July 2006

� San FranciSco Medicine july 2006 www.sfms.org

www.sfms.org july 2006 San FranciSco Medicine �� San FranciSco Medicine july 2006 www.sfms.org

conTenTS

San FranciSco Medicine July �006 Volume 79, number 4Balancing the Scales of Medical discipline

FEATURE ARTICLES

10 Caught in the Process: One Physician’s Experience with the Medical Board AmandaDenz

1� A Change of Heart: One Drug Addict’s Story RaymondB.Kropp,MD

14 Preparing Medical Students for a Life of Reproachless Practice ManishaBahlandKatieKelly

16 Serving on the Medical Board of California: One Physician’s Story BernardAlpert,MD

17 Serving on the Medical Board of California: Another Point of View ArthurE.Lyons,MD

19 Toward a More Accountable Profession: The Case of the Aging Physician WilliamA.Norcross,MD,HeatherA.Ching,MFT,andWilliamSeiber,PhD

OF INTEREST

�1 Help for the Physician in Trouble

�� A Conversation About Renewing: Q&A with Linda Clever, MD AmandaDenz

�4In My Opinion SteveHeilig,MPH,PhilipR.Lee,MD,andMarcusConant,MD

�5Public Health Update: Preparing for Pandemic Influenza OliviaBruch,MSC,andKarenHolbrook,MD,MPH

MONTHLY COLUMNS

4 On Your Behalf

6 President’s Message GordonFung,MD,MPH

7 Editorial MikeDenney,MD,PhD

�6 Hospital News

�9 In Memoriam NancyThomson,MD

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4 San FranciSco Medicine july 2006 www.sfms.org4 San FranciSco Medicine july 2006 www.sfms.org

on YoUr BeHaLF

ediToriaLnotes from the Membership department

The2006-2007MembershipDirec-toryiscoming!ItisduetobeshippedfromtheprintertotheSFMSmembershipinmid-July.

TheSanFranciscoMedicalSocietyisupdatingitsPhysicianReferralServiceinformation.Withinthenextfewweeks,activeSFMSmemberswillbereceivingletters requesting information regardingtheirparticipationintheSFMSPhysicianReferralService.

Have you taken the survey yet?The San Francisco Medical Society isdedicated to making membership morevaluableandenjoyableforallofitsphysi-cianmembers,wherevertheyareintheircareers.Werecentlycirculatedanonlineneedsassessmentsurveytothosemembersfor whom we had email addresses. Wealso asked members to pass the surveyontononmemberphysicianstogettheirinputaswell.

Wewillshortlybesendingthesur-veyout tomembers inhardcopy form.However,youcanstillparticipateinthesurvey online—and direct nonmemberphysicianstorespondaswell—bygoingtowww.sfms.organdclickingonthesurveylink, which will be on the home page.Your input is important—weencourageallmemberstorespondandtocirculatethis importantneedsassessment tool totheirphysiciancolleagues.

department of Public Health Launches chronic Viral Hepatitis registry

Approximately25percentofpeoplechronicallyinfectedwithhepatitisBvirus(HBV)willsufferprematuredeathfromcir-rhosisoftheliverorhepatocellularcancer.TheburdenofchronicHBVinfectionmaybeparticularlyhighinSanFrancisco,sincemanySanFranciscanscomefromareasinAsiawhereHBVishighlyendemicorhave

A sampling of activities and actions of interest to SFMS members.

otherknownrisksforHBVacquisitionsuchasmenhavingsexwithmen.

TheSanFranciscoDepartmentofPublic Health, Communicable DiseaseControlandPreventionSection,hasiniti-atedtheChronicViralHepatitisRegistryinordertocharacterizeHBVprevalenceandriskfactorsandtoidentifymissedopportu-nities forHBVscreeningandpreventionamongcityresidents.PeoplewithchronicHBVinfectionwillbeidentifiedfromlabo-ratoryresultsreportedtotheDepartmentofPublicHealth.

ForasampleofchronicHBVpatientsidentified,abriefdataformwillbesenttothehealthcareproviderinordertoobtainbasic informationonpatientdemograph-ics,riskfactorsfordisease,andreasonsfortesting.Ifyoureceiveadataformononeofyourpatients,pleasetakea fewmomentsto complete and return it by fax to theDepartmentofPublicHealth.Toobtainmore informationorcontact theprojectmanager,pleasevisit theCommunicableDiseaseControl andPreventionwebsiteatwww.sfdph.org/cdcpandnavigatetotheChronicViralHepatitisRegistrypage.

cMS Says Hospitals can Pay for on-Site cMe Programs for Physicians

TheCentersforMedicare&Medicaid

Services(CMS)recentlyannouncedthatitwillallowhospitalstopayforon-siteCMEforitsmedicalstaffphysicians.This isanimportantandlong-awaitedinterpretationofCMS’sphysicianself-referralanti-kick-back rules,whichuntilnowappeared toprohibithospitalsfrompayingforanyCMEonbehalfofphysicians,becausesuchpay-mentsmightbeconsideredcompensationforpatientreferrals.

“Traditional on-site hospital grandroundsandother similar in-houseeduca-tionprogramsprovidedbyhospitals areimportantandconvenientwaysforphysi-cianstoearnCMEcreditandforhospitalstoensurehigh-qualitypatientcare,”wrote

July �006Volume 79, number 4

Editor Mike Denney, MD, PhD

Managing Editor Amanda Denz

Copy Editor Cynthia Rubin

Cover Artist Nico Johnston

Editorial Board

Chairman Mike Denney

Obituarist Nancy Thomson

SFMS oFFicErS

President Gordon L. Fung

President-Elect Stephen E. Follansbee

Secretary Charles J. Wibbelsman

Treasurer Stephen H. Fugaro

Editor Mike Denney

Immediate Past President Alan G. Greenwald

SFMS Executive Staff

Executive Director Mary Lou Licwinko, JD, MHSA

Director of Public Health & Education

Steve L. Heilig, MPH

Director of Administration Posi Lyon

Director of Membership Therese Porter

CMA Trustee Robert J. Margolin

AMA Representatives

H. Hugh Vincent, Delegate

Judith L. Mates, Alternate Delegate

Judith L. Mates, AMA’s Women

Physicians Congress Governing Committee

Stephen Askin

Wade Aubry

Toni Brayer

Corey Maas

Jerome Fishgold

Alan Greenwald

Erica Goode

Board of directors

Mei-Ling E. Fong, MD

Thomas H. Lee, MD

Carolyn D. Mar, MD

Rodman S. Rogers, MD

John B. Sikorski, MD

Peter W. Sullivan, MD

John I. Umekubo, MD

Gary L. Chan, MD

George A. Fouras, MD

Jeffrey Newman, MD

Thomas J. Peitz, MD

Gretchen Gooding

Samuel Kao

Thomas Lee

Arthur Lyons

Rita Melkonian

Kathleen Unger

Kenneth Maybury

John W. Pierce, MD

Daniel M. Raybin, MD

Michael H. Siu, MD

Richard L. Caplin, MD

Lucy S. Crain, MD

Jane M. Hightower, MD

Brian J. Lewis, MD

Michael Rokeach, MD

Jordan Shlain, MD

Alan M. Teitelbaum, MD

Judith Mates

Ricki Pollycove

Jordan Shlain

Leonard Shlain

David Smith

Leo van der Reis

Stephen Walsh

4 San FranciSco Medicine july 2006 www.sfms.org www.sfms.org july 2006 San FranciSco Medicine 54 San FranciSco Medicine july 2006 www.sfms.org

CMSadministratorMarkMcClellan,MD,ina letter toAMA.“Wedonotbelievethatsuchprograms…necessarilyconstituteremunerationtothephysicianswhoattendthem.”

CMS will, however, continue toprohibithospitalpayment forphysicians’off-siteCMEprograms.

ContactCMA’slegalinformationlineat (415)882-5144or [email protected].

Physicians Urged to defer Menin-gitis Vaccine for Some Patients Until Supply improves

Last year, the Centers for DiseaseControlandPrevention’sAdvisoryCom-mitteeonImmunizationurgedthat11-and12-year-olds,high school freshmen, anddorm-dwellingcollege studentsbevacci-natedagainstmeningitis.CDC’sthree-yeargoal is tohaveanewmeningitisvaccineroutinely administeredat the same timeasthemeasles-mumps-rubellashotfor12-year-olds.

However, anexceptionallyhighde-mandforthevaccinehaspromptedCDCtorecommendthatphysiciansdefervaccina-tionof11-and12-year-oldsuntilthesupplyimproves,buttocontinuetovaccinatehighschoolfreshmenanddorm-dwellingcollegestudents.Other persons athigh risk formeningococcaldisease,includingmilitaryrecruits and travelers to areas in whichmeningococcaldiseaseisprevalent,shouldalsobevaccinated.

Physicians shouldkeep trackof the11-and12-year-oldswhosevaccinationsaredeferredsotheycanbevaccinatedassoonasthesupplyimproves.

ContactRobinFlagg at (415)[email protected].

Get 40 Percent off Palm Z�� Pda with epocrates; offer Good While Supplies Last!

CMAandtheCaliforniaHealthCareFoundation(CHCF)havecollaboratedtoput easy-to-use technologyandvaluable

informationaboutdrug formularies—in-cludingMedicarePartD—literallyinthepalmofphysicians’hands.

Forabundledpriceof$99,physicianscanpurchaseaPalmZ22handheldcom-puterandtheEpocratesRxPropremiumsoftware.That’snearly40percentofftheregularprice.Thisoffer,availabletophysi-ciansandotherclinicians,isonlygoodwhilesupplieslast.

WiththelaunchofMedicarePartDinJanuary,MedicarerecipientsinCalifor-nianowcanchoosefrom48healthplans.Themultiple formularies complicate theprescribing challenges facingphysicians.Thesetoolswillhelpphysiciansmanagethevolumeofinformationneededtopickthecorrectmedicinesandprovidehigh-qualitycarefortheirpatients,especiallythosewithchronicconditionswho requiremultiplemedications.Epocrates-enabledhandheldcomputers allowaphysician inanexamroomto identifywhichmedicinesare inwhichformularies,checkfordruginterac-tions,andfinddrugalternatives.

Alreadyhaveahandheldcomputer?AccessthePartDformulariesfreethroughEpocrates’onlineandhandhelddrugrefer-enceguides.Anddon’t forgetthatCMAmembers receive30percentoffone-yearsubscriptionsand35percentoff two-yearsubscriptions to any Epocrates product.Studentsandresidentsreceive50percentoffallEpocratesproducts.

ContactCMA’smemberhelp line,(888)233-2937.

cMa defends Women’s reproductive rights

CMArecently submittedanamicusbriefinsupportofalawsuitbroughtbytheStateofCalifornia challenginga federalabortion-related spending restriction thatcoulddenyCaliforniaagenciesmorethan$49billioninfederalfunds.Therestriction,knownastheWeldonAmendment,essen-tiallyallows“healthcareentities”torefusetoperform,payorprovidecoveragefor,orreferforabortionsregardlessoffederal,state,orlocallawstothecontrary.

AlthoughCalifornialawprotectstherightof religious facilitiesand individualhealthproviderstorefusetoparticipateinabortion services,California law requiresthatsuchservicesbeprovidedinmedicalemergencies.UndertheWeldonAmend-ment,Californiacouldbedeniedtensofbil-lionsofdollarsoffederalfundsifitenforcesstate laws,which require thatphysicianstreat all patientswhosehealthor life isendangered, including fromdangers thatarisefrompregnancyandcanbepreventedonlybyemergencyabortion.

“Theamendmentcoulddeprivewom-enwhoneedemergencyabortions—andonlywomenwhoneedemergencyabor-tions—fromtheprotectionsaffordedtoallotherpatientsbyCalifornia’sregulationofthemedicalprofession,”wroteCMAinitsbrief.“CongresswouldnotthinktoprohibitCaliforniafromdiscipliningadoctorwhorefusedtoperformCPRforpatientssufferingfromcardiacarrest, refused tooperateonpatientssufferingfromseverecranialbleed-ing…orrefusedtogivefluidstopatientswhoweredehydrated.”

CMA’sbriefexplainedthatthereareavarietyof reasons thatwomendevelopmedical complicationsduringpregnancythatjeopardizetheirlivesandrequireim-mediateabortions.CMA’sbriefarguesthattheWeldonAmendmentviolateswomen’sconstitutionalrighttoseeklifesavingemer-gencyabortioncare.

Formore informationcontactCMAthrough the legal information line (415)[email protected].

For Local Events of InterestVisit the SFMS Website

Our events page is now updated on a

regular basis to include SFMS events and

other local events of interest. Just go to

our home page and click on “Calendar of

Events” on the left-hand side.

Visit us at: www.sfms.org


I fwearetotakeanobjectivelookatmedicalcaredeliveryandthephysician’srolethereisatleastonesignificantflawinourcurrentsystemwhenitcomestosupportingandmanagingour

mainprovidersofhealthcare.Forapointof comparison, let’s takeaconventionalbusi-

nessmodel.Thefront-lineentrylevelworkerishiredtodothework.Thatpersonhasasupervisortotrain,monitor,andsupporthimorher.Therearereviewsofperformance,andifaproblemdevelopsthesupervisoristhefirstlineofsupportanddiscipline.Thesupervisorisonanotherlevel,notonlyhavingknowledgeoftheworkinvolved,butalsopossesingthetrainingorskillstosuperviseandmanageotherworkers.Uponemorelevelarethemanagersanddirectors,whohave the taskofoverseeing largergroupsofpeople,butwiththeaddedresponsibilityofcreativelymanagingtheworkforcetocreatemaximumproductivity.

