Before and After EMR

Lee Leer, MD, discusses “EMR From the Trenches” in In My Opinion, from the Humboldt-Del Norte County Medical Society Bulletin.

Much has been written lately about Electronic Medical Records (EMR’s). Some of the authors have even spent a bit of time working with an EMR.

Many authors are not particularly positive though at least recently even those who don’t like EMR’s bow to their inevitability. Most seem to feel that something is lost in the patient interaction when computers come into play.

I propose to paint another picture. I believe, and have experienced, that EMR’s not only contain the tools to improve “objective” quality (such as health screening benchmarks), but also “subjective” quality (what goes on in the exam room and its impact on patient satisfaction).

Before moving on, however, I must remind myself what pre-EMR life was like. I would get a chart (or charts, in the case of complex, long-term patients) with various bits of loose and bound paper in and on the chart. I would hopefully review all these bits of paper (x-ray reports, labs, consult reports, and the like) before going in the room with the patient. Every few days, a chart simply could not be found in time for a patient’s visit. It would often have been buried in the stack of charts on a provider’s desk…

You know the gig (pre-EMR): I get in the room, hopefully with a chart balanced on my knee, and begin to review current results with the patient. Often, they ask, “What were the results last year?” Leisurely flipping through the chart is followed by frenzied tearing through misfiled pages, different volumes, and sections devoted to Workers’ Comp. Concurrently, I’m attempting to jot a few notes from our encounter, or else keep it all in my head to dictate at the end of the visit. If the patient asks me about a drug or disease or procedure I’ve never heard of (an increasingly frequent occurrence, I fear), I take notes and promise to get back to them. If we are beginning a new medication, I “fire up” my memory banks and “run” a drug interaction check. If the potential drug interactions are significant, or if my memory banks are empty, I excuse myself and try to find printed material on interactions. This can consume several minutes. Finally, I fill out a visit charge and a diagnosis on a paper form. I give that paper to the patient and hope they won’t discard it before they reach the front desk. When the person working outbound acquires the paper and successfully interprets my scribbles about follow up, we’re done!

Currently (post-paper records), I turn my computer on each morning, look through my list of patients, and review potential problems with my medical assistant. We make sure that all studies to be reviewed are available and in the chart (i.e., on the computer). When the patient is ready, I walk into the exam room carrying my small laptop. I sit, make eye contact, and have a several minute conversation with the patient, during which time my computer does nothing but warm my knee. Eventually during the discussion, I will look down to the computer and type in a few words. Typically, by the time the visit is complete I’ll have finished at least the rough outline of the “subjective” portion of my note. All labs, current and old, are retrieved, reviewed, and compared with a couple of clicks. Medications are renewed by a few more clicks. Drug/drug interactions, drug/ allergy and drug/diagnosis contraindications are automatically checked. Usually, the prescription is electronically transmitted to their local pharmacy as we speak…

To read all of Dr. Leer’s article, go to www.humboldt1.com/~medsoc/images/bulletins/NOVEMBER%202008%20BULLETIN_for%20web.pdf

Otis, One Ornery Orangutan

Dr. Stanley Perkins details his encounter with an orangutan named Otis, in “Animal Rites: Some Patients are Wilder than Others,” in the Summer 2008 Bulletin of the California Society of Anesthesiologists. Dr. Perkins is an anesthesiologist at Sharp Memorial Hospital in San Diego, where he cares for a variety of humans. When not putting people — or animals — to sleep, he flies his Turbo Commander with his dog, Amy, in the co-pilot’s seat.

It had all the elements of a horror flick: a gurney, two unsuspecting doctors, and a violent yet sedated patient. In dim light the gurney glides onto a freight elevator, a dull clang reverberating as the wheels bump across the threshold. Slack-faced, with gazes riveted upward, the men watch the lighted arrow make its slow arc. Suddenly, a huge hairy hand springs up, seizing one of the men by the wrist. His eyes wide with panic, the doctor struggles to free himself while the elevator lumbers on, slowly carrying the men and their charge out of sight.

As every fan of horror knows, such a scene never bodes well for the doctor. This time, though, the scene was real; I was the doctor and my patient was one ornery orangutan. In the two decades I’ve volunteered at the San Diego Zoo and Wild Animal Park as a veterinary anesthesiologist, that tussle with Otis was the closest I’ve come to being the guy who, when the elevator door opens, is sprawled lifeless on the floor.

Otis was one of two male orangutans at the zoo. The other, Ken Allen, had earned acclaim as an escape artist. Whenever he grew bored, he would set about loosening the bolts of his cage. A quick slip through the door, a scamper up an incline, and a swing over a wall, and Ken Allen would be out, strolling amid a crowd of people, as if he were just another zoo patron. Each time his keepers discovered one of his escape routes, they closed it off, but he would devise a new one. He never seemed to mind being led back into his enclosure, though; he simply relished the challenge of finding new flight paths.

Otis had none of Ken Allen’s geniality. He was a bundle of hirsute hostility, and he detested veterinarians —and anyone associated with them — most of all. With the highest strength-to-weight ratio of any primate, orangutans are not to be trifled with, especially when they have Otis’s disposition. Whenever I received a call from the zoo about an animal in distress, I would jump into my car and head right over. If that call was about Otis, though, I had to fight the urge to jump into my car and head home instead.

On the day he grabbed me, Otis was scheduled for cosmetic surgery: He needed a wart removed from his nose. But at the zoo even the simplest examinations require sedation. Jeff Zuba, the veterinary intern, tranquilized Otis with a dart so we could transport him to the veterinary hospital. I administered the anesthetic while the veterinarians removed the wart, conducted a physical exam, and untangled his long locks.

