .bendmemorialdinic.com

MARGARET J. PHILP, MD

St. C h arles Family Care

211 NW Larch Ave• Redmond

JENNIFER SCHROEDER, MD

B e nd Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541 - 382-4900 w ww .bendmemorialdinic.com

JB WARTON,DO

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541 - 382-4900

www . bendmemorialdinic.com

ROBERT ANDREWS, MD

Desert Orthopedics

Locations in Bend gr Redmond

541-388-2333

ww w .desertorthopedics.com

LINDA CARROLL, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741 www.highlakeshealthcare.com

TIM HILL, MD

The Center:orthopedic a NeurosurgicalCarea Research Locations in Bend gr Redmond

54 1-5 4 8 -2164 w

541-382-3344

ww. stcharleshealthcare.org

www . thecenteroregon.com

ADVEGTISIHGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY I

NANCY H. MALONEY, MD

Bend Memorial Clinic

JAMES NELSON, MD

The Center: Orthopedic rh Neurosurgical CarerhResearch

Locations in Bend gt Redmond

541-382-3344

LARRY PAULSON, MD

The Center:Orthopedic rh Neurosurgical CarerhResearch

Locations in Bend 8t Redmond

541-382-3344

DAVID STEWART, MD

The Center:t Orthopedic rh Neurosurgical CarerhResearch

Locations in Bend gt Redmond

541-382-3344

JON SWIFT, DO

Desert Orthopedics

Locations in Bend 8t Redmond

541-388-2333

VIVIANE UGALDE,MD

The Center: Orthopedic rh Neurosurgical CarerhResearch

Locations in Bend gt Redmond

541-382-3344

MARC WAGNER, MD

The Center:Orthopedic rhNeurosurgical CarerhResearch Locations in Bend 8t Redmond

541-382-3344

AMBROSE ILSU, DPM

Cascade Foot Clinic

41-3 8 8 -2861

DEAN NAKADATE, DPM

Deschutes Foottit Ankle

1501 NE Medical Center Drive• Bend 541-382-4900 w w w .bendmemorialdinic.com

2408 NE Division Street• Bend 5

www.thecenteroregon.com

t i

www.thecenteroregon.com www.thecenteroregon.com www.desertorthopedics.com www.thecenteroregon.com www.thecenteroregon.com

www,cascadefoot.com

929 SWSimpson Ave,Ste220 • Bend 541 -317-5600 w w w ,deschutesfootandankle,com

BROOKEHALL, MD I

St. Charles Preoperative Medidne

Bend Memorial Clinic

JAMIE DAVID CONKLIN, MD

St. Charles Pulmonary Clinic

LOUISD'AVIGNON, MD

Bend Memorial Clinic

ERIC S. DILDINE, PA C

St. Charles Pulmonary Clinic

T. CHRISTOPHER KELLEY, DO Bend Memorial Clinic

JONATHONMCFADYEN, NP

Bend Memorial Clinic

KEVIN SHERER, MD

St. Charles Pulmonary Clinic

41-7 0 6 -2949 w

ww. stcharleshealthcare.org

JONATHON BREWER, DO

2500 NE Neff Road• Bend 5

541-382-4900

Bend Eastside 8t Redmond

Locations in Bend gtRedmond

541- 7 0 6-7715

Bend Eastside grRedmond Locations in Bend gt Redmond

Bend Eastside gtRedmond

www.stcharleshealthcare.org

541-382-4900

www.bendmemorialdinic.com

5 41-7 0 G-7715

www.stcharleshealthcare.org

541-382-4900

1501 NE Medical Center Drive• Bend 541 -382-4900 w Locations in Bend A Redmond

www . bendmemorialdinic.com

541- 7 0G-7715

ww w.bendmemorialdinic.com ww . bendmemorialdinic.com www . stcharleshealthcare,org

TRACI CLAUTICE-ENGLE, MD Central Oregon Radiology Assodates, P.C.

14 60 NE Medical Center Dr • Send 54 1 -382-9383

www.corapc.com

ROBERT HOGAN,MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

STEVEN MICHEL, MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

PATRICK BROWN, MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

STEVE KJOBECH,MD

Central Oregon Radiology Assodates,P.C.