Theseindividualshavespecifictraininginmanagement,in-cludingmotivationanddiscipline.Whenanindividualbecomeslessproductiveorhasbehavioralissuesthereisabuilt-insystem,albeithierarchical,toaddresstheproblemanddeterminewhethersuspensionorterminationisappropriate.

In themedical caredelivery system, thephysician is theentry-levelworkerwhoprovidesdirectcare to thepatient.Butthissystemlacksthehierarchythatmostbusinessespossess.Thereisn’tsupervisioninprivateorcommunitypracticesettings,wheremostmedicalcareisdeliveredonceaphysiciancompleteshisorhertraining.Andincommunityhospitalsphysiciansaregrantedprivilegesbasedontheirtrainingandcompetenciesandarethenallowedtopracticethoseprivilegesinaself-governedsystemthatlooksmainlyatcomplicationsorcomplaints.Intheacademicset-ting,whichIammorefamiliarwithlately,abusinessmodelsystemdoesexisttoanextent.Theentry-levelworkersaretheinternhousestaff.Thesupervisorsandmanagersaretheresidents,fellows,andattendingstaff,butnoclearlevelsexistabovethat.Theattendingsareencouragedtobegoodmentors,teachers,andphysicians,but,inreality,theirtrainingdoesnotspecificallyincludemanagementordisciplinaryskillstousewhileoverseeingtheentry-levelworkers.

During practice we’ve come to appreciate what is goodworkandwhat isnot,andmostofushavedevelopedourowncriteriaorguidelines todecidewhatappropriatebehavior is for

physicians.Mostofourtrainingremains“seeone,doone,andteachone.”Andfortunately,orunfortunately,wedon’twitnessalotofdeviance—whichwouldallowustolearnfromothers.

With thechangingpracticeofmedicine fromthehospitalsettingtotheoutpatientsetting,problemscometolightthroughdif-ferentchannels.Somepatientsnowcomplaintothemedicalboard,themedicalsociety,theirhealthplans,theirlawyers,orthecourts.Insuranceagencieshavealsogotteninvolvedbymonitoringphysi-cians.Someuse“qualityinitiatives”todetectthephysicianwhoisanoutlierintermsofexcessactivityand,recently,notachievingastandardofpracticeforcertainqualitymeasures.Inhospitalsthenurses,supportstaff,andhousestaffmonitorattendingphysicianqualityandbehavior,eventhoughnoneofthesepeoplearetrainedtobethemonitorsofphysicians’performance.

Ifaproblemisdetectedthereisnouniversalsystemtodealwith it.Physicians incommunitypracticewhodonotassociatethemselveswithahospitaldonothavesupervisors.Theyonlyhavetheirownsenseofethics,values,andpayors’orpatients’complaintstoreflecton.Forthosephysiciansingroupsthereistheadditionaldynamicofpartnerrelationships,buttheresponsibilityofsupportingandmanagingtheproblemphysicianisusuallynotataskdesignatedtoanyonegroupmember,unlessthegroupisverylarge.

Inmanagementcoursesforbusiness,thereareawholehostofoptionsonhowtodealwithdisruptiveemployeesandhowtosetupyourorganizationtoaddresstheseissuesdirectlyandrapidly.Certainlywithlargegrouppracticesandinthehospitalsettingsproblemphysicianswhohavebeen identifiedaredealtwith invaryingways,usuallybycommittees.Butoneproblemwiththissystemisthatphysicianswhoaregivenchargeofthecommitteesalsohavelimitedtraininginemployeemanagement.Andwheredoesthatleavesoloorsmallgrouppractices?

Perhapsthisshouldbeanactivityofthelocalmedicalsocieties,ormaybethemedicalboard—butisthatwhatwereallywant?Idon’thavetheanswers,butthiseditionofSan Francisco Medicinecertainlyaddressessomeofthesituationsthathaveariseninourcurrent system.Taking thechangingpracticeofmedicine intoaccount,weneedtolookathowoursystemissetupanddesignabetterwaytohelpthephysicianswhoaredoingthemainworkofdeliveringcaretothecommunity.

Who Is Responsible for Our Physicians?

Gordon Fung, MD, MPH

PreSidenT’S MeSSaGe


deParTMenT TiTLe HereMike Denney, MD, PhD

Double, Double, Doctor in Trouble

ediToriaL

I nGreekmythology,Hecate,who servesasaguideatbothgraveyardsandcrossroads,isthemostenigmaticofallthegod-desses.Apersonificationofparadox,sheisdescribedasbotha

hagandalovelyone,shepresidesoverboththedarkandthebrightphasesofthemoon,sheacknowledgesbothevilandgoodness,andshecanbestowbothpunishmentandblessings.Hecateisagoddessoflife,death,andrebirth.

Thismythicaldeityofbothshadowandlighthasbeenpor-trayedthroughouthistoryasaredoubtablefigure,appearinginsuchdiversevenuesasthePersephonemyth,Shakespeare’sMacbeth,WilliamBlake’s poems,HellboyComics, the television seriesBuffy the Vampire Slayer,themovieCharmed,avideogameabouttheAgeofMythology,andapopularInternetgamecalledRisingForceOnline—tonameafew.

InMacbeth,thewitchescastaspellofdoomastheychant,“Fairisfoul,andfoulisfair;Hoverthroughthefogandfilthyair.”Asthoughundertheircurse,Macbethgoesonamurderousram-page.That’swhenHecateentersthistroubledstoryandharshlyrebukesthewitchesforexpressingonlytheirdarkandevilside.Shecomplainsthatshe“wasnevercalledtobearmypart/Orshowthegloryofourart.”Undaunted,thewitchescontinuetostirtheirwickedbrew,chanting,“Double,double,toilandtrouble/Fireburnandcauldronbubble.”

AsinthisissueofSan Francisco Medicinewetrytobalancethescalesofmedicaldiscipline,isitpossiblethatthemany-facetedHecatecanbeourguide?Tobesure,allofuswhohavebeencalledtothehealingprofessionsmustmaintainimpeccablemoralandethicalstandards—bothtoactinthebestinterestsofpatientsandtodonoharm.Yetwhenweareforcedto“hoverthroughthefogandfilthyair”ofmedicalwrongdoing,boththeaccusedandthosewhostandinjudgmentarewonttobecomepsychologicallyim-mersedinacauldronofdoom.Perhapsthatiswhymostofus,uponreceivingourcurrenteditionoftheMedicalBoardofCalifornia’sAction Report,areinexorablydrawntothebackpagestoseewhoamongushasbeenpunished.

Doctorswhocommitcrimesorunethicaldeedsorwho forwhateverreasonarenotcompetenttopracticesafelymusthavetheirbehaviorcorrected,bepunishedwhenappropriate,andhopefullyberehabilitated.Todolesswouldbeadisservicetohumanity.Still,

doctorswhoarecompetentandhavethehighestintentionsyetfindthemselvesunderscrutiny—thosewhomakehonesterrors,whounderstresssuffertemporarylapsesinjudgment,orwhomightbefalselyaccused—mightbegintowonderif“fairisfoul,andfoulisfair”inoursystemofpeerreviewandmedicaldiscipline.

Withinaprofessionwiththehighidealofhealingothers,evenbeingaccusedofwrongdoingcanseemtobeafallfromgrace.Whencollegialpeerreviewandcorrectiveactionprogressestoaccusa-tionsofpossiblegravetransgressions,mostphysiciansmightfeeltobeunderthespellofHecate’sdarksideofthemoon.Andwhenthesystemofjudgmentmovesfromcooperativequalityassurancereviewtotheseeminglyhostilelegalarenaofmedicalboardandcourtroom,wemay,indeed,hearthewitcheschanting,“Double,double,doctorintrouble/Fireburnandcauldronbubble.”

Tomakemattersworse,medicaldisciplineisdeterminedbyadministrativelaw,forwhichtherulesofevidenceandthecriteriaforjudgmentarelessaboutone’sconstitutionalrightsasacitizenandmoreabouttheprivilegetomaintainalicenseasaphysician.Wemightwonder:Whoarethe“expert”physiciansforthestatewhowillsitinjudgmentofourworthiness?Bewilderedbytheseshiftsfromacollegialmedicalsystemtoanadversariallegalmodel,wemaywanttocomplainasdidHecatethatshe“wasnevercalledtobearmypart/Orshowthegloryofourart.”

Inviewofall this,perhaps itwouldbehelpful if,whetherbeingaccusedorsittinginjudgment,wephysicianscollectivelyrememberthatHecateactsasguidenotonlyingraveyardsbutatcrossroads,andshebestowsnotonlypunishmentbutblessings.Sheisoftendepictedashavingthreeheads,representingthethreepathsonwhichonemayproceedwhenarrivingatacrossroads.Inthetroubledchambersofmedicaldisciplinethosethreeheadsmightbenamedprevention,correction,andrehabilitation.

Asinthesepagesourcolleaguesreportontheparadoxicalna-tureofmedicaldiscipline,wecanacknowledgethatoneofHecate’sheadsisthatofasnake,thatearthlycreaturethatshedsitsskinandregeneratesanewoneeveryyear.WecanstrivetorememberthatHecateisagoddessnotonlyoflifeanddeath,butofrebirth.

T hroughouttheyearstheHippocraticOathhasundergonemanychangesthatreflectthechangingfaceofmedicalpractice.Today,mostmedicalschoolsusemodernversionsoftheoathoriginallycraftedinancientGreece.Theoathbelow,writtenbyLouisLasagna,isoneofthemorewidelyusedofthemodernversions.It

isalsotheversionusedbytheUniversityofSanFranciscotoswearnewgraduatesintotheprofession.

The OaTh Of Lasagna

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard‑won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply for the benefit of the sick all measures which are required, avoiding those twin traps of over treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say, “I know not,” nor will I fail to call in my col‑league when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not dis‑closed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart or a cancerous growth, but a sick human being, whose illness may affect both family and economic stability. My responsibility includes those related problems if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all, those sound of mind and body, as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.


BaLancinG THe ScaLeS oF MedicaL diSciPLine

herlegalskillscreatively,andwasjustpiningtogetbacktoheroldself.

“We went through a series of rela-tively conventionaltreatments using indi-vidual broad-spectrumand combined antide-pressant agents, usingaugmentationstrategies,utilizing thyroid hor-mones and metabolicinterventions,andsomeother standard proto-cols,” says Dr. Cox.“Over the courseof ayear’stimeshedidn’tre-spond,soweeventuallydecided to use MAOinhibitors.”

A Quick Course in Antidepressant Agents

Agents that arewidelyused forde-pressiontoday,likeZoloft,Prozac,andtheotherselectiveserotoninreuptakeinhibitors(SSRIs),areconsideredquitesafeanduserfriendly.Adverseeffectsareminimalandthereisnorealriskofaccidentaloverdose.Thereare alsonewer-generation,broad-spectrumagents thataffectnot just sero-tonin,butalsonorepinephrine.Thesecanhelpasubsetofpeoplewhodon’trespondtoSSRIs.

Typically, psychiatrists prescribingantidepressantsfollowasequencethatstartswithsimpleragentsandmovesontothemorecomplex,broader-spectrumones.Ifpa-tientsdon’trespondtoadual-actionagent,twocomplimentarydual-actionagentsmaybeprescribed simultaneously. If that stilldoesnotwork,psychiatristswilloftentryaugmentationstrategies,addingsubstances

Caught in the Process: One Physician’s Experience with the Medical Board

like thyroidhormonesor lithium to themix—whichhasa30to60percentchanceofmakingadifference.Monoamineoxidase

(MAO) inhibitorsareoften the next step.Theyareessentiallythebroadest spectrum ofall currently availableantidepressants—theyaddress every neu-rotransmitter that islikelytobeinvolvedindepression.

“ButMAOinhibi-tors have fallen intodisuse,becauseof theriskofwhat isknownasthe‘wineandcheese’reaction,” Dr. Cox

notes.“Itisveryeasytoingestsomethingthatwillcreatea serious,andeven fatal,reaction,andinthelate‘70sanumberofpeopletakingthesemedicationsdiedaftergoingtowineandcheeseparties,becausebothagedcheesesandwinescontaintheseelements.”

“AsaresultMAOinhibitorsbecameregarded as complicated agents to use,”headds,“sowhenthenewer,saferagentscameout,physicianswere justdelightedtonothavetoprescribeMAOinhibitorsanymore.Butthebottomlineisthateventhough thesenewer agents are ‘cleaner,’safer, andbetter tolerated,noneof themhas replaced theMAOinhibitors as theultimatetreatmentbeforeyoustartthink-ing aboutheavy-duty interventions likeelectroshocktherapy.”