During the return trip, I administered the last of the anesthetic. Since we were only minutes from Otis’s enclosure, I figured we’d be fine. Unfortunately, I had forgotten the sluggishness of the freight elevator that led down to his cage. Jeff and I were cramped into the tiny elevator with our bodies pressed against the gurney. I was holding the oxygen mask over Otis’s face when suddenly I felt his prehensile grip. Now gasping for breath myself, I peeled his leathery digits one by one from my wrist and struggled to reinstate his oxygen mask. When the elevator door finally banged open, Jeff and I sprinted, with the gurney in tow, back to Otis’s cage. By the time we had settled the orangutan in his bedroom, he was fully awake and spitting mad. Jeff later confessed the escape plan he had formulated as soon as Otis grabbed my wrist: He would dive under the gurney—and leave me to my own devices.

For more on anesthesiology and animals, go to www.csahq.org/pdf/bulletin/animal_57_3.pdf

A Blockbuster First Novel

Stephen Jackson, MD, editor of the CSA Bulletin, reviews a book in the Fall 2008 issue: OXYGEN, by Carol Wiley Cassella, MD, an anesthesiologist in private practice with the Virginia Mason group in Seattle.

…I strongly urge each of you to read Oxygen, especially because it examines in great depth the gamut of the important and too-often-neglected topic of physician wellbeing. Indeed, while engaging the reader with a mesmerizing plot that has full relevance to the art and science of the practice of anesthesiology, she explores life’s personal and professional choices as we progress through our careers as physicians and anesthesiologists. In fact, from a wellness point of view, I will be bold enough to suggest that Oxygen be required reading for all of us…

So, with the author’s blessing, we reprint (with Simon and Schuster’s permission) the first chapter of Oxygen for your enjoyment.

People feel so strong, so durable. I anesthetize airline pilots, corporate executives, high school principals, mothers of well-brought-up children, judges and janitors, psychiatrists and salespeople, mountain climbers and musicians. People who have strutted and struggled and breathed on this planet for twenty, thirty, seventy years defying the inexorable, entropic decay of all living things. All of them clinging to existence by one molecule: oxygen.

The entire complex human machine pivots on the pinnacle of oxygen. The bucket brigade of energy metabolism that keeps us all alive ends with oxygen as the final electron acceptor. Take it away, and the cascade clogs up in minutes, backing up the whole precisely tuned engine until it collapses, choked, cold and blue.

Two portals connect us to oxygen — the mouth and the nose — appreciated more for all their other uses: tasting, smelling, smiling, whistling, blowing smoke and blowing kisses, supporting sunglasses and lipstick designers, perfumeries and plastic surgeons. Seal them for the duration of the morning weather report and everything you had planned for the rest of your life evaporates in a puff of imagination…

The entire review and book’s first chapter are at www.csahq.org/pdf/bulletin/casella_57_4.pdf.

A Grandmother’s Wisdom

In the Winter issue of Sonoma Medicine, the magazine of the Sonoma County Medical Association, Sanjay Dhar, MD, asks the question, “Are you smarter than my grandmother?”

My grandmother passed away several years ago, but I am reminded of her almost every day. My memories of her are more relevant than ever in these times of financial crisis, cost-cutting, global warming, overuse of natural resources, limited health care, lack of trust in government, lack of jobs, and uncertainty about our future and that of our kids.

My grandmother used to be looked down upon by her neighbors because she grew “misshapen” tomatoes in her backyard. Today I pay a lot of money to buy these misshapen heirloom organic tomatoes that she grew. She also grew herbs in her kitchen garden and would always sing to them. Today some scientists claim that music can make plants more productive. She always said that we should eat food the way it is produced in nature: raw. Today a growing subculture promotes the consumption of uncooked, unprocessed, organic foods…

My grandmother would always buy things only after she was sure she had the money to spend. Today with the credit crunch, we may want to follow her example. Her slogan was, “If you don’t have the money, you don’t need it.”

Everything got recycled in my grandmother’s house. Newspaper was used for packaging, stuffing and wrapping; old clothes were stuffed into pillows, bedding and insulation; vegetable and garden waste was given to the animals. Today we pay to send our waste to the local garbage companies for recycling and pay even more to buy it back (as 100% consumer recycled paper). How about using newspaper to wrap your gifts this winter holiday season?

My grandmother objected to moving into our larger new home. She always said that she could only sleep in one bedroom. Today, after a few decades of growth in home sizes, we are considering how we can reduce our carbon footprint by building smaller and more energy efficient homes…

My grandmother taught me values and habits that are so needed in our current era: the importance of “being a family”; the importance of an education; the importance of respect, of self-reliance, of being ethical and conscientious, and of sharing with people less fortunate than me. But I know that even now I am not as smart as my grandmother.

To read the entire article, go to at http://scma.org/magazine/articles/?articleid=317.

Destruction and Beauty in Pakistan

The San Mateo County Medical Association Bulletin devoted its November-December issue to medical volunteerism. In “Living the Dream, and More,” Naveen Mahmood, MD, told of her October 2005 trip to Pakistan.

Ever since I can remember I wanted to become a doctor who could travel all over the world to help people. During medical school and residency I was involved with patient education and basic health care in rural Pakistan. However, three years ago, the ultimate experience came unexpectedly. In October 2005, a 7.6 magnitude earthquake hit northern Pakistan. By December my family and I traveled to Pakistan, at our own expense, to volunteer at remote locales.

We collected 700 pounds of medications and supplies in the U.S. In Pakistan we rented a van and drove for a day to get to Abbotabad, one of the northern cities hit hard by the earthquake. We visited the local university hospital that had been turned into an outdoor trauma center. Volunteers from all over the world were present, working tirelessly; large tents were converted into operating suites and temporary wards to accommodate the large post-operative patient population.

The scene was surreal. In Balakot, not a single building was left standing. All we could see were piles of rubble and debris, a sea of innumerable tents and the sheered mountains in the background. This was all juxtaposed against a magnificent background of clear blue skies, beautiful snow covered mountain peaks, and the famous River Neelam flowing through the destroyed city.