14 60 NE Medical Center Dr • Bend

541-382-9383

www.corapc.com

GARRETT SCHROEDER, MD

C e n tral Oregon Radiology Assodates, P.C.

14 60 NE Medical Center •DrSend

541-382-9383

www.corapc.com

DAVID ZULAUF, MD

Central Oregon Radiology Associates,P.C.

14 6 0 NE Medical Center Dr • Send

541-382-9383

www.corapc.com

THOMAS KOEHLER,MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Send 54 1 -382-9383

www.corapc.com

JOHN STASSEN, MD

Central Oregon Radiology Associates, P.C.

14 60 NE Medical Center Dr • Send 5 4 1 - 382-9383

www.corapc.com

JEFFREY DRUTMAN, MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Send 54 1 -382-9383

www.corapc.com

RONALD HANSON, MD

Central Oregon Radiology Associates,P.C.

14 6 0 NE Medical Center Dr • Send

541-382-9383

www.corapc.com

Central Oregon Radiology Assodates,P.C.

14 60 NE Medical Center •DrBend

541-382-9383

www.corapc.com

WILLIAM WHEIR HI, MD

Central Oregon Radiology Assodates,P.C.

14 60 NE Medical Center •DrSend

541-382-9383

www.corapc.com

LAURIE MARTIN,MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

Central Oregon Radiology Associates, P.C.

www.corapc.com

JAMES JOHNSON,MD

I ' ' I

PAULASHULTZ, MD

14 60 NE Medical Center Dr • Send 5 4 1 - 382-9383

ADVEGTISINGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY STEPHEN SHULTZ, MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

CLOE SHELTON, MD

Central Oregon Radiology Assodates, P.C. 14 60 NE Medical Center Dr • Bend 54 1 -382-9383

www.corapc.com

NOREEN C. MILLER, FNP

St. Charles Rehabilitation Center

2500 NE Neff Road• Bend 5

GREG BORSTAD,MD

Bend Memorial Clinic

Bend Eastside gi Redmond

541-382-4900

ww w .bendmemorialdinic.com

CHRISTINA BRIGHT, MD

Bend Memorial Clinic

Bend Eastside A Redmond

541-382-4900

ww w.bendmemorialdinic.com

DAN FOHRMAN, MD

Deschutes Rheumatology

2200 NENeffRoad,Suite302 • Bend

541-388-3978

www.bendarthritis.com

BEATBERHANSEN.DISPENZA,MD

Deschutes Rheumatology

2200 NENeffRoad,Suite302 • Bend

541-388-3978

www.bendarthritis.com

TIANNA WELCH, PA

Deschutes Rheumatology

2200 NENeffRoad,Suite302 • Bend

541-388-3978

www.bendarthritis.com

JONATHON BREWER, DO

Bend Memorial Clinic Sleep Disorders Center

Bend Eastside gi Redmond

541-382-4900

www . bendmemorialdinic.com

ARTHUR K. CONRAD,MD

St. Charles Sleep Center

Locations in Bend Si Redmond

541-706-6905

www .stcharleshealthcare.org

DAVID L. DEDRICK, MD

St.Charles Sleep Center

Locations in Bend gi Redmond

541-70G-G905

ww w .stcharleshealthcare.org

Bend Eastside gi Redmond

541-382-4900

ww w .bendmemorialdinic.com

T. CHRISTOPHER KELLEY, DO Bend Memorial Clinic Sleep Disorders Center I

DAVID HERRIN, DC

Redmond WGBnessgiCh iropractic

DAVID CARNE, MD

St. Charles Surgical Spedalists

DARA H. CHRISTAE1Xd MD

Bend Memoria

GARY J. FREI, MD, FACS

Bend Memorial Clinic

SEAN HEALY, PA.C

Shh i

Bend Memorial Clinic

DARRENM. KOWALSKI MD FACS Bend Memorial Clinic

JOHN C. LAND, MD, FACS SARG

St. Charles Surgical Spedalists

1501 NE Medical Center Drive• Bend 1201 NE Elm i Prineville

•Bd 5

Bend Eastside A Redmond

ddl-382-dd00

541-447-62G3 41- 3 82-4900

541-3 8 2-4900

1245 NW 4th Street ¹101• Redmond 541 -548-77G1

1501 NE Medical Center Drive• Bend

•

.b d

' Idh i .