Dr. Cox is one of less than half adozenpeopleinNorthernCaliforniawhoprescribes these medications, which heusesprimarily for treatment-resistantde-

Amanda Denz

“The process each case goes through is lengthy, with many steps designed to weed out instances where physicians are not in fact at fault—but how long does it take to relieve the system of these cases?”

Formost physicians the thoughtofbeinginvestigatedbythemedicalboardisaterrifyingone.Whethertheythinkaboutitoftenornot,formanythefearremainssomewhereinthebackoftheirminds.ThisiswhatdrivesphysicianstostartreadingtheCaliforniaMedicalBoard’sAction Report byturningtothelastsectionfirst.Andwhilemanyreadthe“AdministrativeActions”tomonitorwhichcolleaguesarelisted,mosthaveprobablyconsideredhowitwouldfeeltoseetheirownnameappear.

AccordingtotheCaliforniaMedicalBoard’s 2004-2005 Annual Report, theDivisionofMedicalQualityreceived7,503complaintsduring thatfiscal year. Fromthesecomplaintsitopened1,443cases,521ofwhichwereeventually referred to theattorneygeneral.Ofthesereferrals34caseswerereferredfurtherforcriminalaction.

Fromfraudtonegligence,themedicalboard’s investigationscover thegamutofpossiblewrongdoings.Theprocess eachcasegoes through is lengthy,withmanystepsdesignedtoweedoutinstanceswherephysiciansarenotinfactatfault—buthowlongdoes it take to relieve the systemofthesecases?ForBrentCox,MD,theanswerwasalmostayear.

Dr.Cox is apsychiatristwho seesanumber of cases of treatment-resistantdepression.Heisanexpertinpsychophar-macologyandoftenhispatientsarethosewhofailtorespondtotypicalantidepressantagents.In1998and1999hewastreatinganolderwoman,alawyer,whowassufferingfrom severely treatment-resistant majordepressivedisorder.Shehadseenanumberofprimarycaredoctors andpsychiatristsandwasnot responding toconventionalinterventionmethods.Shefeltdisengagedfromherfamily,washavingdifficultyusing


Firsttheboardrequestedmoreinfor-mationaboutthecase;theinitialreviewerwasnot apsychiatrist and thought thatsomeonewhowasshouldlookitover,sohe

hadflaggedDr.Cox’scase for follow-up.Next the casewentonto a psychiatristfor review, but thisphysiciandidnotspe-cializeinpsychophar-macologyandwasnotawareoftheprotocolDr. Cox had beenoperatingunder.

Dr. Cox wasthen called in foran interview. Theperson interviewinghim, as a represen-tativeof theboard,was a pediatrician.

Aftertheinterviewhiscasewassentontoanother reviewer, a forensicpsychiatrist,whowrotethatDr.Coxhadmismanagedthecase.Notonlydid shedisagreewithhisuseofMAO inhibitors, but shealsoattackedhisuseoftwodual-actionagentssimultaneouslyearlieroninthecase.Asaresult,hiscasewasultimatelysenttothestateattorneygeneral.

“Youcan’thavethosekindsofpapersfiledagainstyouandnotseeyourlifepassbeforeyoureyes,”saysDr.Cox.“Youenvi-sionyour licensebeing revoked, articlesabout you in thepaper, and yournameinthebackoftheAction Report alongsidedocswhoareembezzlingmoney, sexuallyassaultingpatients, andprescribinghigh-doseOxycontin topatients theyhaven’tseeninfiveyears.”

At this pointheneeded tohire anattorney.Dr.Coxalsodecidedtocallonmanyofhiscolleagueswhowereconsideredexperts inpsychopharmacology towriteabouthismanagementofthecase—includ-ingDr.JayAmsterdam,whohadestablishedtheprotocols.

“AmsterdamwrotebacktomeandsaidnotonlydidhethinktheParnatewasnottheculpritinthiscase,buthefeltthetwoantihypertensive agentsprobably causedthedelirium,”notesDr.Cox.“Theywere

antidepressantagentwas,byvirtueofhowitchangedherlife.”

After being on the Parnate for 6months, the patient went on a trip toBoston.While travelingshe had an episode ofdelirium;Shedidn’tknowwhatdayof theweek itwas, and was markedlydisoriented,soherfamilybroughthertotheER.Atthehospital, thedoctorsdiscovered that, for noapparent reason,plateletcount was down. Theyconcluded that shemusthave ingestedsomethingthat interactedwith theParnate.Theywerenotabletoconfirmthat—shehadnot taken any coldmedicationsor lapsed inthe dietary requirements as far as theyknew—butitseemedthemostlikelyexpla-nation,sotheystoppedallofhermedica-tions.ApartfromtheParnate,she’dbeenonafewantihypertensiveagents.Withinfivedaysshecameoutofthedelirium.

“TheconclusionofthemedicalservicetherewasthatshedevelopedareactiontotheParnate,”saysDr.Cox.“Butaftershecameoutofherdeliriumtheydidnotrestartanyofhermedications—includingthoseforhypertension.”

At thehospital inBoston somebodyroundingon theunithadaconversationwiththepatientandherfamily,informingthemthatthedoseofParnateshe’dbeenonwasbeyondarangethatanybodyhadeverusedbefore,andthatitwaswhathadcausedherdelirium.

WhenthepatientreturnedtoCalifor-nia,shefiledamalpracticesuit.Notwant-ingtodealwithalengthylawsuit,Dr.Coxsettledoutofcourtforasumthatcoveredthepatient’shospitalizationcharges.Afterthesettlementhethoughttheproblemwasover.Eventhoughallmalpracticesuitsarereviewedbythemedicalboard,hefiguredthatsincehe’dbeenfollowingestablishedprotocolandhadnotmismanagedthecase,nothingwouldcomeofit.Hethoughtthemedicalboardreviewwouldbemoreofaformality—untilthelettercame.

“You can’t have those kinds of papers filed against you and not see your life pass before your eyes. You envision your license being revoked, articles about you in the paper, and your name in the back of the Action Report”

pression.“Ioften seepeoplewhohave failed

with everything else, and you do reallyhavetobringinthebigguns—andtheseareamazinglyeffectiveagents,”henotes.“Thedietaryrestrictionsarenotascompli-catedasweoncethought,andafewofthemedicationsavailablearesurprisinglywelltolerated.Theyarenotreallynoxiousdrugsto take—youwon’t seeweight gain,drymouth,orconstipation,whichyouwillseewithmanynewer-generationdrugs.”

One Bad ReactionDr.Cox’spatientwentthroughase-

quenceofconventionaltreatmentoptionsoverthecourseofayearandnothingseemedtowork.“Withthispatient,weagreedthatMAOinhibitorswerethelastthingweweregoingtotrybeforemovingontosomereallyexperimentalorintensiveinterventions,”herecalls.“SoIstartedheronParnateandwemadestep-wiseadjustmentsonthedosage.Butshedidnotrespondtomoreconven-tionallower-enddosages.”

Raisingthedosagewasthenextoption.“Thereisawholeliteratureontheuseofhigher-enddosesofMAOinhibitorsthatcomesoutofJayAmsterdam’sgroupattheUniversityofPennsylvania,”Dr.Coxex-plains.“Hewroteandpublishedarticles10to15yearsagoindicatingthatasubsetofpa-tientsdidn’trespondtoconventionaldoses,butwhenpushedintoahigherdosingwin-dow,experiencedphenomenal responses.Inhisstudiesheexploredwhattheoptimaldosingwindowwasfromthestandpointofsafetyandeffectivenessandconcludedthatthe20-to60-milligramdosingrangelistedonthepackageinsertwaswayoffthemark.For truly treatment-resistant depressiontheidealdosingrangewasmoreaccuratelybetween40 to180milligramsdaily.Healsopointedoutthattheuseofhigherdos-agesdidnotincreasetheriskofdietaryorover-the-counterdruginteractionsandwasremarkablywelltolerated.”

Dr.CoxdecidedtofollowJayAmster-dam’sprotocolandincreasethedoseofPar-nate.Asaresult,thepatientdidrespond.

“Andsherespondedremarkablywell,”headds.“Shehadfewsideeffectsandshebecamevirtuallysymptomfree.Shebecameaglowingexponentofhowremarkablethis Continued on page 18...

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narcotics.IwasraisedintheMidwestinanup-

permiddle-classhouseholdwithtwooldersistersandbothofmyparents.Althoughthingsappearedtobegoodwithinourfam-ilyfromtheoutside,infact,theyreallywerenot. I felt a terrible lonelinessandangertowardmyfather.EvenmyclosestfriendscouldnotimaginewhyIwassoangrywithmydad,but Iwas,and itquietlygnawedatmyinsides.NomatterhowwellIdidinschoolorsports,Icouldnotseemtogetmyfather’sovertloveorsupport.

IdrankheavilyduringmyhighschoolyearswhenIwasnotstudyingorinvolvedinsports.Mypeerssawmeasjustoneofthoseguyswhodranktoomuch,butotherwiseagood studentand sportsman.Duringcol-lege,mydrinkingbecameheavierontheweekends,butIwassofocusedonbecomingaphysicianthatIrefusedtoletthealcohol

interferewithmygoals.I experimented

withmarijuanaanddietpills—tohelpme stayawake to study—butwasn’t really interestedinhowthosedrugsmademefeel.BythetimeIfin-ishedcollegeandmadeit intomedical school,mydrive tobecomeaphysicianseemedtofill

theemptinessthatIhadfeltearlierinmylife.Forawhilelifeseemedtobemovingalongquitenicely.Bytheendofmedicalschoolandmytraininginbothsurgeryandanethesia,Ihadaprettywife,ahandsomeson, a largehouse in the suburbs, andafabulousjobasananesthesiologistatabusyhospital.Whatmorecouldoneaskfor?

Aslifebecameeasierandlessfocused

“When it happened to me, I began looking everywhere for distractions from my inner unrest. The ultimate distraction was narcotics.”

A Change of Heart: One Drug Addict’s Story

Editor’s note: This month we decided to reprint the following story from a 1998 issue of SanFranciscoMedicine. Addiction is a special risk for physicians and other health care workers and can often lead to disciplinary action. All too often this topic is taboo in medical circles. The following article is a personal account by a doctor who experienced addiction’s devastating effects and who describes his road to recovery. SanFranciscoMedicine is gratefull that Dr. Kropp was willing to share his story.

I t ishard tobelievehowmanyyearshavepassed sincemybattlewithad-diction.Howgreatlifehasbecomein

theinterim!Backin1985thingswereverydifferent.Ihadjustlostmyanesthesiajobataprestigioushospital,followinganear-fatalillnessfromwhichIhadbarelyescapedthegrim reaper.Thiswasalldue to the factthattwo-and-one-halfmonthsprior,Ihadmade thedecision totry a little sufentanyl,intravenously, whichquite rapidly led tothenear-deathexperi-ence.

Obviously this“trial”usingan intra-venousnarcoticdidnotcomeoutofthinair.Aswithmanyhealthcareproviders,myquestinlifewas tohelpothers—withouta lotofconcern formyownwell-being—anoblecauseinandofitself.Thisworksformanydoctorsandnursesforawhile,butsomeofusrunoutoftheself-controlthatkeepsuswithintheboundsofsocietalexpectations.Whenithappenedtome,Ibeganlookingeverywhere fordistractions frommy in-nerunrest.Theultimatedistractionwas

forme,veryslowlyandsubtlytheoldfeel-ingsofemptinessthatI’dexperienceddur-ingmyformativeyearsreturned.IcannotsaythatIrecognizeditatthetime,onlyinretrospect.Butastimewenton,thefeelingsbecamemoreintenseandpersistent,andIremembernotingthatIfeltlikeIhadahugeholerightthroughmycore—anemptinessthatcouldonlybe“numbed”away.

Now,withmoney and timeonmyhands,Ifoundalotofwaystoerase(tempo-rarily)thisemptyfeeling.Workinghardwasagreatsolutionforawhile.IfoundthatifIworkedtoexhaustionIreceivedtwopayoffs:first,Ididnothavetimetopayattentiontomy feelings, and second, I receivedalotofadorationandpraiseformy“selfless”wayoflife—thelifeofadoctor.Onethingthatworkingharddidnotdowastobuildastrongmaritalrelationship.Thewaningofmymarriageprobablyledtomoredrinking.ThisoccurredmostlyonweekendsbecauseIwasoncallmuchoftheweek.

Whenworkaholismbegan to fail innumbingmyinnerunrestandmymarriagewasontherocks,Ibegantochasewomentodistractmyself.This,too,ranitscourseandleftmewiththatever-growingholeinmycore.

IknewthatIwasdepressedaboutmyplight in life and recalled frommedicalschoolthatDexedrinewasprescribedasanantidepressantforsomepatients.So,Istart-edself-prescribingDexedrineasaremedyformyills.Thisactuallyworkedforawhile,likealltheother“remedies”—withonecaveat.TheDexedrinegavemeaheadache.Iself-prescribedanoralnarcotictocombattheheadache.Thiswasthestateofmylogicandmyfirstintroductiontonarcotics.Iknewfromtheveryfirst timeI triedthemthatnarcoticswere“myfriend.”Thedrugactu-

Raymond B. Kropp, MD

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allytookawaymyinnerunrestandmademeforgetaboutmyfailingmarriage.

