A case of H1N1, a war on many fronts, communicating with new generations January/February 2010

Down with a Case of the Flu.
Emily Dalton, MD, wrote her final President’s Message in the December issue of The Bulletin of the Humboldt-DelNorte County Medical Society.

It was on “Health Care Reform” and she was in bed with the flu.

…It is hard to believe that when I started the State of California was seriously considering a plan for a statewide program of health insurance for all Californians (a la Massachusetts), and as I finish Schwarzenegger slashed fund-ing for the Healthy Families program, Medi-Cal and Medicare, while the federal government is working on health care reform…

As I have been writing this I have been bedridden for 6 days with what is most likely H1N1. Fever, cough, head-ache, muscle aches and tremendous malaise — enough to make one sorry for the pigs! According to the health de-partment virtually all “ILI” (influenza-like-illness) has tested positive for H1N1, and in pediatrics one cannot avoid a heavy exposure to whatever is circulating. A pediatric intensivist from UCSF came up for a conference and described how unnerving it is to be in the ICU at UCSF right now: it is full of pregnant women on ventilators with H1N1. What an eerie and unsettling image! I can see how this virus would do that — even vaccinated, the first day I got it I could feel the deepest portions of my lungs get irritated and full of what felt like necrotic phlegm. I am finally able to take brief walks without feeling utterly exhausted. But enough whining — on to better things…

To read her original column, go to the website at http://www.sonic.net/~medsoc/images/bulletins/2009-12%20DECEMBER%20BULLETIN_for%20web.pdf.

Who is Our Enemy?
An editorial, “On Finding Ourselves at War,” by Guest Editor Kenneth Y. Pauker, MD, appears in The Bulletin, Fall 2009, of the California Society of Anesthesiologists.

We are at war, and we had better understand that, and act like it. Although we are reluctant soldiers in what has become an expanding and intensified struggle for the safety of our patients and the viability of our profession, fight we must. We cannot simply be conscientious objectors for the reason that we are ethically obliged to secure ground that was made sacred by — and inherited from — our forebears.

Arrayed against us are forces that seek to redefine who we are and what we do. There are those who, to ad-vance their own economic and political agendas, fully intend to divide our House of Medicine and enslave and muzzle us, to break our spirits, to further alienate us from the patients whose welfare has always been at the heart of our medical journey. There are others, so-called “do-gooders” and health care planners, who mean well enough, but who, with their imperfect understanding of the nitty-gritty of the actual practice of medicine, would restrict us, redirect us away from the essentials of our professionalism, create hurdles and diversions that distract us and consume our time and energies, and to boot, visit upon us a plague of unintended consequences. And then there are the usurpers — circling, lurking, and pouncing on opportunities as they present themselves, trying to carve out a little something more for themselves.

So who are we? We are the descendents of Hippocrates, practitioners of an ancient method of discourse and learning, perpetual learners — an inquisitive, reasoning, obsessive, and compulsive lot…. We are protectors of our pa-tients…

So who, then, is the enemy with whom our relations have devolved to the point of war? First and foremost, pow-erful and essentially unchecked as we have seen merger after merger and the amassing of monopsony power, are the health insurers. They have over time ceased being insurers in the common vernacular, but now see themselves as guarantors, regulators, protocol makers, evaluators, and profit makers for executives and investors…

Next on my hit parade of “enemies of the state” of grace are plaintiff attorneys and our (more appropriately, “their”) system of adjudicating claims of medical malpractice. We have been told over and over that what we have in California, MICRA, is the best system in our nation. To me that is not nearly good enough.

We still have essentially a lottery, lawyers sharking around continually in search of a really big hit. Pretty much none of this is about the “Truth of the Matter,” but rather it is all about money, pure and simple, and sometimes a whole lot of money…

And last, but certainly not least, we are at war with ourselves, our alter egos in other specialties who all too often want what they need for themselves, no matter the cost to others in the House of Medicine. Our state and national medical professional societies are fractionated and often nonfunctional. We contribute to organizations within medi-cine that lobby against the positions of one another. As Pogo wisely observed, “We have met the enemy, and it is us.” We must discuss and find a better way to advance our positions, form new alliances across specialty lines…

This editorial represents the views and opinions of its author and not CSA policy.