ww w .stcharleshealthcare.org .bendmemorialdinic.co

www.bendmemorialdinic.com www.stcharleshealthcare.org

54 1 -382-4900

www . bendmemorialdinic.com

1501 NE Medical Center Drive• Bend 541-382-4900 w

ww . bendmemorialdinic.com

1245 NW 4th Street, ¹101• Redmond 541-548-77G1

www.stcharleshealthcare.org em ' ldin'

St. Charles Surgical Spedalists

JEANNEWADSWORTH,PA-C, M Bend Memorial Clini ERINWALLING, MD, FACS B

www.drherrin.com

1655 SW Highland Ave,Ste 6• Redmond 541-923-2019

, PA-C,

GEORGE T.TSAI, MD, FACS

ww. stcharleshealthcare.org

IMOTHY L. BEARD, MD, FACS Bend Memorial Clinic

ACK W.HARTLEY MD FACS

41-7 0 6 -7725 w

en dMemorial Clinic

1245 NW 4th Street, ¹101• Redmond 541-548-7761

enter Dnve• Bend 541-382-4900 w 1501 NE Medical Center Drive• Bend

54 1 -382-4900

www.stcharleshealthcare.org ww . bendmemorialdinic.com www . bendmemorialdinic.com

JEFFCABA, PA-C

Bend Memorial Clinic

BendEastside,WestsidegiRedmond 5 4 1-382-4900

ww w .bendmemorialdinic.com

Am CLEMENS, MD

Bend Memorial Clinic

Bend Eastside, Westside 8 Redmond

54 1 -382-4900

www . bendmemorialdinic.com

Bend Eas side,Wes side A Redmond

541-382-4900

www. eildmemonaldinic.com

2600 NE Neff Road• Bend

541-706-3700

www.stcharleshealthcare.org

Ben Memoria C mc

Ben Eastsi e, Westsi eARe mon

541-382-4900

www. en memonal inic.com

ADAM KAPLAN, PA-C

Bend Memorial Clinic

Bend Eastside, Westside A Redmond 541-382-4900

ww w .bendmemorialdinic.com

KERRY MAWDSLEY, FNP

Bend Memorial Clinic

Bend Eastside, Westside 8 Redmond 541-382-4900

ww w .bendmemorialdinic.com

TERRACE MUCHA,MD

Bend Memorial Clinic

Bend Eastside, Westside gt Redmond 541-382-4900

ww w .bendmemorialdinic.com

Bend Memorial Clinic

BendEastside,WestsidegiRedmond 5 4 1 -382-4900

ww w .bendmemorialdinic.com

CASEYOSBORNE-RODHOUSE,PA-C Bend Memorial Clinic

Bend Eastside, Westside A Redmond

www . bendmemorialdinic,com

LAURIE D. PONTE MD

Bend Eastside, Westside 8 Redmond 541-382-4900

MIKE HUDSON,MD L JACOB, M

AY O'BRIEN PA-C

e m orta C mc

St. Charles Immediate Care

Bend Memorial Clinic

54 1 -382-4900

ww w .bendmemorialdinic.com

AUVEGTISINGSUPPLEMENT

2014 CENTRAL OREGON M E D ICAL DIRECTORY St. Charles Immediate Care

JONATHANSCHULTZ

2600 NE Neff Road• Bend

54 1-7 0 6 -3700 w

ww. stcharleshealthcare.org

NNIFER L. SURBER, M

Bend Memorial Clinic

Bend Eastside, eststde SI Redmond

PATRICK L. SIMNING, MD

Bend Memorial Clinic

Bend Eastside, Westside A Redmond

541-382-4900

www.bendmemorialdinic.com

Bend Memorial Clinic

Bend Eastside, Weststde A Redmond

54 1 - 38 - 9 00

www . endmemorialdinic.com

Bend Memorial Clinic

Send Eastside, Westside A Redmond

54 1 -382-4900 w ww .bendmemorialdinic.com

B e n d Memorial Clinic

Bend Eastside, Weststde gI Redmond

41-3 8 - 9 0 0

MEREDITH BAKER, MD

Bend Urology Assodates

2090NEWyattCourt • Bend

541 - 382-6447

www.bendurology.com

MICHEL BOILEAU,MD

Bend Urology Assodates

2090 NE Wyatt Court• Bend

541-382-G447

www.bendurology.com

JACK BREWER, MD

Bend Urology Assodates

2090 NE Wyatt Court • Bend

541-382-G447

www . bendurology.com

ANDREW NEEB, MD

UrologySpedalistsofOregon

1247 NE Medical Center Drive• Bend

541-322-5753

www .urologyinoregon.com

BRIAN O'HOLLAREN, MD

Ben d Urology Assodates

2090 NE Wyatt Court• Bend