Despite so much destruction, life continued — people cooking in their tents, classrooms being held outdoors, children playing among the ruins, and the predictable five daily prayer calls heard over the speakers. The local people were so calm and so friendly. As we began our daily routine of setting up our “mobile clinic”, everyone came by to offer their help. As soon as the local people heard that there was a medical team available they came down with their remaining families in tow. We saw over 200–300 patients per day and worked without a break.

We were there as a pediatric team but essentially saw whole families. In fact we ended up seeing a large number of female patients since by cultural norms, they only go to female doctors.

Apart from the usual acute care issues such as bronchitis, ear infections, pneumonias and urinary tract infections, we also had to deal with depressed, anxious and traumatized patients. Every patient had a story to tell—children losing parents, parents losing children, young wives losing their husbands and caretakers, now having to figure how to survive on their own… However, at the same time, we witnessed this cohesive sense of community and camaraderie amongst the locals — everyone watched over the local orphans, and over each other.

To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/Nov-Dec08issue_copy(1)/BULLETIN-08NovDecR6.pdf.

Remember the Autopsy?
Dr. Scott Sattler discusses "Medical Autopsy: The Forgotten Teacher" in the March 2009 issue of the Humboldt-Del Norte County Medical Society Bulletin.

Remember when we used to do autopsies on other than just coroner's cases? When I trained at Valley Medical Center in San Jose in the 1960s and 70s, essentially every hospital death went to autopsy unless the family re-quested otherwise and the resident couldn't persuade them differently. The involved medical staff would usually at-tend the procedure. Weekly morbidity and mortality conferences (M & M's) would discuss the case and correlate the pathologic findings with the premortem diagnoses. It was often a humbling experience.

In the mid-1980's, data showed that such autopsies revealed a major misdiagnosis of the primary cause of death in 20 to 40% of cases. In 10 to 15% of all cases, the missed diagnoses would likely have affected patient outcome. Did I mention that autopsies are a humbling experience?

When I first came to Humboldt County (to the Hoopa Indian Reservation to be exact) in 1974, the tradition of medical (as opposed to forensic) autopsy was still going strong. I well remember the woman with advanced diabetes whose chemistries and comfort just couldn't be controlled and, despite intensive care and multiple specialty consulta-tions, whose deterioration was unstoppable. I remember her, in great part, because of her autopsy. The vision of her large undiagnosed pituitary tumor and the dent it had made on her optic chiasm is burned onto my permanent intrac-ranial hard drive. Before that day pituitary tumors were a theoretical construct I'd learned about in med school. That day they became real.

When I moved my practice to Eureka in 1982 we were still doing medical autopsies, but over the years they be-came fewer and fewer. Out of curiosity I went over to the Coastal Pathology office the other day and talked with them about it. They showed me the book where they record all the autopsies done by their group (and by the Humboldt Central Pathology group which preceded them). It contains records going back to 1983, when 40 medical autopsies were performed. By 1986 it had dropped to 30, and by 1989 to 16. There were only 9 done in 1991. By 1999, only 4. In 2005 there were just 2 and there have been none done in the area served by Coastal Path (Humboldt and Del Norte counties) since June of 2007, almost two years ago.

We have lost a helpful friend and an inspiring teacher. On this part of the North Coast, medical autopsy is no more…

Read the entire article at www.humboldt1.com/~medsoc/images/bulletins/2009-03%20MARCH%20BULLETIN_for%20web.pdf.

Osteopaths in primary care
Dr. Stephen Kamelgarn discusses why osteopaths are half of all new primary care physicians in the March 2009 issue of the Humboldt-Del Norte County Medical Society Bulletin.

At least twice in the last several months I've gone to meetings about health care where the statement (or varia-tions, thereof) was made: "Only 7 percent of medical school grads go into Family Medicine as a specialty." Although that number seemed somewhat low, I felt that it could conceivably be real. We all know that primary care receives abysmal reimbursement from the insurers…

In 2008, there were 2,654 available Family Practice residency slots available, and 2,404 were filled (90.6%). Now, if only 1,200 MD's elected to go into Family Medicine and 2,400 slots were filled, who made up the other 1,200? Well, it turns out that the remaining 1,200 slots were filled by graduate DO's. (This isn't exactly rocket science math, since only MD's and DO's are considered doctors and can go into any residency program.) According to AOA statistics, approximately 40% of DO grads choose Family Practice as their primary specialty. There has been an approximately 50% increase in the number of DO grads between 1995 and 2007 with 3,024 graduating last year. This represents about 15.8% of the total number of newly graduated physicians. But it does represent another 1,200 (or about 50%) of the number of new graduate physicians electing to go into Family Practice.

Osteopathic physicians represent one of the fastest growing segments of health care professionals in the US. AOA estimates that by the year 2020, there will be at least 100,000 practicing DO's, and they will represent an ever increasing proportion of the physician pool. The other noticeable trend is that osteopaths tend to be somewhat younger than their allopathic colleagues. In 2008, almost 50% of DO's were younger than 45 while only 39% of MD's were. Conversely, only 10% of DO's were older than 65 while 19% of MD's were. This implies that as we age, our likelihood of having a DO as a physician (especially as a primary care physician) will be fairly high…

To read the entire editorial, please go to www.humboldt1.com/~medsoc/images/bulletins/2009-03%20MARCH%20BULLETIN_for%20web.pdf.

Presidential Stress
Lyle B. Stillwater, MD, discusses "The President and His Hippocampus," in Vital Signs, the journal of The Fresno-Madera And Kern Counties Medical Societies.

Way back in 1979, I had the misfortune to be the only ENT resident at Stanford for thirteen days and thirteen nights including that many nights were on-call in a row (as a result I still hold the Bill Fee Iron-Man award in that de-partment).