The entire article is on the CSA website at www.csahq.org/pdf/bulletin/ednotes_58_4.pdf.

Getting Ready for New Generations.
“Social Media — Fad or Fundamental Shift?” is the subject tackled by Sue U. Malone, executive director of the San Mateo County Medical Association, in the September issue of the society’s Bulletin.

Every day we are hearing more and more about the wave of social media that surrounds us. Is it a fad or a new way of life? Perhaps it is not a fad but a revolution.

Some Interesting Stats:

• By 2010, Generation X* will outnumber Baby Boomers*. Already 96 percent of Gen Xers have joined a social network.

Compare the time it took various forms of communication to reach 50 million users:

• Radio – 38 years
• TV – 13 years
• Internet – 4 years
• iPod – 3 years
• Facebook – 100 million users in 9 months
• iPod – 1 billion users in 9 months
• YouTube – 100,000,000 videos, is the second largest search engine
• Qzone – China’s social network has 300 million users

80 percent of Twitter usage is on mobile Does this mean email is passé?

To assist you, we are planning to redevelop our Web site to better serve members and the public. The new site will provide a self-service online membership locator, directory, and profile, which will permit physicians to create their profile and update their directory listing, join or pay membership dues online. The system will be designed to run with limited administrative oversight aside from regular posting of new content. The site will provide both the general community and physicians with local health-related resource locations, allow members to create and manage classi-fied listings, and furnish the tools for physicians to create a full Web presence…. Physicians will also have the oppor-tunity to share content from our site to Facebook via SMS text message as well as Twitter

*Footnote: These are approximations, as opinion varies: Baby Boomers – born 1946–1964; Generation X – 1965–1981, Generation Y – in the 1980s and thereafter.

Her article can be found at the SMCMA website: www.smcma.org/bulletin/issues/BULLETIN-09SeptemberF.pdf.

A review of various local and regional medical journals March/April 2010

The Devil’s Details
Dr. Stephen Kamelgarn revisits the “Devil’s Glossary” in the January issue of The Bulletin of the Humboldt-Del Norte Medical Society. Here are some items at the start of the alphabet.

This was a guide originally published by the CMA back in 1993 (during the Clinton Health Care Reform debacle) as an aid for medical journalists covering health care in California. Version 1.0 of the Devil’s Glossary was published way back in 1994. I felt that it was time to revisit the issue.

The guide was published using the usual bureaucratic jargon, so (in the finest tradition of Ambrose Bierce) I have liberally provided a translation.

Accreditation: A process by which a number of licensed bureaucrats (medical and non-medical) pass judgement on the adequacy of one’s hospital institution. This gives them a feeling of self-importance, and makes the accredited institution feel loved and wanted. See JCAHO

Advance Directives: …preferences about life-sustaining procedures. Unfortunately, these are almost never available when the patient is comatose in an emergency department, thereby making their existence moot.

All-payer system: A health care pricing or reimbursement system in which all payers, including insurers and government programs, must participate and pay an equal percentage of nothing for physician, hospital and other provider services. In the old days this was referred to as Price Gouging, but we live in enlightened times now…

Ambulatory care: Care delivered only to people who can walk and pay at the same time.

American Medical Association (AMA): A national association of fossilized old men still living out in the medical practice climate of the 1950’s and 60’s…. They claim to be the voice of organized medicine, but since fewer than 20% of practicing physicians belong, they are living in a fantasy world. Today, there are high powered psychotropic medications to dissolve their delusions of relevance…

Bio-medical research: One of many ways to tap into government coffers to pursue one’s pet projects. This is usually affiliated with major universities where the president or department chair needs new living room furniture.

Budget predictability: The fantasy that one can plan in advance for expenditures over a stated time period. In health care, the relationship between predictability and actual expenditures is tangential, at best, thereby leading to both a credibility gap and health care oversight by CPA’s, bookkeepers, and other bean counters whose knowledge of medicine is gleaned from past issues of Reader’s Digest and The National Enquirer.