Thiskindofusagelastedseveralyearsuntil,onceagain,thedrugsstoppedproduc-ingthedesiredeffect.Itwasatimeinmylife,asinmanymen’slives,thateverything seemedtostopworkingforme. Iwasabout40years old, in a blaringmidlife crisis.OnedayI found myself notic-ing how comfortablemypatientswere afterreceiving intravenousnarcotics following sur-gery.Iwonderedwhatitwouldfeelliketoreceivesuchdrugs.ThisiswhenIcrossedtheline.Asananesthesiologist,Iknewhowtohandlenarcotics,andIcertainlyknewalltherewastoknowaboutaddiction,soIwasnotworriedabouttryinga“little”intrave-nousnarcotic.

Today,asIreflectbackonmymentalprocessesandlogicthatledmetouseIVnar-coticsforthefirsttime,Ifinditincredulous.Butthen,Iwasdepressedandinpain.Iwassowillfulandfullofmyownself-importancethatmythoughtprocesseswerenotclear,norwere they inkeepingwith thatof a“reasonable”man. Idonot thinkIcouldhaveeverclimbedoutofthismorassbymyownpower. Ineeded intervention—andIgotit.

It came in the formofanear-deathexperience which started with a viralrespiratoryinfection,butendedinstaphy-lococcussepticemia,lungabscesses,aone-and-a-half-gallongastrichemorrhageandafailureofbothmykidneysandliver.Withinfivedaysofbeingadmittedtothehospital,Iwasgivenlastrites.ForreasonsIcannotfullyexplainotherthanbycreditingdivineintervention, I survived.Butby the timeI left thehospital, theentirecommunityknewaboutmyaddiction, including theBoardofMedicalQualityAssurance.Need-lesstosay,Igotmyintervention—anditliterallysavedmylife.

NormallyIamaquicklearner,butnotin thecaseof recovering fromsubstance

abuse. It tooka relapse afterfinishing arehabilitationprogrambeforeIcouldkickthehabit.WhenIdidfinallykickit,mylifechangedcompletely. Ibegan to listen totheadviceofotherswhowereinrecovery,andnomatterhowmuchIbelievedthat

my ideaswerebet-ter,Ifollowedtheiradvice. I began tobelieve inapowergreaterthenmyself.At first itwas thefellowshipofrecov-ering addicts; buteventually it tookthe form of Godin a much differ-entwaythanwhatIhad learned as achild. This was apersonal,kindGod,whoexpectedthatI

shoulddowhatIcouldandthenletgooftheoutcome.Thiswasamuchmorereasonablewayoflivingforme—anditworked!

Ibeganlivinganddealingwithlife’sproblemsquitedifferentlythanIhadbefore.Ibeganpayingattention to thepresent,understandingthatwhatmattersisrightinfrontofmeallthetime—notinthefutureorinthepast.

Ibegantobelievethatmypurposeinlifewastrulytoshowup,payattention,andnot tell lies; everythingelsewouldworkitselfout—withonecaveat.Istillhadsomeskeletonsinmycloset,whichIneededtodealwith.Ineededtomakeamendswithmyfather.IunderstoodthatonlyIcouldchangemywayofthinkingandsincerelyaltermyfeelingstowardhim.Withthehelpofothers,includingatherapist,Iwasabletomakethoseamends.Hewasalsoverywillingtomakeamendswithme,andweembarkedonatrulylovingrelationshipthroughtherestofhiswaningyears.Bythetimehediedsomefouryearslater,wehadbecomeascloseasIhadeverwishedfor—andhispassingwasanextremelylovingeventforme.

Lifeisstillsometimesdifficult;Idon’texpectthatwilleverchange.Istill,attimes,slipbackintosomeold,badhabitslikework-ingtoohardandnottakingcareofmyself.Buttoday,Iamremarried,toawonderful

woman,andhaveclose, loving relation-shipswithmy twogrown sons.BetweentheloveandsupportofmyfamilyandthenewwayofdealingwithlifethatIlearnedasaresultofmyrecoveryfromaddiction,IhavereturnedtothepaththatIhopeIcanfollowuntil Icompletemymissionwhilealiveonthisplanet.

Since the original publishing of this article in 1998, Dr. Kropp has passed away. When he wrote this piece he was working as the medical director and anesthesiologist at HealthSouth Surgery Center of San Francisco. He was also a member of the CMA and the San Francisco Medical Society and served on both organizations’ Committees for WellBeing of Physicians. After his recovery he also occasionally lectured on physician substance abuse throughout the state.

The Well-Being of Physicians Committee offers confidential guid-ance to physicians with chemical dependency or other problems and is chaired by David Smith, MD, of the Haight Ashhury Free Clinic, Inc. For more information con-tact Dr. Smith or Steve Heilig at (415) 561-0850, extension 270. There are other members of the committee from the staffs at most San Francisco hospitals. Steve or David will put you in touch with the appropriate contact. Rest as-sured that the strictest confidence will be kept and that physicians need not leave their names when calling. If you would rather contact the non-local California Medical Association, its physician hotline is (650) 756-7787.

“I began living and dealing with life’s problems quite differently than I had before. I began paying attention to the present, understanding that what matters is right in front of me all the time—not in the future or in the past.”



Preparing Medical Students for a Life of Reproachless Practice

Editor’s note: This article, written by firstyear UCSF medical students Bahl and Kelly, describes new ways that medical education can address such issues as stress, depression, grief, awe, wholeness, and service so as to prepare students for a life of practice. This prevention can help these physicians later in their careers to avoid subsequent burnout, breaches of standards, and possible medical discipline.

A 2002 studyon theuseofmentalhealth services inmedical schoolfound that almost one-fourth of

first-andsecond-yearmedicalstudentsatUCSFhadmoderate to severedepressivesymptoms,accordingtotheBeckDepres-sionInventorycriteria.Andyet,lessthanone-fourthof those studentswithdepres-sive symptoms soughtoutmentalhealthservices,citingsuchreasonsaslackoftime,lackofconfidentiality,thestigmaofmentalillness,andhighcosts.

Itiswellknownthatmedicalstudentsaremoreprone todepression than theirnonmedical peers.A longitudinal studyat theUniversityofMassachusetts foundthattherateofdepressionamongstudentsenteringmedical school is similar to thatamongotherpeopleofsimilarages,buttheprevalence increases disproportionatelyover thecourseofmedical school.Somebelieve thatmedical students’ increasedriskofdepressioncanbeattributedtothedeterioration of students’ coping strate-giesandpersonalhealthas theyprogressthroughschool.Otherscitetheemotional,academic,andtimechallengesinvolvedinbecomingaphysician,whichcanwearonstudentsandunmaskpsychologicalvulner-abilities.EdieDeniro,UCSFfirst-yearmedi-calstudent,findsthatthesignificanttime

…especiallywhenseeking treatment forpsychiatricproblems,whichhavemoreso-cialstigmathanothermedicalconditions,”saysGraves.

Studentsalsofearthatdocumentationoftheirtreatmentfordepressionwilljeop-ardizetheirfuturecareers,ascandidatesformedicallicensureareexpectedtodisclosethediagnosisofortreatmentforanydisorderthatmightimpairtheirabilitytopractice.Moreover,as theybegin to treat sickpa-tients,depressedmedical studentsusuallybecomeevenmorereluctanttoadmitthattheythemselvesneedhelp.

UCSF,however,makessignificantef-fortstoteachstudentstomonitortheirownhealthandtoencouragethemtoseekouthelpwhenneeded.TheprimaryresourceforstudentmentalhealthatUCSFistheMedi-calStudentWell-Being(MSWB)Program,whichoffersseveralservicesandprogramstopromoteahealthierlearningenvironmentand toassist studentswithabroad rangeofdifficulties.Oneof theMSWB’smostimportantservicesisindividualcounselingfor studentsexperiencingdepression, lossandgrief, anxiety, relationshipor familytroubles, academicdifficulties, andalco-holor substanceuseproblems.AUCSFfourth-yearmedicalstudentwhowishestoremainanonymous soughtouthelp fromtheMSWBProgramwhenherdepressionrequiredhertotaketimeofffrommedicalschoolduringherfirstyear.Shefoundthestafftobeapproachableandsupportive,andshewasparticularlygratefulfortheirhelpinfindingalong-termtherapistwhomshefeltcomfortablewithandwhomshecontinuestoworkwithtoday.

TheMSWBProgramalsooffersseveralgroupprogramsformedicalstudents.The

“Students fear that documentation of their treatment for depression will jeopardize their future careers, as candidates for medical licensure are expected to disclose any disorder that might impair their ability to practice.”

commitment requiredbymedical schoolsometimescausesherstressandlimitshernonmedicalactivities and interests, suchasyoga.Oneof thechallenges thisyear,shesays,hasbeen“re-prioritizing,makingchoices aboutwhichactivities topursueoutsideofmedicalschool.”

Diagnosing depression in medicalstudents can be difficult, as symptoms

ofdepressioncanbeconfoundedby theeffects of stress inherent in student life,and studentsoftendismiss their feelingsasnormalemotionalresponsestomedicalschool.Furthermore,medicalstudentswhoarediagnosedwithdepressionorrecognizethattheyneedhelpareoftenreluctanttoseekout care.SusannahGraves,UCSFfirst-yearmedicalstudent,pointsoutthatthisreluctancestemsfrompeerdiscomfortandsocialstigma.

“SincemostspecialistswearereferredtobelongtoUCSF,thiscanbeuncomfort-ablesincetheywillbeourfuturecolleagues

Manisha Bahl and Katie Kelly


“TheHealer’sArt,”acoursedesignedbyDr.RachelNaomiRemen,directoroftheInstitutefortheStudyofHealthandIllnessatCommonwealandprofessorofFamilyandCommunityMedicineatUCSFSchoolofMedicine, takesahighly innovative, in-teractive,andcontemplativeapproachtohelpingstudentsperceivethepersonalanduniversalmeaningintheirdailyexperienceofmedicine.Offeredtofirst-andsecond-yearmedicalstudents,“TheHealer’sArt”combines large group talkswith smallergroupexperientialexercisesthatexaminetopicsincludingwholeness,loss,grief,awe,andservice.

Theclass“allowedmetogetintouchwithmyselfasahumanbeingandtowhyI’mactuallyhereinmedicalschool,”saysCampbell.

Otherpopularelectivesinclude“Mas-sageandMeditation”and“Spirituality inMedicine.”

Surprisingly,whenpolledabout theemotional andmental strainofmedical

PartnersinMedicineProgramaddressesthestressmedicaleducationcreatesinmedicalstudents’ relationships.Medical studentsandtheirsignificantothersare invitedtoquarterly social and educational events,suchasawelcomingdinneranddiscussionsandpanels on couples’ communication,dual-careermarriages,children,andboardexams.OtherprogramsincludeOnDoctor-ingdiscussiongroups,whichmeetweeklyinthefirstandsecondyearsandmonthlyinthethirdandfourthyearsandprovideaforumforstudentstodiscusstheirreactionsto theprocess of becoming aphysician.StressRounds,whichareone-hourmeetingsheldwiththird-yearstudentsonceduringtheirMedicineclerkshipsandonceduringtheirob-gynclerkships,provideaforumforstudentstodiscussstressfulsituationsthatariseduringclinicalwork,suchasdifficultpatient/housestaffinteractions,thesenseofconstantlybeingevaluated,andthefrustra-tionofbeingatthebottomofthehospitalhierarchy.TheMSWBProgramalsooffersseminarsandpresentationsinresponsetostudentfeedbackontopicssuchascopingwithdeathanddying,talkingaboutdiver-sityissues,anddealingwithboardexams.

Dr.DarynReicherter,assistantdirec-toroftheMSWBProgram,feelsthattheseprogramshave successfullypromoted thementalwell-beingofUCSF students foryears and feels that theflexibilityof theprogramscontributessignificantlytotheiroveralleffectiveness.

“Wedoourbesttomeetthechang-ingneedsoftheclassesastheyarise,”saidReicherter.“Withinthebroadspectrumof‘well-being’formedicalstudents,wetrytocreateasolutionforeachneed.”

Staff psychologist Dr. Sally Handfindsworkingwithmedical studentsverysatisfying.

“Medical studentsdealwith tremen-dousstressand,asinallareasoftheirlives,theyapproachunderstanding themselveswith amazing intelligence and vitality”shesays.

CatherineCampbell,UCSFfirst-yearmedicalstudent,foundanelectivecourseshetookatUCSFusefulinlearninghowtocopewiththechallengesofmedicalschool.

school,manycurrentstudentssaytheyhavefoundtheirfirstyearofmedicalschooltobelessstressfulthantheyhadanticipated.ThayerHeath,UCSFfirst-yearmedicalstudent, attributeshiswell-being to the“pass-fail system [that] reallyhelpsgener-ateateamatmosphere”andthesupportiveprofessorsandstaff.

“Iamtakenabacksometimesbythesincereinterestthatourprofessorstakeinourlives,”saidHeath.