At age 28, I could just tolerate the stress but I did lose 25 pounds in weight over a three week period centered around that time on-call, surviving on canned Ensure, Sudafed, and caffeine.

I was interested to read recently on the anatomical correlates involved in the effects of chronic stress on a normal brain, i.e. the hippocampus over time may decrease significantly in size.

With the recent change in U.S. presidents after eight years of essentially being on-call as the president, available day and night constantly, I started to wonder what effects that constant stress would have on any president's brain…

The president's unique stressors would include the constant need to personally be available every minute of the day constantly for eight solid years, even when on supposed vacations…

Robert Sapolsky at Stanford has shown that a prolonged flood of stress hormones can actually cause shrinking in certain brain areas particularly in the hippocampus. A major role of the hippocampus is in memory. It is not unusual for persons with prolonged stress to report forgetfulness and difficulty learning (certain portions of the hippocampus can recover and the stress response is reversed)…

The ultimate brain effects would manifest themselves in depression, anxiety and most importantly dysfunction in decision-making.

A Novel History Ph.D. Thesis Project would be for a Masters student to review all two term presidents to see if in the last year or two of their second term, consistent poor presidential decision making existed, no matter who the president was, compared to earlier in their stint as president.

It would also be interesting for all future presidents to get a baseline brain MRI scan, and then repeat the study eight years later to see if the hippocampus has decreased in size, more than expected from reviewing an age-matched control group…

The entire article is at www.fmms.org/index.php?id=48.

What doctors were writing about a half century ago.

The Yesteryear column during 1997 gave brief monthly reviews of what happened years ago in our medical society. Although our society was established in 1868, the written record occurred some 82 years later. The official publication of our society began in September, 1950 as "The Bulletin."

Dr. Charles E. Grayson, MD, was the editor. His copy, donated to our library, was the source of this report. There were reporters for Sutter General, Sutter Maternity, Mercy, and the County Hospital. Each hospital had a brief written report monthly. There were reports from the medical staff meetings of each hospital as well as the Society meetings held on the third Tuesday of the month. There was a book review column and a "Sense and Nonsense" column. Dr. Grayson, in his first editorial, indicated "The Bulletin" was not intended as a newsy chit-chat to be discarded after read, but "a voice for our interest... expression of our opinions."

Volume 1, the 1950s
Here are some voices from those early years of our written record, when we were the Sacramento Society of Medical Improvement (which remains our corporate name today) and our member's concerns were about compulsory medicine, the doctor draft, etc. Attributions are recorded if available.

These are our last archive copies and cannot be removed from the locked portion of our library. Plan to spend an afternoon or two at the society office to explore these rare volumes.

The President's Message: We Dare To Do
AGITATION for various types of medical legislation inimical to the health of the nation prompted the American Medical Association to embark on a large scale educational campaign. The campaign has gone far to thwart the propaganda issued by various pressure groups and individuals whose objective is to inaugurate a system of compulsory health insurance. But it is not enough. County medical societies must do their part to prove to the people of the United States that American medicine, free of political interference, has done, is doing and will continue to do the best medical job in the world.

The proximity of the state legislature makes it particularly important for our society to have a strong public relations program. This year such a program is being instituted. Through the cooperation of our members we intend assuring every one in this county of expert medal care, twenty-four hours a day, regardless of ability to pay. Actually this is nothing new. It's not a dream of the future. It's here now. The medical profession has always cared for the sick, rich and poor. The indigent have been cared for through part pay c1inics and the county hospitals and doctors have always attempted to scale their fees to fit the budgets of their full-paying patients. What is new, is the fact we are offering the guarantee to the public as society, instead of as individual physicians. - Andrew Henderson, Jr, MD, Sept. 1950

Executive Secretary's Message: Our Public Relations Program - Blueprint for Building
MANY MEMBERS of the medical profession seem to know better what they do not want than what they want. Perhaps this is the profession's greatest weakness in public relations.

Medical men have definitely and irrevocably stated they want no part of regiment medicine - now or ever. The public isn't so sure. Warning has been repeatedly sounded from all quarters that if the profession is to successfully combat socialized medicine it must come forward with an alternative and unanimously and vigorously support such an alternative. The profession can not just say "no" and oppose; it must settle its views on what it does want and convert those views from vociferous assorted negatives to tangible positives.

Your society has taken a big step forward on the positive side. It has awakened to the imperative necessity of earning good relations with the public and has embarked on an extensive public relations program with that objective in mind.

Members of the medical profession can be and are justly proud of the fine traditions, the accomplishments and the aims of the American system of the private practice of medicine. That system is based on free enterprise, individual initiative and service to the public. It is worth preserving. But if it is to be preserved the public must be made fully aware of the merits of the system and its superiority over all others - extant and proposed. And the public - right here in Sacramento, as elsewhere - must be enlightened to the inherent dangers not only to the medical profession but to itself, in the various proposed schemes directed toward the regimentation or compulsion of medicine. - Jane Algeo Watson, Sept. 1950

It's Your Duty... As An American
A communication from the California State Chamber of Commerce reveals that out of every 100 California citizens entitled to vote in the 1948 general election, only 60 went to the polls.

With nearly half of our citizens staying at home, every Communist and crackpot, in effect, casts two votes by ganging up and concentrating in strategic places. Because of the apathy of those who stay home, these political minorities wield tremendous influence. We can't afford to let them get away with it. Urge your friends, your employees and your patients to join the crusade to get out the vote in the November election.

It's one of your paramount duties as an American. This freedom of ours can be lost by indifference and supineness. Human freedom was gained by vigilance and struggle - it's not a gift to man.

Summary: Doctor-Draft Law
The doctor-draft law, S-4029 - Public Law 779 - was signed by President Truman September 9. The law affects all non-reserve medical men. It is a grant of authority to the President and details of administration wait on Selective Service and military regulations, to be issued on the basis of this authority. Pending these announcements the following are known facts: Who Must Register? Physicians who have not reached the age of 50 and are not members of military reserves.