541-382-6447

EAN SUTTLE, PA-C THOMAS H. WENDEL, MD RENT C. WESENBERG, MD

MATTHEW N. SIMMONS, MD U r o logy Spedalists of Oregon

www. endmemorialchnic.com

www . endmemorialdinic.com

www.bendurology.com

1247NE Medical Center Drive • Bend

54 1-322-5753

www.urologyinoregon.com

541- 382-G447

www.bendurology.com

NORA TAKLA, MD

Bend Urology Assodates

2090 NEWyatt Court• Bend

ROD BUZZAS, MD

Advanced Spedalty Care

1247 NE Medical Center Drive• Bend

541-322-5753

www.advancedspedaltycare.com

EDWARD M.BOYLE,JR.,MD,FACS

Inovia Vein Spedalty Center

2200 NE Neff Road, Ste 204• Send

541-382-834G

www.bendvein.com

ANDREW JONES, MD, FACS

Inovia Vein Specialty Center

2200 NE Neff Road, Ste 204• Bend

541-382-834G

www.bendvein.com

DARREN KOWALSKI,MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

WAYNE K. NELSON,MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialdinic.com

SAMUEL CHRISTENSEN, PA-C Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 -382-4900 w ww .bendmemorialdinic.com

WAYNE K NELSON, MD

1501 NE Medical Center Drive• Bend

54 1-382-4900 w ww .bendmemorialdinic,com

Bend Memorial Clinic

P AID AD V E RTISIN G S U P P L EM E N T To be included in the next issue of the PULSE/Connections Medical Directory, contact:

Kylie Vigeland, Account Executive ( H e a lt h & M e d i c a l) 541.617.7855

Body ofknoI/I/ledge ~ PDP QUlz g "3

0 'sa nea an ica Plus: fertility at the home office, 007's booze problem and other study topics that may (or may not) be fake BY MARKIAN HAWRYLUK

ach year billions of dollars are spent on groundbreaking medical research, including studies trying to unlock a cure for cancer, AIDS or Alzheimer's disease. Then there are the studies that leave you scratching your head. How did that study get funded? Think we're exaggerating? See if you can pick out which of these studies were actually published in medical journals and which ones we made up. (Or course, we cannot guarantee that some enterprising researchers won't pick up on our ideas.)

REAL OR FAKE?

Astudyonthesurvivaltimeofchocohtesinahospitalward • foundthatchocohtessurvivedameanof51 minutes.Chocolates were consumed most often by nurses or medical assistants, followed by doctors. Researchers concluded that while the survival time was relatively short, further studies were needed.

Ananalysisofemergencyroomvisitsfoundthatchildrenwhere • morelikelytobeinjuredafterfallingoutofawindowifthey hndedonahardsurfaceratherthanasoftsurface.

Knownasthe"Beer6oggiesStudy,"Britishresearcherstested • whethermenweremorelikelytojudgewomenasattractive afterconsuming multiplepintsofbeer.The study found a direct correlation, with increasing rates of consumption leading to higher scores for attractiveness on a 1-to-10 scale. The curve leveled off after eight beers, although researchers suggested that may have been linked to the resulting visual impairment.

Astudyfoundthatcontinuouspositiveairwaypressurethera• pyimprovesgolfscoresinmenwithsleepapnea.Researchers compared 12 golfers with sleep apnea to 12 golfers with similar handicapswho did nothave sleep issues.Using a CPAP mask reduced handicaps by an average of 11 percent. The researchers said it was important to find the unique factors that motivate patients to comply with treatment.