Capitation: A method of payment for health services that is the darling of Kaiser-Permanente, insurance companies and other HMO health policy wonks. A provider is paid a fixed, less than subsistence fee for each person served over a period of time without regard to how much care that person actually requires…

Cherry picking: Yet another clever ploy by insurance companies…. Here, they only accept healthy people for coverage. They then have the option to cancel that person’s policy as soon as he/she gets sick, and really needs the insurance…

To read more of the Devil’s Glossary, go to: www.sonic.net/~medsoc/images/bulletins/2010-01%20JANUARY%20BULLETIN_excerpts.pdf.

An Anesthesiology Convention is…
Stephen Jackson, MD, editor of the CSA Bulletin of the California Society of Anesthesiologists writes on “A Carnival for Anesthesiologists” in the winter 2010 issue.

Because of illness, he could not attend the ASA convention in New Orleans. But he recalled an earlier ASA contention in the Big Easy:

…two decades ago when the Loma Prieta earthquake exploded toward the end of the ASA meeting. I recall distinctly how I became aware of the quake: I had been demanding that the bartender change the channel on the big screen TV over the bar to show the San Francisco Giants-Oakland Athletics World Series game rather than the incessant panoramic view of smoke rising in a city and a crumbled freeway bridge. Neither he nor I could immediately explain why all the channels had the same aerial view…

…the magnificent ASA Annual Meeting truly is…a huge gathering of anesthesiologists from around the world. And, when held in New Orleans, the ASA Annual Meeting (and any other large meeting held there) has been dubbed, appropriately, a “carnival!” Indeed, the anthropologist Lawrence Cohen considers conferences and conventions such as ours to comprise not entirely or even mostly scholarly goings-on, but rather carnivals — “colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries…tourism and trade…the care and feeding of professional kinship, and the sheer enormity of discourse.”

Indeed, the popular physician writer, Atul Gawande, in his book, Complications, is of the same mind and comments “that [for] such national meetings…some [surgeons in his case] had come just to be seen, others to make their name, still others for the spectacle of it all…. Yet…one still had the sense that the draw was deeper than mere carnival.”

Read the entire article by Dr. Jackson at www.csahq.org/pdf/bulletin/ednotes_59_1.pdf

Screening for Breast Cancer?
In the November/December issue of the Bulletin of the San Mateo County Medical Association, Dr. Philip R. Alper had this response to a colleague’s views on breast cancer screening:

Dr. Borofsky’s arguments for not tampering with the breast cancer screening guidelines are impeccable…but they are not the last word on the subject. There are two undisclosed, underlying assumptions made by supporters of the existing guidelines: 1) all services that offer value to individual patients should be provided and 2) there is no trade-off between money and clinical utility in determining overall societal value. Perhaps a third underlying assumption is that the money supply is infinite…

The luxury of such thinking has done much to fuel the epidemic of specialism (if I dare be so impolite) that now characterizes American medicine. To do well by unrestrainedly doing good must be highly appealing; the AMA lists 112 Specialty Societies under its rubric of the Federation of Medicine. Only a handful of these concern themselves with primary care.

It has essentially been left to primary care to concern itself with integrating competing needs and costs in ways that “right way” and “wrong way” specialty thinking finds alien. Surely it is easier to define one’s horizon by the limits of one’s own specialty obligations and declare everything else “not my area of expertise.” But that leaves both competition for funding and professional freedom in the arenas of politics and public relations.

How does this meandering speculation relate to breast cancer guidelines? When the news of the new guidelines came out, I was struck by the complaint that the U.S. Preventive Services Task Force wasn’t composed of experts who presumably know the most about the subject but rather of generalists who — dare we say? — can’t be trusted to provide the last word. Such was the flavor of the comments made by the American Cancer Society and by representatives of the various specialty organizations concerned with breast cancer…

Read the article and more on the issue at www.smcma.org/bulletin/issues/BULLETINNovDec09.pdf.

A review of various local and regional medical journals May/June 2010

The Regulatory Mess
Hal Grotke, MD, asked, “Should I Trust the Government?” on the President’s Page of the March 2010 Bulletin of the Humboldt-Del Norte County Medical Society.