Read more in Volume one, 1950.

Borborygmi: "George Kicks Carl in Teeth"
(This space is reserved for you - a place where you can blow off steam - talk back to the editor. Both bouquets and brickbats are welcome. We'll print ALMOST anything to which you'll sign your name.)

George Bernard Shaw, 94-year-old dramatist, trips over some pebbles in his British back yard, breaks a thighbone and is shipped to a nearby hospital for an operation.

The old rooster has been a Socialist since the Latter Bronze age or thereabout. Socialist medicine is now in full blast throughout Great Britain. All ordinary medical services are "free," meaning paid for out of taxes, so you get the pleasant illusion that it's costing you nothing when you accept such aid.

Does Shaw go in for Socialist medicine in this case? He does not. He's one of the rotten rich whom he has always professionally denounced, and stingier with his dough than almost any other living wealthy person. Nevertheless, he kicks old Karl Marx, founder of Socialism in the teeth. Shaw demands a private room at $6.08 a day, for which he will have to pay out of his own fishhooked pocket, and specialist services, for which he will also have to pay.

When top-drawer Socialists like Shaw, Attlee and Bevin can't take their own brand of Socialist medicine, just how good or how desirable for anybody is that medicine?

Talk Delivered by Distinguished speaker at September Meeting: Dr. Hans Selye
It is doubtful that our Society has ever heard a more brilliantly delivered talk than that of Dr. Hans Selye as he unfolded the story of the development of the adaptation syndrome which he and his colleagues have worked out over the past fifteen years. Our Society was treated at our September meeting to a scholarly presentation such as we are not like to hear again for a long time.

In 1936 Dr. Selye was interested in the possibility of finding a new ovarian hormone, other than an estrogen or progesterone. In the course of the investigations it was found that the extracts used for injection into experimental animals caused certain characteristic changes: 1) gastro-intestinal ulcers, 2) thymic and lymphatic atrophy, 3) hypertrophy of the adrenal cortex. It was found that these changes were not due to any ovarian hormone and it was soon discovered that other substances could produce the same effects. It was found that the more impure the extract, the more extensive were the changes and it was felt that toxicity of the substance had something to do with the reaction.. It was subsequently discovered that anything causing stress will do the same thing - cold, pain, excitement, etc.

Stress proved to be a very useful word, not much used in somatic medicine, though since Selye's introduction of the term it has been generally accepted. The adrenal and lymphatic changes and intestinal ulcers represent somatic reactions to stress. This set of circumstances is called the alarm reaction.

It is now known that the thymico-lymphatic atrophy is due to corticoid activity. The ulcers are an example of a pure damage change, a sign of the lost battle in the stress reaction.

Selye felt it was worthwhile pursuing the study of the mechanism of defense against stress, and there then evolved the concept of the adaptation syndrome.

Dr. Edmund E. Simpson's extensive review of the address can be read in Volume one, page 13, in the library reading room.

Message from the Governor to the Connecticut State Medical Journal
The health of our people is a basic national asset which is being preserved and constantly improved by a free medical profession whose standards of health and care are the highest in the world.

To the 3,300 physicians of our State we in Connecticut owe in large part our own enviable health record which ranks with the best even in this singularly favored country. In behalf of our citizens, I wish to express our gratitude to body of professional men and women whose skill, integrity and compassion are unmatched.

It is my unalterable conviction that the maintenance and betterment of the health of our people cannot be accomplished by compulsory measures. Both individually and as a body the members of our medical profession have clearly and consistently demonstrated their sense of public responsibility. Hence, as a matter both of justice and of common sense any plan for health betterment must first take into account the opinion and experience of the profession.

Government controls of medicine would be not only contrary to every American concept of privacy and decency. It would also be a negative and detrimental answer to the problem of the health of our people. To the great credit of our Connecticut physicians, they have given a positive answer to this question by their encouragement of voluntary health plans and by their intelligent and close cooperation with such plans which now cover hundreds of thousands of our peop1e. With the continued help of the profession, we in Connecticut must broaden these plans which enable the citizen to guard against the economic hazards of sickness without heavy taxation or compulsion, and without the intrusion of government as a third party between physician and patient. - John Lodge, Governor of Connecticut.

Articles from 1965
In 1965, the size of the journal changed fom 8 ½ x 5 ½ inches, catalog size, to 8 ½ x 11 inches and was reduced to six pages. Medical Care Foundations, the HMO movement, Kaiser Permanente and National issues become the common topic for the local society.

Outgoing president L. Morgan Boyers, MD, in his message: Chiding, Changes and Challenges.
The Chiding:
Your medical society officers and committeemen are as dedicated to our members and their professional organization problems as we all are to the practice of medicine.

However, during recent elections it was not unusual to hear someone express a desire for a particular man to run for office because he represented a specialty or particular field of practice.. Gentlemen, your officers and Board are above special pleading; the implication is unworthy of anyone. Since when did we departmentalize our Society and its governing body?

The Changes:
Our glossy Bulletin, so long a familiar friend on the local medical scene, is "bowing-out" with this issue by Board of Directors' action. The only reminder will be the annual directory issue to be continued in its old format and in addition to the 12 Bulletin issues.

Rising labor costs, the demand of time, changes in emphasis in the advertising world, and implications in proposed IRS rulings all have had their impact.. We make this change with a sense of nostalgia, but sincerely hope that the new format will gain greater interest and support.

The Challenges:
Our new president, Don Hause, assumes office at a time of great change, new pressures, and intense public involvement and concern.

Just as last year seemed to end an era in Medicine, the new year portends the beginning of a new one.