Researcherscondudedthatwomenwhoworkathomehave • higherfertilityratesthanwomenwhoworkinanoffice.Stayat-home women were more likely to have children than office workers. Women who home-schooled were the most likely subgroup to have given birth at least once.

C-O

GREG CROSS

Aresearch projectconsideredthepotentialspreadofbacteria • whenblowingoutcandlesonabirthdaycake.The researchers tested whether salivating before blowing out the candles affected the results. To simulate a realistic party atmosphere, test subjects consumed a slice of pizza prior to blowing out the candles. The study determined that it led to more bacteria being spread on the cake than when test subjects didn't eat before.

Astudyconductedatmorethan250worksettingsfoundthat • individualswhoworeshortsleevesonthedaythatfreeflushots wereprovidedtoworkersweremuchmorelikelytogetvaccinatedthanthosewhoworelongsleeves.The researchers suggested that providing flu shots during the summer or turning up the heat in the days before the flu shot clinic would boost overall vaccination rates by 27 percent.

Researchersexaminingemergencyroomvisitsfor gunshot • woundsfoundthatindividualsweremorelikelytobeshotaccidentallyifagunwasloaded.Risk factors for gunshot wounds included pulling the trigger, not keeping the safety on, and pointing the barrel toward a body part while cleaning.

Astudytestedthreephceboformuhtionstodeterminewhich • wasmoreeffectiveatcuringdepression.None had a statistically significant difference in efficacy compared with the others.

~ A r eviewofall 14James BondnovelsconcludedthattheinL/n famous Bntishsecretagentconsumedfourtimestherecommendedamountofakoholforanadultmale.That would put him at risk for alcoholic liver disease, cirrhosis, impotence and alcohol-induced tremor.

Answers:I. Real. 2. Real. 3. Fake. 4. Real. S. Fake. 6. Real. Z Fake. 8. Fake. 9. Real. 10. Real.

Page 50

WINTER/SPRING2014•HIGH DESERTPULSE

ProfileiJENNIFERBOONE

ANDYTIJLLIS

BY TARA BANNOW

day in the life of Jennifer Boone involves a lot of unloading. Clients tell Boone, a licensed professional counselor in Bend, about their fears. They share tales of crippling depression. Of grief. Loss. She loves her work. But by the end of the day, it gets to be a heavy load. "That has its own intensity to it," she said. Perhaps out of necessity, the 37-year-old mother of two has found a place she can go to turn her brain off for a while. She's been doing a workout called CrossFit at her gym, Xcel Fitness in Bend, for nearly two years. CrossFit is a strength and conditioning program that blends a fast-paced rotation of aerobic exercise, gymnastics and Olympic-level weightlifting. It's in these sessions that Boone does her own un-

WINTER/SPRING2014•HIGH DESERT PULSE

loading. She enters the room harboring stress and frustration, only to let go of it as she sets her body in motion. "It's so intense, I can't think about anything," she salcl.

Tough workouts On a recent Monday morning, Boone's CrossFit routine began with a "light" warm-up: 100 or so jumps with a jump rope, 50 sit-ups against a wall while holding a large medicine ball against her chest and some other goodies thrown in there. Boone andmore than a dozen of herpeers,moving to the beat of hip-hop music blaring throughout the large, industrial-looking room, then shifted into a series of exercises using kettlebells, weights that look like cannonballs with handles — swinging them up and down, eventually graduating to an exercise that involved holding the kettlebells above their heads

"I was looking forsomething wherel felt likel could haverelationships with people."Jennifer Boone, now a professional counselor, was describing herinterestin college psychology — butshe might as well have been talking about her CrossFit classes atXcel Fitnessin Bend, where"you're working so hard together that you feel somewhat connected."Above, Booneswings a kettlebell. The CrossFit programincludes weightlifting as well as aerobics, typicallyin groups.