Feng-YenLi,UCSFfirst-yearmedicalstudent,believes that thepass-fail systemandthestructureofthecurriculumwithitscombinationoflecture,smallgroups,andonlinemoduleshavemademedicalschool“morefunandstress-freethanIthoughtitwouldbe.”Manyotherstudents,however,acknowledgethesignificantacademicandemotionalchallengesofmedicalschoolandrecognizethat,ultimately,medicalstudentsmustlearnhowtotakecareofthemselves,astheylearnhowtotakecareofothers.



Serving on the Medical Board of California: One Physician’s StoryBernard Alpert, MD

w henIwaspresidentoftheMedi-calBoardofCalifornia from2001 to2002, Iwasawareof

mydualroleasboththe“regulator”asanofficeroftheboardandthe“regulated”asapracticingphysician.Sincetherearerela-tivelyfewofuswithbothmonikers,wehaveatacitresponsibility,indeedanobligation,tocommunicatewiththehundredsofboardemployeesand toarticulate thenecessityandvalueofregulationtothecommunityoflicensedphysicians.

My initial task was to address andengage indialoguewithCalifornia’scoreofboard investigatorsata statewidecon-ferenceinSacramento.Afewdaysbeforetheconference,DaveThornton,chiefofenforcement for theMedicalBoard,wasseatedinmyofficewaitingroom.Hewasthereonboardbusiness.Apatientofminewithsomefamilymemberswasalsointhewaitingroom.IgreetedMr.Thorntonandintroducedhim,includinghisjobtitle,tomypatient,whohappenedalsotobeagoodfriendofmine.Mypatient’sbrowfurrowedwithconcern,andheblurtedout,“Ohdear,Dr.Alpert,Ihopeeverythingisallright.”

Attheconference,Itoldthisstorytothegatheredstaffmemberstoemphasizethepowerfulimpactthataformalvisitofanin-vestigatorfromtheMedicalBoardhasuponthepsychologicalandprofessionalwell-be-ingofaphysician.Ispokeofmyintentiontoenhancetwo-waycommunicationwiththevariousstafffromthepointofviewofonewhoisbothregulatorandregulated,avantagepointtheycouldnothave.Thein-vestigatorsopenlywelcomedthisexchangeandseemedtogoabouttheirworkseriouslyandprofessionally,andhopefullywithanenhancedsenseofhumanity.

Asmyworkontheboardprogressed,

that ranksconsistentlyat the topof therankingsmust thereforeexhibitbehaviorbyoneoftwomechanisms,bothofwhich,paradoxically, reflectpoorlyon the state.Eitherthestatehasaninordinatenumberofproblematic licensedphysicians, or itexercises inappropriateoverutilizationofdisciplinaryactions.Moreover,astatethatregularly ranks50theitherhasextremelyfewphysicianswithdifficulties,orhasin-appropriateunderutilizationofdisciplinaryactions.Thedesirablegoalsare,ofcourse,thatastateboardwouldexerciseappropri-ateandfair,andhopefullyfew,disciplinaryactions,withhighstandardsofprofessionalconductmaintainedasaresult.

The Medical Board of Californiahas no disciplinary quotas—it respondsto complaints. It remains vigilant as tolicenseimpropriety.Thereisnoevidencethatcomplaintsgounaddressed, and theconcurrenttrendsinmalpracticeclaimsdonot leadtoaconclusionthatdisciplinarycasesarebeingignored.Alownumberofdisciplinaryactionsseemstoactuallyreflectanappropriateposture in ahigh-qualityenvironment.Conversely,ahighnumberoflicenseactionswoulddefinitelyindicateaproblem,ofeitherlowmedicalqualityoranoverdisciplinaryenvironment.

Overall,IfeelthatthemembershipoftheMedicalBoardofCaliforniaisexqui-sitelysensitivetothenecessityoftimelinessin theprocessingofbothdiscipline andlicensing.Still,therealitiesofrecentbudgetcutsandreductionsinstaffhaveplacedanexceptionalburdenon the system.How-ever,thegoalremainsthatofmaintainingthehigheststandardsofmedicalcareforthecitizensofCalifornia.

Ialsotriedtomaketheinvestigatorsawarethatasregulatorswecouldnotignoretheenvironments in which the “regulated”worked.Thevastchangesinmedicalprac-ticepatternsweretakingatollonpracticingphysicians. The inversion of incentivesandresultantparadoxescreatedbyvariousprospectivepayment systems, alongwiththelayeredstructuresofthemanagedcareenvironment,werecreatingapalpabletrendof anxiousness in the livesofpracticingphysicians.

Nowadays,anestimated80percentofphysicianswillexperiencetheoccupationalstresssyndromeknownasburnout,amea-sureof institutionaldysfunction.Surveysroutinely indicate that largenumbersofpracticingMDsdiscourage theirchildrenfromenteringmedicineasaprofession.OursisthefirstgenerationofAmericanphysi-cianswhere thishasbeenobserved.Thissaddensme.Ispecificallymaintainthatourlicenseepoolisoneofsociety’smostvalu-ablehumanresourcegroups,andthattheenergy-depletingforcescurrentlyaffectingtheprofessionarecounterproductivetoourcollectivegoalofactuallyraisingthestan-dardsofcare.Italsoseemstomethatthepublichasnotyetconnectedthesedotstotheextentthatitisintheirpowertoeffectmeaningfulchange.

When Iwason theMedicalBoard,I reviewed our disciplinary goals. As aframework,Iinvokedtheconsumeradvo-cacygroupPublicCitizen’sratingscaleforstatemedicalboards,which ispublishedannually.Thisgroupranksboardsfrom1to50basedonthenumberofdisciplinarycaseshandledduringtheyear,therebyas-suringthataboardgetsahighstandingifitexhibitsanabundanceofdisciplinaryac-tions.Ipostulatedthatonthisbasisaboard



Arthur E. Lyons, MD

Serving on the Medical Board of California: Another Point of View

m y appointmenttotheMedicalBoardofCaliforniaafewyearsagocameasasurprisesinceIwas

notaparticularpartisan for thegovernoratthetime.IacceptedbecauseIfeltitwasimportant.Itisnotoftenthatonecanbeinapositionthatmaymakeadifferenceinthewaymedicineispracticedandthisappearedtobeanopportunitytodojustthat.Iwasnotdisappointed.

ThepositionsontheMedicalBoardareallvoluntary.Madeupof12physiciansand9laypeople,itispartoftheDepartmentofConsumerAffairs,whichincidentallyalsoincludesboardsforbeauticians,dryclean-ers,andcontractors.Appointmentsaretheprerogativeof thegovernor, subject toarubber-stampapprovalbythestatesenate.Theboardconsistsoftwodivisions,thatofLicensureandthatofMedicalQuality.Iwasappointedamemberofthelatter.Aftermyinitialappointment,whatcameasanevenbiggersurprisewasdiscoveringthededica-tionandqualityoftheotherappointees.

TheboardmeetsasawholeonlyfourtimesayearfortwodaystotransactbusinessatvariousplacesinCalifornia.Itsmeetingsaremostly,butnotentirely,open to thepublic.AfterIwasgivenaquickorienta-tionby theAdministrativeDirector,mydeskquicklybecameadailyreceptacleofforwardedfiles.Filereview,Ilearned,waswheretherealworkoftheboardiscarriedout.

There are 100,000or sophysicianslicensed to practice in California. TheMedicalBoardhasbeengiventheresponsi-bilitybythelegislaturetoprotectthepublicfrombadmedicine. It isnot concernedwithchiropracticcare,whichhasitsownboard,legalizedseparatelybypublicrefer-endum.Furthermore, itcannotguarantee

goodmedical care,norcan it adjudicatefeedisputes.

Thestaffoftheboardisrequiredtore-spondtocomplaintsaboutdoctorsbroughttoitfromanysource.Itcannotitselfiniti-ateacomplaint.After initialevaluation,manycomplaintsaredeemedfrivolousandaredisregarded.Inadditiontodiscipliningdoctors,protectionof thepublic includeshelping physicians maintain their prac-tices—ifatallpossible.Theboardtakesthisresponsibilityseriouslyandhasasystemofprofessionalrehabilitationandretrainingfordeficientdoctors.Licensesarerevokedonlywhenthatseemstobethemostresponsiblecourse,whenrehabilitationisnotanoptionorhasfailed.

Boardmembersreviewcasesandcon-firmthattheinvestigationsbyboardstaff,consultants,andattorneysareappropriateandthatthepenalty,ifany,isreasonableconsideringtheoffense.Onlyifthereisamajordisputewillthedivisionasawholeholdaformalhearing.TheActionReportistheboard’snewsletterandisdistributedregularlytoreport itsactivities, includingdisciplinaryactions.

Afterservingfouryears,Icameawaywithcertainimpressions.Themostsignifi-cant,Ibelieve,isthattheMedicalBoarddoesanexemplaryjobinpolicingCaliforniaphysicians.However,weknowweonlyaddressthetipofthe iceberg.Whenoneunderstands that theboard isperpetuallystarvedformoneytopayforinvestigatorsorconsultantswhopursueandreviewalle-gations,itisremarkablethatitdoesaswellasitdoesinprotectingthepublicfromthemedicallyincompetent.

WhileIwasontheboardtherewasabudgetandhiringfreezethataffectedalloftheactivities.Thishappenedinspiteofthe

factthattheboardisself-supporting,sinceitsbudgetiscoveredentirelybyphysicians’licensure fees.During the freezenotonlywas theboardprevented from spendingitsownmoney,butthegovernorwasabletousethatmoneyforotherpurposes.Asanon-civilservantIcouldneverunderstandthat,thoughthepaidstaffseemedresignedtoit—tothemitseemedtomakesense.

As for theboard itself, I found themembers extremely conscientious, tak-ing their responsibilities very seriously.Membersarefromallpartsofthestateandthe physicians represent virtually everyspecialty.Thelaymembersweresimilarlybrightandunusuallywellinformed.Thereisvirtually100percentattendanceatallmeetings and I believe every case wasthoughtfullyconsidered.

Theattorneysassigned to theboardfrom the attorney general’s office,how-ever,areanotherstory.Theyarefrequentlyveryinexperienced.Mostcasesaresettledwithout the necessity of a hearing, butthe settlementsworkedoutbetween thephysician’sattorneyandtheboardtoooftenseemedinappropriate.Iwasimpressedwithhowoftentheattorneysmissedthepoint.Often, thereappeared tobenoapprecia-tionofhowdangerouscertainphysicians’activitieswere. I amnot referring to thecrossingof sexualorpersonalboundaries,noramIreferringtosubstanceabuseprob-lems,bothofwhichareusuallypenalizedappropriately.However, Iwasaware thatdefective judgment and dangerous anduselesstreatmentswere,often,notfullyap-preciatedwhenworkingoutpenaltiesandremedialactions.Examplescometomindofpoorpracticesuchaselectiveprocedureswithseriouspotentialcomplications,such

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18 San FranciSco Medicine july 2006 www.sfms.org

assurgeryforweightlossorbackpain.Ac-cusationsandresultingsettlementsinsuchcasesoften seemed irrelevant,blamedondefectivepaperworkor the like, insteadofbeing recognizedas indicativeofgrossincompetence.Ontheotherhand,physi-cianswereoccasionallypursuedfortrivialreasonssimplybecauseofinadequacyofourconsultantsorinexperienceonthepartofourattorneys.

Inaddition tomattersofdiscipline,theboard’sDivisionofLicensure reviewsandapprovesmedicalschooltrainingwiththeintentofincreasingthenumberofcom-petentpracticingphysicians in the state.WhileIwasontheboard,wealsosetupaprogramtohelpunderservedpopulationsinCaliforniawithaloanpaybackprogramforyoungdoctors.Thisprogramwas theresultoftheimaginationandforesightoftheboardpresidentatthetime,SFMSmemberBudAlpert.

TheonlydownmomentsIcanrecallwerewhen,periodically,amemberofthelegislaturewouldappearbeforetheboard.Thiswould invariablybedisagreeable tome.Somesortofpoliticallyinspiredgrand-standingandanexpressedorimpliedthreatusuallyseemedtoaccompanythevisit.Theimpliedthreatwasthattheboardwas“notdoingitsjob.”FrequentlyIhadtoresisttheurgetorespond.Eventhoughthejobpaidnothingandtooktimefrommypractice,Iwanted tocontinue.Toparaphrase theEnglishsatiristW.S.Gilbert,spareusfromthe“statesmenwithanitchfrominterferinginmatterswhichtheydonotunderstand.”

MyexperienceontheMedicalBoardwasareassuringandatrulyrewardingone;hopefullyIdidsomegood,andIhadanop-portunitytomeetwonderfulanddedicatedindividuals.To serveourprofessionandourstateisarareprivilege,andIencourageothersinourSanFranciscoMedicalSocietytodothesame.

Continued from page 17...ingestedrightbeforetheepisodebegan,butnoonehadpaidattentiontothembecausetheywere standardmedications.So IdidaMedlinesearchandpulledupabout16references citingdelirium inconnectionwiththecombinationofantihypertensiveagentsshewastaking.”

Afteraboutfourmonthsofback-and-forthwiththeattorneygeneral’soffice,thecasewasdropped.Buttheentireexperience,Dr.Coxsays,leftaresoundinglydauntingimpression.Notonlydidhe spend thou-sandsofdollarsofhisownmoney,buthelostweight,onmanynightscouldn’tsleep,andbegantoquestionwhetherornothecouldcontinuewithhispractice.