Statutory laws and regulations have been hard on us, to say nothing of case law. Thanks to Medicare, if we choose to provide medical care for people over 65 years old, or with permanent disability, we must submit bills electronically. Of course, most of us have people for that, but we still do it by extension. Thanks to HIPPA we can no longer tell a spouse, without specific permission from a patient, that a patient has herpes simplex virus infection. Thanks to new regulation from California Department of Managed Healthcare, if we cannot offer an appointment to a patient in a prescribed timeframe we may have civil liability. And thanks to MICRA if our doctor harms us with some egregious neglect we are severely limited in how much we can be compensated financially. (I include that last one a bit tongue in cheek.)

All of those laws and regulations, with the possible exception of electronic billing, exist because of large scale and repeated failure to do the right thing. None of those laws and regulations work entirely the way they were intended anyway. The greatest failure of those specific laws, to my knowledge, is the second P in HIPPA. Although there is now a federal mandate for COBRA coverage for people leaving a job at which they were lucky enough to have employer provided health insurance there is no regulation of premiums. Very few recently unemployed people can afford to buy such coverage. As for the new California regulation regarding timely access, the loophole for doctors is that we can simply document why we think the patient is unharmed by delay. The much bigger loophole for insurance companies is that they are not the ones being regulated. If there is an insured person in the area who needs to be seen it doesn’t matter that the insurance company pays so little that no doctor is willing to see a patient with that insurance. This regulation only applies to patients with insurance specifically regulated by DMHC and to physicians who contract with such health plans. As far as that regulation is concerned we can still delay indefinitely scheduling patients who are uninsured or have indemnity coverage such as Medicare without a managed care supplement…

How did we get into this mess in the first place?

Read all of this article, and the next item, at http://www.sonic.net/~medsoc/images/bulletins/2010-3 MARCH BULLETIN_web.pdf.

Obesity Rates
In the same Bulletin, Ann Lindsay, MD, Humboldt County Public Health Officer, discussed obesity.

According to data from the Centers for Disease Control and Prevention the national obesity rate has held steady for the past five years. The new data are based on health surveys involving height and weight measurements of 5,700 adults and 4,000 children.
The results shows 68 percent of adults are overweight, with African American having the highest rates of obesity, followed by Hispanics and Whites. About one-third of children aged 2 to 19 were overweight, with the percentage of extremely obese children steadily increasing…. We have yet to see the leveling off trend in Humboldt County.

The GIGO Factor
Karen S. Sibert, MD, Associate Editor of the CSA Bulletin wrote on “Peering over the Ether Screen; The Electronic Medical Record: Garbage In, Garbage Out” in the Winter, 2010 issue.

My first patient of the day was a congenial man in his 50s with a history of prostate cancer and radical prostatectomy, scheduled for replacement of a defective penile prosthesis. The history and physical in his chart was a pleasure to read because it was printed and legible, as opposed to the handwritten scrawls we often encounter. Imagine my surprise, however, at reaching the section about this patient’s previous surgical history, and finding that he was supposed to have had none. I looked twice to make sure I was reading it correctly. No prior surgery. Impossible, of course — he had had both prostate surgery and the initial penile prosthesis placement. Then I realized the obvious truth: We were sabotaged once again by the fatal ease of data entry error in a computerized record…

Worse still is the potential propagation of errors in the patient’s medication list. The other day we had two patients in preop with the same, quite common, first and last names. Looking over the computer printout of my patient’s medications and seeing Keppra listed, I asked him if he was doing well on Keppra and how long it had been since he had a seizure. He looked puzzled. He didn’t take Keppra, he said, and to his knowledge had never had a seizure. We quickly figured out that the nurse had merged his med list with that of the other “John Smith.” That was the easy part. The hard part was fixing the mistake. It turns out that once the nurse “closes out” and prints the record, apparently it takes an act of God to undo it. In the meantime, Keppra remains on the med list…

Back to my patient with the penile prosthesis: Once I had determined that everything in his H & P was going to require independent verification before it could be relied upon, I took a longer look at the internist’s recommendations for perioperative care. I include them verbatim:

“Pt is at low risk for surgery. Please avoid shifts in Blood Pressure and Volume. As is true with all surgery the anesthesiologist should mind the blood pressure as this will reduce any unknown cardiac risk the patient may have. A profound anemia would add further risk, which this patient has no evidence of. Should heavier than expected bleeding occur, please keep Hct over 30 for further cardiac risk reduction.”