Page 51

Profilef JENNIFER BOONE

•

and slowly, with calculated movements, lowering their bodies to the floor and back up again. Throughout all of this, Boone appeared collected. She aligned her movements with her breath — exhaling and inhaling with each swing of the kettlebell. There are days when she's so stressed out with work and family, Boone said she doesn't even want to go to her CrossFit class. Once she's there, though, that all changes. Recalling one particularly stressful day, Boone said, "We finished and I realized, 'Oh my gosh, I just totally let go of all of that.' It was amazing. I felt really refreshed and ready to go at the end. That is why I do it. That's what gets me in here a lot of times: Knowing how good I'm going to feel at the end." As the class progresses and the exercises get tougher, shouts of encouragementcan be heard over the music. "Nice work!" "Keep going!" "Good job!a Boone has never been in the military, but she said she imagines CrossFit creates bonds in the same way boot camp might. As she and her classmates push their bodies to their limits, there's an inherent need to talk to one another about it. "You're working so hard together that you feel somewhat connected through that experience," she said, aAnd it's just a lot of fun. We laugh a lot. We cheer each other on. CrossFit's really big on encouraging one another and pushing your friend to do a little more than they think they can."

A people person A Bend native, Boone left her home after high school to pursue her undergraduate degree in psychology at Lewis 8 Clark College in Portland. After graduating in 1998, she took a break from school and worked administrative jobs, eventually taking a position at Oregon Health & Science University, where she renewed her desire tojoin the ranks of professionals devoted to helping people. She

Complete Health 8 Wellness

Dr, (.elso Gangan •

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High Cholesterol High Blood Pressure Heart Disease Stress Testing Diabetes

Dr. Derek Palmer

Lori McMillian, PNP

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• Women's Health Employment Physicals • Arthritis • Coag Clinic • Lung Disease • Adult tL Child • Acute lllness Treatment Wellness Physicals

Redmond Nedical Clinic

Care l Relationships l Educstion

(541) 323-4545 1245 NW 4th Street • Suite 201 • Redmond, OR

briefly considered following her mom's path to nursing, then decided against it. She went back to Lewis & Clark, this time leaving in 2007 with a master's degree in counseling psychology. "I was looking for something where I felt like I could have relationships with people, not sort of feel like they were just sort of passing in and out of my work life," Boone said. In2007,Boone and herfamily moved back to Bend. Exercise had been a constant in Boone's adult life long before CrossFit. Growing up, her parents were )rKk ANDYTULLIS avid exercisers, but it wasn't until college that it became a daily part of her own routine. College was her Jennifer Boo ne has two daughters, Sofia, 12, left, and Vivien,7. first taste of real stress, especially the stress Boone associates with sitting at a desk for long periods of time. Cardio In their married life, Zak made sure he was around after work to activity and weightlifting in the morning became the remedy that watch the girls when they were younger so that Jennifer could work prepared her for a day of being sedentary while she learned. The out. It's not as high a priority for her husband as it is for her, Jennifer practice spilled out into her post-college life, when she took on desk said, but he's still respectful of her desire to hit the gym. jobs and, ultimately, into her counseling career. Boone's work allows her to schedule patient visits around her Havingan encouraging husband helps,she said.And herdaugh- CrossFit classes. Now that her kids are more independent, she's betters, 12-year-old Sofia and 7-year-old Vivien, have grown up know- ter able to piece together a schedule that permits time for exercise. ing that exercise is an important part of their mom's life. Setting a In the end, she said, her patients benefit from a more focused, positive example for her daughters is another reason Boone said she mentally clear therapist. "People know if you're sitting there and you're not really there," takes care of her body. She strives to teach them, "how to take good care of themselves she said. "They know if you're preoccupied with something, and that's a horrible feeling." as a woman, as a girl in this culture," Boone said. Boone's husband, Zak Boone, became familiar with her love for To ensure clients are getting Boone's full attention, she has taken exercise early on. Their relationship started in college, but they rare- to scheduling four or five sessions per day instead of seven, as she ly would get out of bed at the same time. had in the past. "He will still tell stories about when I would get up at the crack of That, and she tends to her mind and body with exercise. "I honestly don't think there's anything — medication or even talk dawn and leave for the gym and he'd sleep for hours afterward," "Even when we met he knew that was really Boone said, laughing. therapy — that can replace it," she said."Those are all part of beimportant for me. It was just a given, something I was going to do ing well, but having a solid exercise routine can save people a lot of every day if I could make it happen." money andtime." •

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TIPS(SECOND OPINIONS

When should youget a second opinion?