“IdothingsinmyclinicalpracticethatarereallycuttingedgeandrisktakingandIhadneverbeenmedical-legallyphobicuptothatpoint,”hesays.“I’vealwaysdonewhatIhadtodotogetpatientswellandI’dneverlookedovermyshoulderandwonderedifsomeonewasgoingtosuemeordroppedacaseandreferredittosomeoneelsebecauseIdidn’twant to take thedifficult steps. Iamoneofthepeopletheyreferthosecasesto—soifIdidn’tseethem,whowould?”

“I realized that I was in danger injustdoingwhat it is that Ido,”headds.“Itwasn’tjustMAOinhibitors;itwasthenatureofmypractice,sinceIdothingsthatotherswon’t.Ipushdosesofdrugsbeyondwhereotherpeoplewill take them, Iusecombinationsthatarenotwidelyused,andIdothesekindsofthingsbecausemanyofmypatientshavereallyrunoutofoptions.AfterthisexperienceIwasreallyexaminingwhetherIwantedtocontinueinthefieldbecauseIfeltlikewhatIwastryingtodo

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annual General Meeting of the San Francisco Medical Society

HoldtheDate!TheSFMSGeneralMeetingwilltakeplaceonMondaySeptember11th,2006,from6to7:30pm.TentativeguestspeakersincludeMayorGavinNewsomandCMAPresidentMichaelJ.Sexton,MD.

Thenominationscommitteewillbepresented.Membersarealsoinvitedtoattendtheregularboardmeetingwhichwillimmediatelyfollowthegeneralmeeting.ThispresentsagoodopportunitytomeetwithSFMSleadershipandlearnfirsthandwhatSFMSandtheCMAareinvolvedinonbehalfofSanFrancisco’sphysicians.

wascompromised.”Partofhisdisillusionment stemmed

fromthemedicalboard’sprocess,hesays.Asoneofahandfulofareapsychopharmacolo-gistswithexperienceusingMAOinhibitors,hefelttheboardhadnotturnedtosome-onewithequalorgreaterexpertisewhenreviewinghiscase.Instead,hewatchedasphysicians—colleagueswho,undernormalcircumstances,mightconsultwithhimontheir casesof treatment-resistantdepres-sion—reviewedhisworkandpassedjudg-mentonhistreatmentchoices.

“Myexperiencewaslikebeinggroundupslowlybyabigmachinewheretherewerenoindividualbadguys;infact,manyofthepeople I encounteredwere goodpeopledoingwhatitwastheyweresupposedtobedoing,”hereflects.“Butthemedicalboardseescasesinvolvingeveryspecialty,andtheydon’tseemtoknowwheretoturntofindspecialists touseas reviewers.Theyhavepeoplefromvariousdisciplineswhoconsultwiththem,butmanyofthemaregeneralists.AndthatiswhatIsawinmycase.”

Attention San Francisco PhysiciansSF Medicine Magazine Seeks Your

Creativity!

We want to publish poetry, short anecdotal

stories, photography, drawings, collages,

and photographs of paintings or sculptures

created by SF Physicians. Please don’t be

shy, submit your artwork! Send all material

to Amanda Denz, 1003A O’Reilly Ave. San

Francisco, CA 94129, or by e-mail, adenz@

sfms.org.

18 San FranciSco Medicine july 2006 www.sfms.org www.sfms.org july 2006 San FranciSco Medicine 19


William A. Norcross, MD, Heather A. Ching, MFT, and William Seiber, PhD

Toward a More Accountable Profession:The Case of the Aging Physician

T heMedicalBoardofCaliforniaaskstheUCSDPhysicianAssessmentandClinicalEducation (PACE)

Program,an independentprogramof theUCSDSchoolofMedicine,toassessphy-siciansforclinicalcompetency.Typically,thisassessmentfollowsafteradministrativecharges are filed against thephysician’slicenseanddisciplinaryactionisimposed.PACEfacultyandstaffconductanumberofteststodetermineifaphysicianhasdefi-cienciesinanyareaofclinicalcompetencyoriftherecouldbeotherfactorsthatcon-tributedtothedisciplinaryaction.Overtheyears,severalMBCreferralshaveledtothediscoveryofphysicianshavingneurocogni-tivedeficitssufficienttointerferewiththeirabilitytopracticemedicinesafely.

A typical instance was one of an80-year-old vascular surgeon who wasdisciplinedbecauseofproblemswith thepostoperativemanagementofapatientthatresultedinafataloutcome.Hewasfoundtohave significantdeficits inmemory, adiminishedability to learnnew informa-tion, abnormalvisuospatial perceptions,andadeficitinfinemotorfunctionofthedominanthand.

Another example is that of a 74-year-oldprimarycarephysicianwhodem-onstrated confusion, disorientation, andinappropriateresponseswhileparticipatinginaPACEeducationalprogram.Hewasreferredforamedicalevaluationandformalneuropsychologicaltesting,whichrevealedfindingsconsistentwithachronicorganicbrainsyndrome.

Inallcaseswherehealthconcernsarediscovered,theinformationissharedwiththephysicianandhe/sheisstronglyencour-agedtobeevaluatedbyhisorherpersonalphysician(s).

Webelieveitislikelythatinmanyofthesecases,asintheexamplesabove,theneurocognitivedeficitsthatPACEuncov-eredweredirectly relatedto theevent(s)that led to theirdisciplineby theboard.Inthemajorityofthesecasestherewasnoevidence that thephysician’shospitalormedicalgroupquestionedhiscompetency,putrestrictionsonhispractice,ormadeaneffort to referhim for furtherevaluation.Thiswastrueevenincasesinwhichthedoctorhadsufferedastrokeandtherewasgrossevidenceofparalysis,abnormalspeech,and/orobviousdeclineinmentalfunction.Asaprofession,physiciansareveryreluctanttoapproachacolleagueaboutaperceivedhealthproblem.Moreover,physicianswithcognitiveproblemsareoftenunwillingorunabletoseekhelporretirefromclinicalpractice.Itissadtowitnessaphysicianendacareerofdedicationandserviceinsuchatragicmanner.

Although themajorityofphysicianswhochoosetocontinuetopracticemedi-cinebeyondage65are likelytobecom-petentandsufficientlyhealthytopracticemedicine safely, the incidence of manyseriousdiseasesincreaseswithage.Unfortu-nately,manyofthesediseasesoccurinsidi-ouslyandmanymaynotbeapparenttothepersonafflicted.Inpopulation-basedstudiesofcommunity-dwellingpersonsage65andolder,mildParkinsonismwasfoundinabout25percentinpeopleover65,andsymptomsandsignsofpre-dementiain1to2percent,witha significant rateof annualconver-siontodementia.Whilehighereducationappears toconferamildprotectiveeffectfromdementia,thereisnoreasontosuspectthatphysicianswouldnotsuffertheriskofincreasinglikelihoodofneurodegenerativeprocesseswithage.Other studies showa

significantincidenceofhearingimpairmentandvisionlosswithaging.

Commercialairlinepilots,aprofessiontowhich themedicalprofession isoften,arguably,compared,dealwiththeincreas-ingincidenceofdiseasewithagethroughaprogramofmandatory,intensivetestingandassessmentandcompulsoryretirementfromflyingatage60.(Iamtoldthattherequirementisneitherevidence-basednorpurelyrelatedtohealthorfitnessconcerns.Iofferthisonlyasaninterestingpointofcomparisonwithanotherhighly regardedprofessionwhosemembersareresponsibleforthewelfareandsafetyofthepublic.)

Thereisnoconsensusregardingrou-tinehealthor competency screeningofphysicians.Toourknowledge, theonlymandatoryassessmentprogram for agingphysiciansisconductedbyCanada’sCollegeofPhysiciansandSurgeonsoftheProvinceofOntario,whichrequiresphysiciansage70andolderwhowishtocontinueactivemedicalpracticetoundergoacompulsorypeerrevieweveryfiveyears.Butworldopin-ionisdividedonthisissue.Inconsideringthe samegeneral issue, theNewZealandHumanRightsCommissionstatesthatanyformof compulsory assessmentofphysi-cians solelybasedonage representedagediscrimination.

Whileweagree thatdiscriminationbased solelyonage is abhorrent,we feelcompelled to recognize that a host ofdiseases causingdecrements inphysical,sensory,andneurocognitive functions in-creasessharplywithadvancedage.Whetherthefindingisrelatedornottophysicalandmentaldecline,agrowingbodyofevidencedemonstrates that physicians who havebeen inpractice longerareat significant


Why is Employment Practices Liability Insurance needed?* • Statistics show an employer is more likely to have an employment claim

than a property or general liability claim.• The average amount paid for out-of-court settlement is $40,000.• Defense of the average EPLI case, through trial, costs over $45,000.• The median compensatory award in EPLI cases is $218,000.• 67% of all employment cases that litigate result in a judgment for the plaintiff.• 10% of awards in cases involving discrimination and wrongful termination

are in excess of $1,000,000.• Six out of ten employers have faced employee lawsuits within the last five years.

Employment related suits usually involve one or more of the following: discrimination, sexualharassment, wrongful termination or workplace torts. The purpose of the SFMS program is to providemembers with the needed tools and protection generally missing from other insurance policies.

SFMS’s claims made program provides members with significant benefits: • Web based training for members, office managers and employees to help minimize exposure

to employment practices lawsuits.• Access to a legal information hotline staffed by employment practices attorneys.• Review of employee handbooks and employment applications.• Economically priced Employment Practices Liability Insurance** that provides for defense costs

and losses an insured becomes legally obligated to pay as a result of a covered claim.• Choice of policy limits of $250,000, $500,000 or $1,000,000.• Low minimum premiums.• Low per claim deductibles.• 60 day extended reporting endorsement included.

For more information on the Special First Time Buyers Program or to receive a brochure andapplication, call a Marsh Client Service Representative at 800-842-3761 or [email protected].

‘‘A former employee is suing me for wrongful termination. Does my insurance cover that?”

It does if you have Employment Practices Liability Insurance.

* Society for Human Resource Management – 2002 ** Coverage provided by a carrier rated A by AM Best

© 2006 Seabury & Smith Insurance Program Management • CA License #SL0633005777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 •[email protected] • www.MarshAffinity.com • 6/06

Sponsored by: Administered by:

Affinity Group Services

www.sfms.org july 2006 San FranciSco Medicine �1


o ccasionallyeveryphysicianneedshelp—whetheritbewithlegalproblems,stress,mentalhealth,orsubstanceabuse.ThefollowingisalistofonlineresourcesassembledbyCMAand

SFMStoguidephysiciansthroughtheirtroubledtimes.

Referral Resources:•Medical Board of Californiawww.medbd.ca.gov•MBC Diversion Programwww.medbd.ca.gov/Diversion.htm•County Medical Societies www.cmanet.org/publicdoc.cfm/63/0/countyall•California Specialty Medical Societieswww.cmanet.org/publicdoc.cfm/60/0/linklist/55•American Medical Societywww.ama-assn.orgLegal Information:•CMA Medical-Legal Online Librarywww.cmanet.org/bookstore/cmaoncall.cfm•AMA Legal Resourceswww.ama-assn.org/ama/pub/category/4541.html

Physician Stress and Burnout:•Finding Meaning in Medicinewww.meaninginmedicine.org/home.html•Center for Professional and Personal Renewalwww.cppr.com/

Mental Health:•National Institute of Mental Health(NIMH)www.nimh.nih.gov

Substance Abuse:•California Department of Alcohol and Drug Programs-Resource Center (CaliforniaOnly)http://www.adp.ca.gov/•Substance Abuse and Mental Health Services Administration (SAMHSA)www.samhsa.gov/•International Doctors in Alcoholics Anonymous www.idaa.org•National Institute on Drug Abuse(NIDA)www.drugabuse.govTreatment Facilities:•SAMHSA’s Searchable Directory of Treatment Programshttp://dasis3.samhsa.gov/•State of California Narcotic Treatment Program Directorywww.adp.ca.gov/pdf/clinicdr.pdfRecovery Meetings:•Northern California AAwww.aanorcal.org/service.htm•Northern California NA meetingswww.norcalna.org/meeting.html•Dual Recovery Meetings www.draonline.org/meetings.htmlOutside California:•State Medical Societieswww.ama-assn.org/ama/pub/category/7630.html

Help for the Physician in Trouble

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Amanda Denz

A Conversation About Renewing:Q & A with Linda Clever, MD

greattimetoputtheoryintopractice.Sometimes you getwornoutdoing

good,and sometimes terrible thingshap-pened to you. How do people becomebuoyant,engaged,andexciteddespiteallofthis?

If,atthepointwhereyouareinlife,youeitherknoweverythingoryouhavelostthatcompellingneedtoexplore,howdoyougetthecouragetokeepexploring?Andwhenthingsaregoingwell,howdoyoustillkeep

lookingforward?Howdoyoukeepfrombe-ingabarnacleofapersonandmakeyourselfaleapingdolphinofaperson?

SFM: So how did you eventually put theory into practice?