Because Medicine has always been concerned with the improvement of health care and its widest availability, your new officers and their able leadership will, I am convinced, meet these new challenges with forthrightness, dedication, and intelligence.

Medical Societies-Labor Unions: Parallels Drawn
In an address by William Scheuber, Executive Secretary of the Alameda-Contra Costa Medical Association to the East Bay Central Labor Council, he draws parallels between labor and medical societies. He recalls a number of accusations: Doctors have the toughest union in the world. Organized medicine is interested in keeping down the number of doctors so that it can maintain a "closed shop." Doctors are afraid of competition. Doctors make too much money. Medicine defends incompetents and cheaters and is unwilling to disciplining its wrongdoers.

Mr. Scheuber discusses each allegation in detail in the January 1965 issue.

Foundation for state workers - 429 physicians sign up.
The Medical Care Foundation of Sacramento was formally reactivated February 23 [1965] when a nine-member MCF Board of Trustees was elected by the Society Directors meeting in special session. The Directors' action was in response to a motion passed without a dissenting vote at the February 16 general meeting.

The MCF has been inactive since December, 1961, when the Trustees forwarded their resignation to the Board Directors because of inability to secure 50% of Society physicians as MCF participating members. The reactivation is in response to the State Employees' Retirement System request for extension to the 24,000 state employees in the Sacramento area of an "individual practice prepayment plan," represented statewide by Medical Care Foundations, and a "comprehensive group practice prepayment program, specifically referring to the Kaiser Health Plan.. The Kaiser Health Plan will also be available for the first time to Sacramento area state employees during the 30-day enrollment period. Both the MCF and Kaiser programs become effective May 1, 1965...

President Donald Hause, MD: the Society needs to face the facts of life and practice.
It may be the year of the Great Society in Washington but here in Sacramento the Medical Society, too, has some facts of life and practice to be faced.

It has been true for these many centuries, the physician's chief reason-for-being is to serve society by caring for the sick and injured. We in American medicine today consider we have contributed to an outstanding job over the past hundred years. I believe there is no doubt as to the truth of this statement.

We believe, indeed we know, that the best medical care for the greatest number of persons is only possible through a plan that allows patients to select - and remain with - their own doctors and hospitals. We believe, too, our patients know this but are requesting certainty of coverage be available to them through a full service benefit plan.

The Foundation Plan will be made available to state employees in this area. We must unite in making it work as it has in other areas. It will work here.

The time has long passed for philosophy.

Times change.

A patient-group has spoken and asked our assistance. We should do our best to assist them in the plan of their choice and still provide the best personal medical care possible.

John M. Mott, MD, Physician-in-Chief of the Sacramento Permanente Medical Group has the lead article in the Bulletin.
The advent of the Kaiser Health Plan, a Kaiser Foundation Hospital and the Permanente Medical Group in Sacramento has been the subject of more questions in the medical community than any other event in the past year. Bulletin Editor Dr. Frank Brown invited Dr. John M. Mott to answer some of these questions and outline the plan's health care concepts.

Read the entire article in the April 1965 issue.

President Donald Hause, MD, in his April Message, cautions lay health organizations.
To do good is a common desire of many people and organizations. In no other endeavor have more do-good organizations been developed than in the health field.

Every year many new ones are founded as one or another group of highly motivated people band together to see that some particular health problem is conquered. Many of these organizations are based on some strong emotional feeling associated with personal loss. The people involved develop tremendous drive to do something for others so affected or afflicted. All of these organizations, and they run the gamut from Red Cross, Cancer, Heart, Polio, Birth Defects, ad infinitum, started with an idea of doing good for someone in a crisis. All have zeal and high purposes. But inevitably the medical facts of life come to their attention and it is then that the medical profession needs to be present for guidance for no matter how high the ideals, sooner or later the program emphasis shifts from education to fund raising and then to case finding and fund dispensing. Strong emotional appeal is the basis of many such drives so as to obtain the greatest contributions, generally with great fanfare and publicity to show the world the good the organizations can do.

The problem, as we see it, is to be sure such funds, once raised, are not spent recklessly or on unwise projects. Many times it appears as though funds are wasted on fruitless projects or in maintaining a large executive staff. If the medical profession does not maintain close liaison, it is not unusual to see them go off on tangents which to lay members seem correct but which the physician knows are needless and are duplications of research.

Read more in the April issue of 1965. There are a number of articles on the MCF, Kaiser Permanente, calls for involvement, not isolation, throughout this volume.

The next volume, 1966, highlights Medicare and the new UC Davis School of Medicine.

Health Reform? Build on our History.
Stephen Kamelgarn, MD, Editor of The Bulletin of the Humboldt-Del Norte County Medical Society gives us his changing views of single payer healthcare in the February 2009 issue. His article is entitled, "Can We Get There from Here? Should we Listen to our History?"

Over the years I've written a number of diatribes expressing a need for the United States to adopt a "Single Payer" Health Care System. We've finally inaugurated a president who is, at least somewhat, amenable to listening to a variety of plans for health care reform. This would seem to be a time that we single payer advocates can push our agenda; or is it?

In the Jan 26, 2009, issue of The New Yorker Atul Gawande (one of the magazine's medical correspondents) has written an intriguing article about health care reform. While he is in favor of single payer, he feels that we are in the grip of past precedents and history. He makes a very persuasive case for "listening to our history." This holds true not only for health care reform, but for any transformative technology or practice in a society. He briefly traces the history of single payer in both France and Great Britain and shows why their plans have taken the form that they have.

In the article he states: "Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy." His point being that no matter what we Single Payer monomaniacs may want, we are going to have to build it upon what we already have. If we attempt to get "too radical" too quickly we will wind up with a gigantic failure on our hands.

I remember reading an interview with President Obama early in the past presidential campaign where he tried to defend his health care proposal. He stated that if he were to design a health care delivery system from the ground up, it would definitely be a single payer system. But he doesn't have that luxury and must "patch" our current system.