Seeking a second opinion is a personal decision. However, experts say, there are still important things that should be kept in mind in every case. BY TARA BANNOW

Seek a second opinionany time you feel uncomfortable with your diagnosis,said Erin Moaratty, chiefofmission delivery with the Patient Advocate Foundation, a nonprofit that helps patients manage health care struggles. Second opinions tend to happen more among patients who've been dealt more serious diagnoses,such as cancer, multiple sclerosis or Type1 diabetes, she said. "All of those things would probably trigger some uncertainty in their minds, and they may want to seek out a second opinion at that point." Ifyou ever hear a doctor say,"Nothing can be done for you; there is no treatment available and you should seek hospice care," get a second opinion, she said. There may beongoing clinical trials you could enroll in, or alternative options your doctor didn't consider, she said. Doctors often give what's called a differential diagnosis,a list of several conditions the symptoms might mean, said Carla McKelvey, a general pediatrician in Coos Bay and past president of the Oregon Medical Association. In those cases, a second set ofeyes looking at the lab tests and imaging studies can be beneficial, she said.

Can you afford it? Before picking up the phone to make the appointment, firstcheckwith your insurance providerand find out whether your policy covers second opinions. Most companies cover them — especially ifyour primary care doctor recommended it — but people need to make sure the second physician is covered under their insurance company's provider network, Moaratty said. Rare conditions require specialists,and often there are only a few of those in a community, she said. However, it's also important that the second opinion comes from a physician who specializes in your condition. Ifthe initial opinion came from an oncologist who specialized in breast cancer, for example, and your diagnosis was carcinoma, you'd want to see a doctor who specializes in your specific type ofcancer, Moaratty said. "You just want to make sure you're prepared mentally and financially for what might come," she said."You want to make sure your insurance will payfor it." Medicare will pay 80 percent of the costofboth a second and third opinion, according to the PAF.Patients who belong to a Medicare Health Maintenance Organization are entitled to a second opinion, but some plans require a referral from your primary care physician, according to the PAF. Insurance companies typically will not pay for lab tests if they were already performed for the diagnosis, sobe informed about which testsyou already had done,and get copies ofthem.

Should you tell the first doctor? The medical system has shifted toward a patient-centered primary care home model in which primary care physicians oversee patients'care and coordinate their services, McKelvey said. That means that when it comes to seeking a second opinion, the most important thing to do is tofirst have a conversation with your primary care doctor,who likely will be able to direct you to the appropriate doctor for a second opinion."They can make sure the patient is directed to someone who is well-qualified," McKelvey said. SGoogle is great, but it doesn't always provide the best choices." Ifthe first doctor knows where else the patient is seeking care, he or she can communicate with the other doctor and share information. Letting the first doctor know also can save money by way of preventing lab tests or X-rays from being duplicated."Ifthey don't know about that, then they may order the same tests," McKelvey said."Then (the patient) may have unnecessary exposure to radiation if they get extra X-rays. They may have repeat labs they don't necessarily need. So it's really important that that conversation stays open and transparent on both sides."• Page 54