Although I don’t know for sure, I would bet money that this internist had a check-off list on his computer with someone’s idea of appropriate advice for the anesthesiologist. How would I ever have managed the case without it? Is this really the quality of information we can expect from a completely paperless system? Computers, after all, don’t generate content; they only store it and make it available for retrieval. At the end of the day, if you put garbage in, you’ll get garbage out, and any time we thought we saved will be spent sorting through the trash.
The entire article by Dr. Sibert is available at http://www.csahq.org/pdf/bulletin/sibert_59_1.pdf.

On Breathing
The Spring 2010 issue of Sonoma Medicine is devoted to breathing. This is part of the introduction by pulmonologist James Gude, MD.

The word pneuma, literally meaning “that which is breathed or blown,” was used by ancient philosophers to describe the soul or vital spirit of a person…

Breath and breathing matters are the themes of the contributors to this issue of Sonoma Medicine. As a consultant to five rural intensive care units in Northern California, I value the role of respiratory specialists. Indeed, four of the top 10 rural ICU diagnoses involve respiratory distress: acute and chronic respiratory failure, community acquired pneumonia, chronic bronchitis and emphysema (COPD), and asthma.

All four of those ICU pulmonary diagnoses involve smoking…

All his comments, and the entire issue, is at http://www.scma.org/magazine/?vol=66&num=2.

A review of various local and regional medical journals July/August 2010

Learning from Our Errors
Karen S. Sibert, MD, the Associate Editor of the CSA Bulletin wonders in the Spring, 2010 issue about “When is the best time for mistakes?”

Back in the 1990s, my husband and I spent a year working at one of the largest hospitals in West Virginia. The patients were the nicest people in the world, and the hospital staff was terrific — kind, generous, and hard working. Some of the surgeons were excellent, but others definitely were not. My husband (a cardiac anesthesiologist) and I had to cope with surgical complications the likes of which we had never seen before. Patients walked into the hospital for elective aortic aneurysm repair and left in a hearse because the surgeon could not get the aorta back into one piece. I particularly remember watching the geyser of blood that erupted one day when a surgeon sliced open the right ventricle during what was supposed to be a simple mediastinal debridement. Steve and I thought we were capable anesthesiologists when we arrived in West Virginia, but we were better by the time we left.

Maybe the best place to train anesthesia residents isn’t the one with the top surgeons or the most dedicated teaching anesthesiologists. If surgeons are skillful and supervise their residents closely, the anesthesiologist won’t face surgical disaster often and may be unaccustomed to dealing with it. Likewise, if attending anesthesiologists guide their residents’ hands at every opportunity, anesthetic missteps will be rare. That may not be a blessing for the anesthesia resident who should learn how to manage both surgical and anesthetic mayhem.

If you’re in private practice and don’t work with residents, you may not realize just how much pressure there is today to watch the resident’s every move during a case. We’re compelled to chart our presence at the preoperative assessment, induction, line placement, emergence, and any “critical event.” Many of us whip out the fiberoptic bronchoscope at the first whiff of a problem airway rather than let the resident have another try. Attending surgeons rarely leave their residents alone in the operating room except to close skin. To do otherwise could be interpreted as poor quality care.

Certainly I don’t want a resident to make every mistake I’ve made; it’s better to learn some things by hearing tales of horror than by living them. That is the point of a good “morbidity and mortality” conference. But we had far less supervision as residents years ago, and nothing focuses the mind better than the need to fix a mess of one’s own making…

Today’s arbitrary restriction of “duty hours” worries me too. In case you haven’t heard, there is a limit of 80 hours a week for the residents of any specialty to be in the hospital, and that may soon drop to 60 hours. This includes night call hours when they may be asleep. Surgical residents now break scrub abruptly in the middle of a case, like Cinderella when the clock strikes twelve, lest they overstay their legal time limit. If they work up a patient at night in the ER, they can’t scrub in on that patient’s surgery the next day. Anesthesia residents rarely interview their inpatients the night before surgery. The concept of continuity of care, or taking ownership of one’s patients, apparently has gone for good…

For the first time, we’re starting to see residents graduate, go into practice, and then come back to do fellowships because they realize how much they didn’t know. One private anesthesia practice near Los Angeles no longer hires anyone directly out of residency because they have found new graduates unable to function independently. The question I have for the talking heads who make the residency rules is this: Is it better to make decisions and face the consequences when you’re a resident, or to make all your mistakes later when there may be no one around to help you?