Dr. Clever: Thatwasthechallenge.Agroupofcolleaguesand friendsgot to-getherandstartedRENEW.Theybecametheboardand theadvisers, and I starteddoinggrandroundsatvariousplaces.Thenwe started seminars andworkshops, andfinallyConversationGroups©—whichwewill bedoingwith theMedicalSociety.RENEWstartedwithphysiciansandthen

immediately startedworkingwithnurses,thenschoolteachers,attorneys,andotherprofessions.

SFM: What are the Conversation Groups like?

Dr. Clever: “Con”meanswithand“versus”meansturn,sowhenyouarehavingaconversationwithsomeoneitmeansyouarewillingtoturnwiththemandgetanewidea—thisisnotjustaboutreshufflingthedeck,it’saboutgettingnewcards.

At the Conversation Groups, thetopicisrenewing.Wediscussrenewingandrefreshing,andwefigureouthowtoregaineffectiveness,enthusiasm,andoursenseofpurpose,fun,andjoy.Wealsohaveagoodtimetogether!

OneofourfirstconversationgroupsstartedatCPMCand is still goingaftersevenyears.Wetalkabouttopicssuchas:Whatissuccess?Howdoyougetthroughatoughday?Howdowedealwithaging?Howdowe liveourvalues?These topicsarealwaysonourminds,butwedon’ttalkaboutthemthatmuch.Whenyouareinaconversationwithpeopleyoumightnotknowverywell,butwhomyoutrust,youcancometogripswithsomeofthesethings,andmoveahead.

SFM: Who do you think will enjoy or ben-efit from these Conversation Groups?

Dr. Clever:RENEWisn’tforpeoplewho are profoundly in trouble. It is forpeoplewhowanttobecomebuoyantagain.It’s forexplorers,discoverers,peoplewhowantmoreofanadventureinlife.It’sforwonderers.Sincewearemorefragmentedthesesdays,thisprovidesanopportunitytocometogetherwithpeoplewhoeitherare

T hismonthSan Francisco Medicine hadtheopportunitytospeakwithLindaClever,MD,abouthowphy-

sicianscanremainbuoyantandenthusiasticdespitestressandotherpressuresbroughtonbymedicalpractice.Dr.Clever’sprogramRENEWwasdevelopedwith thisaim inmind.Intheupcomingmonths,Dr.Cleverwill beworkingwith theSanFranciscoMedicalSocietytocreateaRENEWpro-gramformembers.

SFM:What led you to develop RENEW?

Dr. Clever:I’maninternistandIwastrained in internal medicine, infectiousdiseases,occupationalmedicine,andcom-munitymedicine.ThroughoutmycareerI’vealwaysbeeninterestedinhowlivesandwork/career interactbecausewearemorethanjustonedimension.Ourbodies,oursouls,our families,our friends,ourwork,andourneighborhoods—wehave all ofthesethings.

Then,severalyearsago,allofthewheelscameoffmylifeinaseriesofterribleways.Withinaperiodof18monthsmymotherdied,myhousewasbrokeninto,Ilosttwojobs,myfatherdied,andthenmyhusband,whoisalsoaninternist,wasdiagnosedwithcarcinomaoftheprostate.Heisfinenow,butafterallofthat,itwasnecessaryformetorethinkallofmybasics,toreallydefinewhatwasimportanttome.

When Ihad servedon theStanfordBoardofTrustees,oneoftheothermemberswasJohnW.Gardner,whostartedCom-monCauseafterhewasSecretaryofHealth,Education, andWelfareunderPresidentJohnson.Hehadwrittenagreatdealaboutexcellence,leadership,andaboutrenewing.AndhereIwasinthetimeofmylifewhenIneededtorenewandIthoughtthiswasa

�� San FranciSco Medicine july 2006 www.sfms.org www.sfms.org july 2006 San FranciSco Medicine �� San FranciSco Medicine july 2006 www.sfms.org

thinkwehaveoneofthehardest jobs intheworld.Ourjobsareextraordinarilysad,sometimes,andchallenging,andwonderful.Manyphysicianswoulddoitoveragain,andthentherearesome—andthesenumbersare increasing—whowouldn’t, andwhowouldn’tadvisetheirchildrento.Thatistragic.

But Ido think that, just likeevery-bodyelse,physiciansneed tokeep learn-ing—whethertheytakeaclassinsomethingthatintereststhem,anythingfromSanskrittowatercolor, or they join a group thatdoes something interesting. In additiontothelearningthatwehavetodoinourcareers, exploringpersonal interests is soimportant.

Wephysiciansneedtostayinvolvedwiththeworld,keeponreadingthenews-papersandstaying informedaboutpublicevents.Manyphysiciansbecomedivorcedfromtherestoftheworld,butwedohaveanobligationtoliveinit.

Wehavesuchadifferentresponsibil-ity thanmostotherprofessions.Weholdresponsibility forpeople’s lives and theirfutures.Thewaywedifferfromfirefightersandotherpeoplewhosavelivesisthatwehavearelationshipwithourpatientsand

thequalityofthatrelationshipaffectsthem.Toknowwhatwearedoingandtodonoharm—thosearealsohugeresponsibilities.Andhowdowedealwiththat?

Theseare all things thatwediscusstogetherduringconversationgroups.Manypeoplewanttoknow,“HowcanIdoitall?”Andtheansweristhatwecan’tdoitall,allatonce,butwecandecidehowtopickandchoosewisely.

It’s so important thatour spirits arehigh.Notjustforourpatientsbutforourfamiliesandcolleaguesandourselves.

like-mindedorhaveat leasthadsomeofthesameexperiences.Thiswayyoudon’thavetofigureeverythingoutyourself;youcangetideasfromothers—otherswhoareinthesameboat.Andthesameboatcanbeage28to88,becausepartofthatboatinvolves trying tofigureout “what is thepurposeoflife?”

SFM: What do you hope to accomplish with the conversation groups at SFMS?

Dr. Clever: Firstof all, itwouldbegreattogetaregulargroupofattendeesandtokeepthegroupgoingforalongtime.Andsecondwouldbe thatevery time,peopleleave with new ideas, or they find newpaths,ornewself-confidence,and/ornewapproachestolife.Peoplewhocomeshouldfeelthattheyarenotalone.Thisreallyisawaytobuildcommunity.

SFM: What other things can doctors do in their lives to stay energized or keep from getting stagnant?

Dr. Clever: Iknowthiswillbeashock-ingstatement…butIthinkthatphysicianshavethesameDNAaseveryoneelse.Ido

RENEW is coming to the San Francisco Medical Society!

The San Francisco Medical Society is introducing a RENEW program for SFMS members starting July 19 at 5:30 p.m. with a second meeting on August 16 at 5:30 p.m. at the SFMS Presidio offices. The preliminary meetings will be complimentary and will feature the delicious catering of the SFMS chef! RSVP to Carol Nolan, [email protected] (415) 5610850 extension 0. For more information about RENEW visit www.renewnow.org.

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T heethicalstandardsofthemedicalprofessionhavecon-sistentlyanduniversallycondemnedanyparticipationbyphysiciansindirectorindirectabuseofprisonersorany

otherpersonforanyreason,asembodiedinthedictum“First,donoharm.”

Additionally,thedominant“evidence-based”opinionregard-ingtheutilityoftortureisthatitelicitsfaultyinformationandin-creasestheriskofretribution—ofthetorturingnation’sownsoldiersandcitizensbeingabused.Thenavy’sowngeneralcounselhassaidthatmistreatingprisonersis“almostincalculablyharmfultoUSforeign,militaryandlegalpolicies.”Ithasalsobeencalled“awonderfulrecruitmenttrigger”forpotentialterrorists.

Bymid-2005, therewasdisturbingbutsolidevidencethatsince9/11,codesof treatment were violated in US-runfacilities inCuba, Iraq,andpossiblyAf-ghanistan. SomeAmericanphysicians,possiblyincludingsomeCaliforniamedi-cal licensees,were implicatedashavingbeen directly or indirectly involved insuchabuses.

Aleadingmedicalethicist,StevenMiles,MD,haswritteninThe LancetandinhisnewbookOath Betrayedthat“notonlyweredoctors,nurses,andmedicssilentwhileprisonerswereabused;physi-ciansandpsychologistsprovidedinformationthathelpeddeterminehowmuchandwhatkindofmistreatmentcouldbedeliveredtodetaineesduringinterrogation.Additionally,theseharshexamina-tionsweremonitoredbyhealthprofessionalsoperatingunderthepurviewoftheU.S.military.”

Concernedthatnotenoughwasbeingdonetoupholdhal-lowedethicalstandards,wewrotealettertotheNew England Journal of Medicine—whichhadpublishedsomeofthedisturbinginforma-tion. Inour letterwepointedout thatallphysicians, includingthoseservinginthemilitary,arelicensedbyastatemedicalboardandbeholdentothesameethicalstandardsasanymemberofourprofession.WeaskedthatthatthemilitarydisclosethenamesofphysiciansinvolvedinabuseofprisonerstomedicalboardsandtheAMAforinvestigationandpossiblediscipline.

TheNEJM publishedour letter inOctober2005.There-sponse?Virtuallynone.TheAssociatedPressdiddisseminateanewsreleasebutevenourownlocalnewspapersandmediadidnotcoverthiscallforaccountability.EventuallythechairmanoftheboardoftheAMAsentalettertotheNEJMinresponsetoours,

explainingAMAactionstodate,andreiteratingthat“physicianinvolvementinsuchmistreatmentcomprisestheintegrityofthemedicalprofession”—buttheNEJMchosenottoprintit.TheeditoroftheAMA’sownfinenewspaper,American Medical News,didnotrespondtohalfadozenattemptstodiscussanarticleoropinionpieceonthistopic.

Werewenaiveinexpectingotherstoshareour—andtheAMA’s—concern?Weexpectedthathavingacallforactioninthenation’sleadinggeneralmedicaljournalmeritedsomeresponse.Apparentlywewerewrong.Butwhy?

It’slikelytherearemultiplerea-sons.Perhapssomemilitaryphysicians,withintherigidhierarchyofthemilitaryandunder theduressofwartime,aremorepronetoslipintheirstandardsduetovariouspressures.Perhapsfewreallybelieve that thekindofdocumentedmaltreatmentweandothershavecited,whichhasevenresultedinatleastonedeathamongprisoners,istruly“torture”and is thuspermitted–which is justwhat some leaders inWashingtonare

nowarguingtobethecaseastheyseektoweakentheGenevaConventions.

Tobeclear,wefullybelievethatthevastmajorityofmilitaryphysiciansareethicalpeople,andthatthosewhohavetransgressedareatinyminority.ButthisepisodehasprovokedinusadisturbingflashbacktotheearlydaysoftheHIVepidemic,startingaquartercenturyago.Scientificandmediareportsweretellingussomethingbadwasoccurring.Someamongthe“powersthatbe”ignoredthewarnings—“andthebandplayedon”,asSan Francisco ChroniclejournalistRandyShiltstitledhislandmarkbookonthoseearlydays.Thosedelayscostmanypeopleverydearly,andarenowrecalledbymanywithshame.

Willmanyofusalsolookbackinshameatoursilentcomplicitywithabuseperpetuatedbyourownfellowcitizens?

Steve Heilig, MPH, is on the SFMS staff and is coeditor of the Cam-bridgeQuarterlyofHealthcareEthics. Philip Lee, MD, is professor at both Stanford and UCSF medical schools, UCSF Chancellor Emeritus, and former United States Assistant Secretary of Health. Marcus Conant, MD, is clinical professor of medicine at UCSF and a leading figure in responding to the HIV epidemic. Their views here are their own.

in MY oPinion

The Band Plays On—Again:Getting Away with Torture? Steve Heilig, MPH, Philip R. Lee, MD, and Marcus Conant, MD

“Our lives begin to end the day we become silent about things that matter.”

—Martin Luther King Jr.

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forhealthcareworkers,firstresponders,andothers(seedocumentonwww.sfdph.org/cdcp);heighteningawarenessofpublichygienepractices (e.g.,handwashing, coughetiquette); strengtheninghospitalsurgecapacityplans;acquiringasmallcacheofantiviralagentsandpreparingtostagestateorfederalstockpilesofmedicinestotreatconfirmedorsuspectedcases;developingprotocolsforisolat-ingconfirmedorsuspectedcasesinthehealthcareand/orhomesetting;developingprotocolsforhome-orfacility-basedquarantineofpeopleexposedtoaconfirmedorsuspectedcase;outliningsocialdistancingstrategies(e.g.,limitinglargepublicgatherings).

Tominimizesocialdisruptionsandtheeconomicimpactofapandemic,thehealthdepartmenthasbeencollaboratingwithacityagencywideAvian/PandemicFluTaskForce.Sincefallof2005thetaskforcehasbeenworkingtoensureacoordinatedresponseandtoseethatessentialcityservicesremainfunctional.SFDPHhasprovidedapandemicflucontinuityofoperationsplan(COOP)template(seewww.sfdph.org/cdcpforacopy)andongoingguidancetoleadersandplanners.

Thehealthdepartment is also assistingother communitygroupswithplanning.Variousmeetingsandpresentationsonpan-demicflupreparednessarebeingheldthroughtheHospitalCouncilEmergencyPreparednessTaskForce,InfectionControlWorkingGroup,businessassociations,andorganizationsthatmeettheneedsofspecialpopulations.ACOOPtemplatetailoredforbusinessesandorganizationswillbemadeavailableinJune.