Aside from the fact that we're dealing with the most political of processes, with vast amounts of money at stake - money no insurance entity will willingly surrender - we also have to take into account all that's gone before. Massive change "by fiat" will usually fail - witness the disaster of Part D Medicare.

The point being that we, as health care reformers, will have to adapt that which we already have, rather than coming up with something de novo. Besides the hundreds (if not thousands) of different health insurance plans we have in the US, we also have several government funded plans: Medicare, Medicaid and the VA to name but three.

Medicaid is so horribly underfunded that it doesn't answer anybody's needs except the very poor.

So, it becomes operant upon us to work to strengthen and expand Medicare. To me that seems to be the least traumatic, most equitable alternative. It also has the greatest chance of success, being an adaptive change to an already existing system, rather than something brand new.

Read Dr. Kamelgarn's entire editorial at www.humboldt1.com/~medsoc/images/bulletins/.

Calling? Career? Job?
Philip R. Alper, MD, discusses whether physicians view their work as a Calling, a Career, or a Job and how it changes over our professional life in the March 2009 Issue of the Bulletin of the San Mateo County Medical Association. His article is, "Would You Choose Medicine Again?"

Back in 2001, Barry Sheppard polled the SMCMA membership on a set of questions dear to his heart: essentially, how do colleagues view their work as a physician? Is it a calling, a career or a job? Has the answer changed since graduation from medical school? And would you still become a doctor if you knew then what you know now?

Barry was impressed by the 28% response rate and intrigued by the number of doctors who modified the questions before they answered them. Most of all, he was impressed by the high level of positivity of the responses, something he said he would not have predicted.

On graduation, nearly half, 46% of the respondents to be exact, viewed medicine as a calling, while 52% considered it a career. Only 2% voted for "a job." Once in practice, 30% still considered medicine a calling, while 56% now described it as a career. Job-minded physicians increased to 14%. In all, two thirds of physicians who responded did not change their mind with the passage of time. And a striking 70% said they would still become physicians all over again, even with the benefit of hindsight.

There was a hint that more recent graduates would be less inclined to choose medicine again than older doctors, but even they voted "yes" 59% of the time. Dr. Sheppard brightened at the end of his introspective analysis and spoke of "our strong and, for the most part, abiding love for our chosen profession." Even though I myself have often grumbled about what could be much better in medical practice, I must admit that I too was pleased with the results.

I don't know that at any time I've considered medicine a "calling." For me at least, the idea is too pretentious, implying more things than I think I've given to medicine or my patients. But neither has it simply been a career for the 52 years since I graduated from medical school, much less a job.

I know I took - and take - the Hippocratic Oath seriously. Respect for patients, honesty and doing my best for them go without saying. Perhaps "a sacred trust" rather than "a calling" comes closest to the mark, though that too is rather pretentious. Were I to take Barry's quiz now, I probably would have tried to change the questions because they are too hard to answer as given.

Would I choose medicine again?

That's a more straightforward question. The answer is "yes," but I'm not entirely sure why. I've been a doctor so long that the role seems to fit naturally. I've never been free to abstractly choose whether or not to become a physician again. What would I take myself for if I did something else?

There is a big problem with opinion polls like these. It's not clear whether negatives represent healthy grousing like the attitude portrayed on TV in M.A.S.H., how deeply the sentiments are felt and whether they would lead to action...

One thing I miss is the number of people in health care who were willing to help me fulfill my role as a doctor. The pharmacist who dropped everything when I called years back has been replaced by the pharmacy technician who explains that the pharmacist is busy counseling a patient and that I will have to wait. Old-time nursing home directors like Mrs. Huntley in Magnolia Gardens, where often nurses made rounds with me and knew "our" patients intimately..

Diagnostic tests, surgical procedures and drugs are getting ever-better. But it is tougher for many of us personally. Still, the work seems to be getting done, patients are grateful and medicine endures. Yes, I would become a physician again, even if I'm not entirely sure why.

To read Dr. Alper's entire editorial go to www.smcma.org/bulletin/issues/BULLETIN-09MarchR5.pdf.

Words Make a Difference
Sonoma Medicine devotes the summer issue to Cross Cultural Medicine. This article, “Care in Translation,” is by Rick Flinders, MD.

Don Felipe was one of the campesinos I got to know best during the two years I lived in South America. He was short and dark-eyed and was one of the wisest farmers among the new homesteaders on the Paraguayan subtropical frontier.

One day as we were riding horseback to visit his parents in his native village, I made the mistake of saying I was hungry. He corrected me, saying that what I had was appetite, and that hunger was a term reserved only for those occasions when one had gone for two or three days without food. He said I had never been hungry.

When we arrived in his parents’ village, we learned that little rain had fallen that spring and that the mandioca crop, his people’s staple food, had failed. His parents hadn’t eaten in six days. That, Felipe reminded me, was hunger. He made me promise that I wouldn’t forget the meaning of hunger when I returned to my own country.

If so much can ride on the meaning of a single word, what are we missing in the daily exchange of language with our patients from Asia, Africa, Europe, Central America and South America? And even if we understand the language, what meaning do those words convey in the context of cultural differences that can splinter the meaning of such basic concepts as illness, health, life and death? We can barely agree on these terms inside our own medical and cultural paradigms.

In this issue of Sonoma Medicine, we explore the reality and needs of cross-cultural medicine from a variety of experiences and perspectives…

To review Dr. Flinders’ synopsis go to www.scma.org/magazine/articles/?articleid=407. The Table of Contents for the summer issue is at www.scma.org/magazine/?vol=60&num=3

Dr. Flinders, a clinical professor of family and community medicine at UCSF, chairs the SCMA Editorial Board.