The entire article can be read online at www.csahq.org/pdf/bulletin/sibert_59_2.pdf.

Politics and Medicine
Philip R. Alper, MD, discusses “The Obama Health Act and the Further Politicization of Medicine” in the April issue of the Bulletin of the San Mateo County Medical Association.

Ever since the enactment of Medicare in 1965, government and politics have become major forces in reshaping American medicine. Only a handful of physicians have been able to avoid the rules, regulations, blandishments and threats of the Medicare program. These are now administered by CMS, the Center for Medicare and Medicaid Services.

Some 25 years after the debut of Medicare, physicians discovered that while Hilary Clinton’s health initiative went down to defeat, its section on physician fraud and abuse lived on. It was adopted in its entirety by Medicare as administrative law, which is just as binding as legislative law. Many of the provisions are so Draconian that they appear not to have been enforced. Which is, more or less, how the interaction of law and politics works as usual. If this leaves physicians unsure where they stand, everyone seems to have learned to live with it.

Next we come to President Obama’s 2010 Patient Protection and Affordable Health Care Act. Like Hilary Clinton’s bill, it contains some measures that physicians generally support, but the overall structure is similarly legalistic, complicated and unwieldy. (It is 1,000 pages longer than Hilary’s bill.) The new law offers many job opportunities in the more than 120 health care agencies that it creates. It also invites the Internal Revenue Service to participate. One would have to ignore all past experience to believe that such an expanded corps of regulators will have a benign impact on physicians…

Clearly, the new law attempts to be supportive of primary care. The devil, however, remains in the details. For example, a bonus of 10% is awarded to primary physicians. But it is only for five years and it only applies if 60% of services to Medicare patients are “primary care services.” How will these ultimately be defined? Who can predict or depend upon a bonus that is statistical and opaque in the course of practice? Will this and similar measures entice young physicians into careers in primary care? My guess is that the horse-trading and outright bribery that were so prominent in Congress during the creation of the legislation will not work in enhancing primary care.

Nor are new primary physicians likely to be very popular with their specialist colleagues who will be squeezed by the promise of $500 billion dollars in savings from the Medicare program and who will then see primary physicians as not sharing their pain. Whatever shred of collegiality that is left after nearly three decades of managed care will further unravel.

The new law also promotes large group practice with cash incentives that small group or individual physicians cannot hope to obtain because of their limited ability to comply with the complex regulations governing statistical assessments of their practice activities. Furthermore, only a minority of practicing physicians are in large group practices and since government seems to favor this mode, the majority of physicians may be disadvantaged in future payment schemes.

All physicians will be affected in one way or another and it is impossible to predict all the ramifications of the Obama health bill. Nevertheless, the thrust remains an increase in documentation and greater standardization of care in the service of “best practices.”…

Read the entire article by Dr. Alper at www.smcma.org/bulletin/issues/April2010.pdf.

A review of various local and regional medical journals September/October 2010

The Art(?) of Writing(?)
Emily Dalton, MD, discusses writing in “Where Have All the Flowers Gone,” in the May issue of the Bulletin of the Humboldt-Del Norte County Medical Society.

Last month I attended a conference entitled: Books, Memoirs and Other Creative Nonfiction at Harvard.

It’s a great course, and I highly recommend this method of getting CME credit for writing, having fun, and networking with people in the publishing business.