GREG CROSS

WINTER/SPRING2014•HIGH DESERTPULSE

One voice I A pER soNALEssAY

ly. And again he suffered through ifteen years ago, I would have told you a blood side effects, but his PSA levels retest saved my father's life. Now I'm not so sure. turned to near zero. It's so easy to conclude that a In 1998, my father, Orest, broke the news to our family that he had prostate cancer. A new physitest that uncovers a cancer is a life-saver. We jump quickly to the cian had ordered a prostate specific antigen, or PSA, test when my father turned 65, and subsequent tests assumption that our loved one showed the levels were slowly rising. would have died quickly if the canUltimately he decided on surgery, and I recall how cer hadn't been found and treated. It's the narrative we've been fed thankful I was for that little blood test that discovered the cancer early and in its most treatable phase. I had for years and, perhaps, the narratotally bought into the narrative. tive we'd most like to believe. The surgery would give him years The truth is once a test comes of additional life, allowing my father back positive, it sets in motion a to attend my niece's high school chain of events that shrouds our graduation, my brother's wedding view of any other possible outand scores of family holidays. Orest and AnneHawryluk,ofElkinsPark,Pa., com e . A positive test is virtually I'm still amazed at all he accom- at tendingaw eddingin2009.0restwastreated im possible to ignore. Not many plished, earning a scholarship for col- for prostate ncer ca three times but ultimately can l ook cancer in the eye and not legeand medicalschoolasa non-na- diedan accidental death. blink. And once someone underMarkian tive English speaker with a hearing goes treatment, it is impossible to Hawrylukis the impediment. He spent 26 years as a doctor in the know whatwould have happened otherwise. health projects U.S. Army, including a tour of duty in Vietnam and Two years after his radiation treatments, my father fell down the reporter at stints in the Pentagon and Walter Reed Army Medi- stairs at his home in the suburbs of Philadelphia. He hit his head The Bulletin. cal Center before retiring as a colonel. against the wall at the foot of the staircase, and with his blood Several years after his diagnosis, my father's PSA thinned to prevent clotting, he bled to death at the age of 82. I don't know if my father would have died earlier without treatlevels rose again and his doctors recommended hormone therapy. By this time, he was in his late 70s and I had learned much more about ment, any more than his doctor "knew" he would die of prostate canthe fallibility of the PSA test and the overtreatment of prostate cancer. cer without treatment. With repeated elevated PSA tests following I began to wonder whether this continued treatment was really worth treatment, his cancer may have been more persistent, more dangerit. Were we treating a life-threatening illness or something that grows ous than average. I may have had the last 15 years with my father so slowly that it might not affect him in any meaningful way? only because of his treatments. On the other hand, my father enMy father was skeptical but relented to the treatments. He suf- dured years of side effects. They were, in some way, the price he fered through hot flashes and other side effects for several months paid for our frailty, our inability to accept even the smallest odds that before his numbers dropped again. a father and mentor would be taken away from us any earlier than Two years later, his doctors recommended radiation treatment. we had hoped. Whatever years we thought he was buying with his This time I pushed harder. Was there any sense in further treatment? treatments vanished into mere conjecture one October afternoon. I can't help thinking whether any of it was worth it, whether I My father was nearly 80, on blood thinners after a valve replacement and having trouble with his kidneys. My mother asked his oncologist should have taken a stronger stand against further treatment. But it's what would happen if my father declined. just as easy to say screening and treatment were futile after a patient "He will die of prostate cancer," the doctor said flatly. dies, as it is to affirm the value of screening and treatment when As a health journalist, I knew my father was unlikely to live much the patient lives. It's why screening and treatment recommendations longer. Saying those words to your mother or siblings is much more must be based on overall statistics, not on individual stories or the difficult. It makes you sound uncaring to talk about statistics and life ever-present, all-powerful anecdote. expectancy, instead of clinging to the myth that he'll live forever. In the end, there's only one thing I know for certain: I miss my Once again, my father relented — I suspect to appease the fami- father terribly. • BY MARKIAN HAWRYLUK

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Natalie Hoshaw,MD Clare Thompson,DNP,CNM st. CharlesOB/GYN St. CharlesMedical Groupis pleasedto welcomeDr.Natalie Hoshawand ClareThompsonto its teamof providers. As a certified nursemidwife, Thompsonworks closely with physicians toprovide non-surgical obstetdc and gynecologicservicesincluding hospital deliveries. Dr. Hoshawi sanexperienced OB/GYN who hasworked in both U.S.Army andcivilian hospitals during her career, oftenserving asdepartment chief andon committeestaskedwith improvingpatient safety. Both believe inthe health advantagesof eating organic, locally sourcedfoodandwhennot at work, their free timeis spent caring for alargegardenandmorethan 70animals. They lookforward tosharing healthyeating ideaswith their new CentralOregonpatients, especiallymoms-to-be.

Now takingappointments inRedmondandPrinevile

St. Charles OB/GYN

54l-528-8835 I StCharlesHealthCare.orgIIe