Why a Dual Practice?
Philip R. Alper, MD, discusses “Should the Subspecialist be a Primary Physician?” in the San Mateo County Medical Association July-August 2009 Bulletin.

The provision of substantial primary care by specialist physicians is a uniquely American custom. Arguably, it has upgraded primary care and narrowed the often substantial quality gap between hospital-based specialty practice and office-based general practice that is common in other countries. However, any mention of the benefits of dual practice has been drowned out by allegations that, in the United States, we have too many specialists and not enough generalists — and the result is excessive costs. Internal medicine is the best example of a specialty that has blended a commitment to primary care with concomitant subspecialty practice.

I comment on this situation having spent 30 years in the practice of general internal medicine with a subspecialty in endocrinology — principally thyroid disorders and diabetes. I value the subspecialty portion of my practice because it offers me intellectual stimulation, contact with colleagues, and the opportunity to do something “special” for patients.

There are trade-offs. For example, although endocrinology appeals to me greatly, I would hate to practice only endocrinology because I find the rest of medicine so fascinating. And whereas treating a wide range of patients enhances overall clinical acumen, it does narrow the scope of the specialty conditions that I feel qualified to treat. There are also compensations: By offering primary care to those endocrine patients whom I do follow, I see more of them and put their specialty problems in better perspective. How does my interest in a subspecialty disqualify me from effectively taking responsibility for their overall health?…

To read the entire article by Dr. Alper, go to www.smcma.org/bulletin/issues/BULLETIN-09JulyAug.pdf

Health Care and the Baby Boomers
John Kitzhaber, MD, Director of the Center for Evidence-Based Policy at Oregon Health and Science University, writes about “Health Care to Health: The Unfinished Business of the Baby Boom Generation—Part I,” in the Bulletin of the California Society of Anesthesiologists. His article is based on an earlier address, the full text of which is available at www.ohsu.edu/som/alumni.

In this article, I would like to accomplish four things: impress on you the urgency of the growing crisis in our health care system, provide a context for why our current system is so dysfunctional, suggest what we need to do to fix it and discuss how you might assume a leadership role in meeting this challenge.

Are you between 43 and 61 years old? We are the Baby Boom generation, the 30 percent of the U.S. population born between 1946 and 1964. Most of us are the children of those who weathered the Great Depression, served in the Second World War or who helped rebuild the world in its aftermath. They built our system of higher education, created the interstate highway system and the transmission grid, went to the moon, cured polio, eradicated smallpox and put in place the great social programs of the 20th century: Social Security, the GI Bill, Medicare and Medicaid. As a result, our generation has enjoyed more promise and more opportunity than any other generation in the history of our nation. I want you to think about what our legacy is going to be — about the kind of world we are leaving to our children and grandchildren. And on our current trajectory it is not a pretty picture.

Consider the fact that last year Congress voted to raise the statutory debt ceiling to accommodate a $10 trillion national debt. Do you know how much a trillion dollars is? The number is so staggering that it is impossible to comprehend without some frame of reference: A million seconds ago was last week. A billion seconds ago, Richard Nixon resigned the presidency. A trillion seconds ago was 30,000 BC. Our national debt now exceeds $9 trillion and is escalating even as the population ages.

And while Congress is worried about Social Security, the real problem is Medicare. Social Security represents around a $5 trillion problem, but when the Baby Boom generation fully reaches the age of 65 — starting less than three years from now in 2011 — the unfunded entitlement in Medicare is estimated to be over $67 trillion. And we are financing this huge debt by selling securities to China and to other countries still willing to purchase them, not only threatening the fiscal stability of the American government and giving enormous leverage to some of our major international competitors (who at some point may simply refuse to continue underwriting U.S. deficit spending), but also casting a dark cloud of debt over our children’s future.

If we fail to address this — if we fail to act boldly — this will be our legacy. We have been the major beneficiaries of the investments and sacrifices of the greatest generation and now it is our turn to give back, to ensure that we leave our children not a legacy of debt and degradation but a world of promise and opportunity and hope. How we meet this challenge will be the defining issue of our time. It is the unfinished business of the Baby Boom generation and it is inescapably intertwined with the future of the U.S. health care system. To resolve this crisis, two things are necessary. First, we need a shared vision, a set of agreed upon objectives that capture the desired purpose of the U.S. health care system. Second, we need an accurate diagnosis of the underlying problem in our current system…

Read the entire article at www.csahq.org/pdf/bulletin/hlthcr_58_4.pdf

What is Congress Up To?
Cynthia Bermann, MD, provides an “Update on Health Care Reform” in the September issue of Vital Signs, the journal of The Fresno-Madera and Kern Counties Medical Societies.

The obvious subject this month is “what is the Congress trying to do?” The chimeric and rapidly growing legislation is morphing from providing health insurance for the uninsured to a complete overhaul of how medicine is provided. The proposals are changing so quickly that it is impossible in an editorial to address them in any kind of rational manner. I would like to instead take a step back and ask the following:

If the goal is to cover ten to twenty million absolutely uninsured (as opposed to those between insurance, self-insured, or ineligible for coverage as a foreign national), does it make sense to change the way that the remaining 280-290 million citizens receive their health care?

How can insuring the uninsured take over 1000 pages of legislation?

Why would the government spend a dime (much less the millions of dollars actually being spent) on ADVERTISING to push for passage of a bill that is not even completely written?

Given the failure of German, British, and Canadian experiments in health care, the failure of Tenn-Care and the Hawaiian health system, why as scientifically based physicians would we support repeating the same experiment?

Would you want to receive care from a health system that Mr. Obama states would be the equivalent of the USPS as compared to FedEx?

Here are the CMA points on WHAT WE MUST HAVE to continue to protect patients and provide excellent health care. Read them, consider them, and tell your elected representatives what they must do to prevent the devolution of health care in the United States of America…

Read more of Dr. Bermann’s comments www.fmms.org/index.php?id=148.