Self-help books, medical texts, and memoirs comprise the 3 main categories of medical nonfiction. The publishing world is very interested in books that will sell lots of copies and make money. I don’t know why I was surprised by this. (We all need to get paid for our work.) Maybe it is because I live in a remote rural area, or that I have my head in the clouds. Naively, I figured the compensation for one’s writing would be roughly commensurate with the quality. I expected the publicists, agents, and editors to be interested in one’s prose, one’s command of the English language, and one’s writing style — but instead I found myself being asked about my TV appearances. Why would a writer want to appear on TV? If I wanted to be on TV, I would be at a conference for actors. I checked my syllabus — I was in the correct place.

Of the three main entry points into the world of publishing, the most popular for physicians is the self-help genre. The pathway goes like this: start with a “hot” topic bound to generate immediate interest from a target market. Ideally this would be a topic so engrossing that your intended buyers will be compelled to open their wallets and purchase your book right away, instead of going home and seeing if they can download something similar for free. Typical book ideas include using cutting edge knowledge of neurobiology to improve one’s functioning, a new spin on how to lose weight, or how to deal with some common but specific physical/mental disorder.* In order to be legitimate, the physician backing the book must be an “expert” on the topic, but in addition, he/she must be somewhat of a celebrity (hence the TV appearances). It really doesn’t matter if the doctor-author can write or not, because there are many excellent underemployed writers who will write the book for you. Nevertheless, the best books in this genre are written out of altruistic passion by physicians who have a unique sort of help to offer and see an unfulfilled need for their expertise. They certainly don’t do it for the money. Most of us could make more in a month doing our day jobs than we would earn for a year’s work on a full-length book.

Success in publishing is all about having a “platform,” which contrary to common understanding is not a sturdy, flat, wooden structure. A platform is a publishing term for your public persona and your professional reputation and accomplishments.

In order to build that platform, you have to do things that most of the rural physicians I know abhor: Give speeches, get on television and radio, and talk to reporters and the press. I don’t know about the rest of you, but I have learned that the press is not usually our friend. They misquote the things we say and get us into trouble with people we did not mean to offend. Besides, most of us in rural areas are so inundated with demands from large numbers of patients, the obligations of running a business, hospital duties, committee responsibilities, and being on-call that inviting additional (unpaid) professional social contact into our lives is completely unappealing…

*During the week of March 28, number three on the New York Times nonfiction list combines all three of those concepts: Change Your Brain, Change Your Body, by Daniel G. Amen is about using the brain-body connection to lose weight and avoid depression.

Read Dr. Dalton’s entire “In My Opinion” atwww.sonic.net/~medsoc/images/bulletins/MAY%202010%20BULLETIN%20EXCERPTS.pdf.

After 19 years: Au Revoir November/December 2010

Editor’s Note: This is a review of Dr. Del Meyer’s 18 years with our medical society publication. He has been a regular contributor to SSVMedicine (formerly Sacramento Medicine) since 1993. Several years ago, he began two online publications, the MedicalTuesday Newsletter and HealthPlanUSA. They have grown exponentially, so that he now must devote most of his efforts there. While his Voices of Medicine feature will no longer appear here, it can be found in MedicalTuesday. I want to express to you, Del, my personal thanks and that of the Editorial Committee for your fine and enduring contribution to our publication; you will be missed. — John Loofbourow, MD

The Beginning — 1993
I volunteered for the editorial board of the then Sacramento Medicine in 1992. Upon appointment in 1993, I wrote a series of articles on Basic Health Care, Self Care, and Physician Care. At that time there was a push to put more routine care into health plans, even vitamins and fitness centers were suggested, or anything thought to be health related.

I pointed out that this approach would jeopardize all health plans and make them unsustainable. Europe was eliminating costly items of their socialized government plans. This has been borne out by our experience in the United States.

Part of that series dealt with a cost analysis of the process of dying as more people felt that hospitals were the only environment in which to say goodbye to loved ones. As Intensive Care Units were becoming more sophisticated and relatives could hardly get close to their loved ones with all the tubes and monitors, more Americans chose to die at home.

This can be observed in the daily obituary columns that frequently announce that Mr. JB, born in 1918, died at home surrounded by his loving family. A byproduct of this research also revealed that the people who died in their ninth and tenth decade of life, frequently worked into their eight and ninth decades of life. It is now commonly recognized that early retirement significantly shortens life.

I then wrote a series of OpEd articles treating the issues of the day such as: Managed Care — Friend or Foe; HealthCare Insurance — An Oxymoron? Government Medicine — a Fait Accompli. An article on Military Physician Travelogue detailed my two years of global military travel, courtesy of the United States Air Force.

In 1993, the editor, Dr. Richard Johnson, gave me permission to begin a monthly column that I called Hippocrates & His Kin. In 1994 he announced his retirement after 15 years, and I was asked to be editor.

The Editorship: 1994–1997
During the next four years, I was responsible for the monthly Editorial in the eleven issues per year, and continued to write the monthly Hippocrates Column (HHK) until early 2001, when I began a similar column called Hippocrates’ Modern Colleagues published on my professional site, DelMeyer.net. In June 2005, the Hippocrates Column was resuscitated and incorporated into the MedicalTuesday Newsletter, where it continues to the present day.

In October 1994, I began the monthly Physician/Patient Bookshelf column to review books written by our colleagues on any subject or by any author on medical care and practice. These book reviews can be read topically at the HealthCareCommunication.network.

I had the good fortune of becoming acquainted and working with Jim Coyle, MD, an internist of long standing in our community. In fact, my office was located on Coyle Avenue, named after his father, also a physician. About that time I noted that many of the county medical societies around the state were sending copies of their journals and bulletins to our society. As these were discarded, I requested that they be tossed my way.

Since they contained more useful information than I could possibly use in my “Hippocrates and His Kin” commentary, I asked Jim if he would like to help peruse them and consider writing a column based on these “Other Voices” from around the various medical societies throughout the state. Jim’s column, which ran from April 95 through May 98, developed a richly deserved loyal readership. He became a valuable contributor to the editorial board of this journal — his writings were inspiring and insightful.

I continued to write the Editorials, Hippocrates, and Bookshelf columns every month until the end of my term as editor in December 1997.

The Editorial Board: 1998–2010
After Jim’s untimely death on April 15, 1998, I resumed the perusal of these journals from other medical societies, and realized that they contained a wealth of material. Thus in memory of Jim and as a tribute to his fine work, I continued the column, bringing the opinions of other physicians around the state to our readership. Perhaps nothing new — but in a different voice to pique your interest.

I continued on the editorial board for the next 13 years, writing the Voices of Medicine column and occasional book reviews. Since 2002, I’ve written an enlarged VOM, adding it to my electronic newsletter, available throughout our country and internationally.

At this time, I have thousands of colleagues who request my newsletters and more than a hundred thousand who visit my electronic journal sites each month. I now plan to be more involved with this enlarged format and audience that we reach through our MedicalTuesday Newsletter. I see many opportunities to engage our profession globally. There is a lot of work to be done if we wish to save a personalized health care system from the intrusions of a government bureaucracy, where patient care has to compete with every other budget item from the freeways to prisons. During any recession, our patients would suffer from lack of or inferior care.

The Voices of Medicine
Ten years ago, when I entered “Voices of Medicine” in the search engines, I would see the links of my column reported from Sacramento Medicine. Now when I enter “Voices of Medicine” I see thousands of articles on the Voices of … the various medical schools: Voices of PENN Medicine, Voices of VA Medicine, Voices of Military Medicine, New Voices of Medicine, Voices of Genetic Medicine, Voices of Family Medicine, Voices of Traditional Herbal Medicine, Conflicting Voices of Medicine, Voices from the Heart of Medicine, Books for Voices of Medicine, Voice of Medicine Vaccines, Voices of Personalized Medicine, Voices on Diversity in Academic Medicine, Voices of Integrative Medicine and others. The Google search now gives millions of related articles. This is the highest form of praise.

I will miss the voices of my colleagues in the various California county medical societies whose opinions I’ve come to know and respect. I leave the highlighting of their VOICES for someone else.

Meanwhile, I invite you to read and subscribe to the MedicalTuesday newsletter on Medical Practice issues and the HealthPlanUSA newsletter on HealthPlan issues in our country and globally. You may also keep in touch by subscribing to the Blog on either journal.

Au Revoir!