TocommunicateaccuraterealtimeinformationtotheSanFranciscocommunitythehealthdepartmentwilluseavarietyofmediaoutlets, includingwebsitepostings(www.sfdph.org/cdcp),healthalerts faxed toclinicians,public information lines,pressreleases,andpressconferences.Presentlythewebsitehasavian/pandemicflunews,factsheets,flyersforupcomingpresentations,andmore.Manyofthesetoolscanbehandedouttopatientswhohavequestionsorconcerns.

Becauseclinicansplayakeyroleinthecity’sresponseweaskthatyoualsoprepareforapandemicflu.Havethe24/7diseasereportingtelephonenumberhandy,(415)554-2830,knowyouroffice’sorfacility’splan,anddevelopyourownpersonaldisasterplantoensurethatfamilymembersarecaredforwhileyouareatwork.Fordetailsonhowtoprepareseewww.sfdph.org/cdcp.

Whilewehope thatSanFranciscowillbe spareda severepandemic,planningfortheworstbydevelopingcomprehensiveresponseplansandstrongrelationshipswithcommunitypartnershelpsustomeetbotheverydaychallengesandthoseofanydisaster.

s ince1997,avianinfluenzaH5N1,commonlyknownasbirdflu,haskilledmillionsofbirdsglobally,infectedfewerthan250people,andkilledapproximately50percentofthose

knowntobeinfected.TheRNAofinfluenzaAviruses,includingtheH5N1strains,frequentlyundergoespointmutationsandoc-casionallyshiftsdramatically.Thus,thereisconcernthatthisviruscouldmutatetoahighlytransmissiblestrainandwidelyinfectavulnerableworldpopulation.Thispossibilityhaspromptedpublichealthleaderstoprepareforaninfluenzapandemic.

Preparingforpandemicfluisdifferentthanpreparingforotherdisastersinthatthepandemicfluhasthepotentialtolastupto24months.Inanextremescenariothepandemicviruscouldcausewidespreadwavesof illness,overwhelmourhealthcare system,causehighlevelsofabsenteeismineverytypeofworkforce,andresultinshortagesofessentialgoods.Vaccinesmaynotbeavailableforatleastsixmonthsandantiviraldrugsmaynotbeeffectiveorwidelyavailable.

TheSanFranciscoDepartmentofPublicHealth(SFDPH)iscloselymonitoringthestatusofavianinfluenzaandispreparingforthepossibleintroductionofthecurrentH5N1strain(noteas-ilytransmissible)orapandemicinfluenzastrain.Keypreparednessgoalsincludeidentifyingdisease,reducingtransmission,coordinat-ingcareoftheill,maintainingessentialservices,communicatingaccuratereal-timeinformation,andminimizingsocialdisruptionsandtheeconomicimpactofapandemic.ToachievetheseSFDPHisworkingonmanyfronts:

Toenhanceclinicians’abilitytorecognizeandappropriatelyre-spondtocasesofH5N1and/orpandemicinfluenza,SFDPHprovidesguidanceviaHealthAlerts,a24/7diseasereportingnumber,(415)554-2830,webpostings,andpresentations.SanFranciscocliniciansreceivedahealthadvisorythataddressedsuspectedavianinfluenzacasesinNovember2005(seewww.sfdph.org/healthalertforacopy)andnumerousclinicianshaveattendedSFDPH-ledavian/pandemicflulectures.Currently,targetaudiencesincludeemergency,primarycare,pulmonary,andinfectiousdiseaseclinicalstaff.Tofindoutaboutlectureschedules,[email protected].

Diseasecontrolteamsaretrained,readytorespondtoreportsandfacilitatetesting.TorapidlydiagnosecasestheSanFranciscoPublicHealthLaboratoryhasacquiredtheequipment,reagents,andskillstoprovidePCRtestingofrespiratoryspecimensforinfluenzaAandBandthesubtypesH1andH3.SoonthelabwillalsobeabletotestforthesubtypeH5.

ToreducetransmissionandensurecarefortheillSFDPHistakingthefollowingsteps:developinginfectioncontrolguidelines

Preparing for Pandemic Influenza in San Francisco

PUBLic HeaLTH UPdaTe

Olivia Bruch, MSC, and Karen Holbrook, MD, MPH


VeteransDiana Nicoll, MD,

PhD, MPA

U.S.CongresswomanNancyPelosi (D-Calif.)cuttheceremonialribbonatthegrandopeningoftheCenterfortheImagingofNeu-rodegenerative Diseases (CIND) at the SanFranciscoVAMedicalCenteronFriday,May12.TheopeningceremonytookplaceontheSFVAMCcampusinhistoricBuilding13,whichhasbeenrenovatedandnowhousestheCINDresearchprogram.

Rep.Pelosiwaspartofagroupofdistin-guishedgueststhatincludedDr.JoelKupersmith,ChiefResearchandDevelopmentOfficeroftheVeteransHealthAdministration,andCol.KarlFriedl,CommanderoftheUSArmyResearchInstituteofEnvironmentalMedicineandad-ministratorofaDepartmentofDefense-fundedresearchprogramatCIND.

ThemissionofCINDistheearlydetec-tionandsubsequentmonitoringofchronicandneurodegenerativebraindiseasesandconditionssuchasAlzheimer’sdisease,post-traumaticstressdisorder(PTSD),GulfWarillness,Parkinson’sdisease, epilepsy, and HIV dementia. Brainimagesareobtainedwithmagnetic resonanceimaging(MRI),anoninvasive,nonradioactivetechnology.AttheheartoftheCINDequip-mentarray isastate-of-the-art4.0TeslaMRIinstrument,theonlyoneofitskindintheVAsystem,which is several timesmorepowerfulthanconventionalMRIdevices.

CINDistheresultofcollaborationbetweentheDepartmentofVeteransAffairs,theDepart-mentof theArmy, theNational InstitutesofHealth, theNorthernCalifornia Institute forResearchandEducation,andtheUniversityofCalifornia,SanFrancisco.

HoSPiTaL neWSSaint Francis

Guido Gores, MDSt. Luke’s

Jerome Franz, MD

OnThursday,June29,weheldourRichardJ.BartlettMemorialLecturewithdistinguishedspeakerWilliamP.Schecter,MD,FACS.OurDistinguishedLectureSeriesaimstoprovideavenuetolistentoandlearnfromsomeofthenation’smostrespectedcliniciansandresearch-ers.Dr.SchecterisaProfessorofClinicalSurgeryandtheViceChairofSurgeryatUCSFandtheChiefofSurgeryatSanFranciscoGeneral.Thetopicofthelecturewas“TerroristmasscasualtyeventsinIsrael:Historicalcontextandclinicalmanagement.”Alongwithhisexcellentlectur-ingtalent,Dr.SchecterisespeciallyexperiencedinthisareaduetotimehespentattheShaareZe-dekMedicalCenterinJerusalem,Israel.BetweenJanuary1andJune30,2004,hestudiedcivilianhospitalresponsetomasscasualtyevents.InhislectureDr.Schecterexplainedtheprinciplesofmasscasualtytriageinthefield,theprinciplesofcivilianhospitalresponsetoamasscasualtyevent,andtheclinicalmanifestationsandman-agementofblastinjuryduetoexplosions.

SaintFrancisMemorialHospitalwasalsohonoredasoneof39nationalrecipientsoftheAmericanCollegeofSurgeons’CommissiononCancerOutstandingAchievementAward.Theaward isgivenonly tocancercare facili-tiesthatachievecommendationinmorethaneightareasofthe45areassurveyedduringthecomprehensiveon-siteevaluation.OurveryownCancerCareCommittee,establishedin1975,sees thatSaintFrancismeets thesehighstan-dardsinprevention,earlydetection,treatment,rehabilitation,emotionalandspiritualsupport,and long-term follow-up services forpatientsdiagnosedwithcancer.

Integrationofmanagementgoes forwardasweawaittheattorneygeneral’sapprovalforSt.Luke’stobecomeafourthcampusofCPMC.Afteraperiodwhenwewere sayinggoodbyetosomeoneonstaffeverymonth,wearenowseeingmorenewfaces,someofthemlongtimeemployeesofCPMCwhoarebringingexpertisebutalsolearningfromourcultureofservicetothecommunity.Theyarealsofindingareasofexcellencehere, suchasobstetrics,whichhasonceagainbeengivenSutter’shighestawardforperformanceinfirstpregnancyanddelivery,thankstoouroutstandingteamofdoctors,mid-wives,andnurses.

ThechildhoodasthmaprogramalsowonSutter’s award for best overall performance.Thisstatuswillbeenhancedinthenearfuturebyagrantof$170,000overthreeyearsfromtheCaliforniaAsthmaPublicHealthInitiative.ThemoneywillallowSt.Luke’sPediatricCentertoparticipateintheBestPracticesinChildhoodAsthmaprogram.Theproject leader isKevinChu,MD,whoadvocatesearlydetection,pre-vention,monitoring, and treatment. Hehashired a full-timeasthmacoordinator,DianaWilliams,PAC,totest,educate,andfollowuponthepatientsinthispilotprogram.

FormanyyearsSt.Luke’shadaSchoolofNursing. It trainedexcellentRNs, someofwhom stillworkwithus.Wenowhave thehappynewsthatSt.Luke’swillonceagainbeacenterfortraining.TheSamuelMerrittSchoolofNursingwilllocatesomeofitsprogramshereintheHartzellBuilding,whichhousedouroldschool.Weexpect theeducational activitieswillkeepournursingstaffattopperformance,enhancepatientcare,andprovideasourceofnursesforthefuture.


HoSPiTaL neWS

St. Mary’sKenneth Mills, MD

ExpectationsforprofessionalismfromourphysiciansrunhighatSt.Mary’s,andthemedicalstaffintroduceditsowncodeofconductsomethree years ago.All physicians attest to thisstandardatthetimeofinitialapplicationtothemedicalstaffandateachreappointment.Wefeelthatourreputationinthebroadercommunityisbasedoninvolvementinqualityimprovement,peerreview,utilizationmanagement,andpatientsafety.Weexpectourphysicianstopromoteasafe,cooperative,andprofessionalhealthcareenvironmentwhereall individualsare treatedcourteously, respectfully, and with dignity.Disruptiveordisrespectfulconductaffects theabilityofotherstodotheirjobscompetentlyandcreatesapotentiallyhostileworkenvironmentforhospital employees,parishioners,patients,andothers.

Wealsorecognizethatphysiciansareonlyhumanandattimesoperateunderconsiderablestress.Wearepreparedtohelpthetroubledordisruptivephysiciandealwiththeseissuesandmaintaintheircontributiontotheirprofessionandthemedicalcenter.WehaveanactiveWell-BeingCommitteethatrespectsconfidentialitybutallowsreviewandmonitoringofbehavior.Weworkwith theDiversionProgramof theMedicalBoardofCaliforniatokeepphysiciansworkinginasafeenvironment.AsaphysicianfamilyatSt.Mary’s,westandreadytosupportourfellowdoctorsintimeofneed.IwouldalsoliketomakeapitchfortheRENEWProgram,thebrainchildofDr.LindaClever(seeinterviewonpage22),which, amongother activities,hasdeveloped facilitatedconversationgroupsencouraginghealthcareprofessionalstoexplorewaystoenhancesatisfactionintheirjourneyasadoctor.

Finally, we encourage all our medicalstafftomarvelatthewonderandgraceoftheirprofession.This isbestdonewithbalance inourlives.Attentiontoselfandfamilyisthebestequalizer.

UCSFLinda Reilly, MD

UCSFMedicalCenterrecentlyopenedthefirstcenterinthecountrytoservethespecificcardiovascularcareneedsofAsiansintheBayAreaandbeyond.TheUCSFAsianHeart&VascularCenterwill focusonadvancedheartcaretreatmentthatisrespectfulofthecultural,genetic,andphysiologicaldifferencesthatdis-tinguishtheAsianpopulation.

The facility, located at UCSF MedicalCenteratMountZion, featuresa stressecho-cardiogram lab,patient screening rooms, andan education and research center equippedwith staff, computers, and readingmaterials.Patientsandcommunitymemberscanusethecentertolearnaboutheartdisease,andpreven-tionandtreatmentoptions.Patientswillalsoreceive informationand language-appropriateeducationalmaterials, and interpretersareonstaffandavailabletospeaktopatientsintheirnativelanguages.

The UCSF Asian Heart and VascularCenterwillalsoserveasanidentifiedleadershipinstitution to coordinate andplanbasic andclinicalresearchefforts.

WhileAsianAmericans share the sameriskfactorsasthegeneralpopulation,includinghighratesofhypertension,obesity,diabetes,andsmoking,studieshaveshownimportantdiffer-ences incardiovascular functionandoutcomein Asian Americans. “There is a scarcity ofprograms that cater toAsiansculturally, lin-guistically,andmedically,”saysGordonFung,MD,directorofthenewcenter.“Addingtotheproblemisalackofclinicaldataonthispopula-tion,makingitdifficulttomaster-planresearchandtailortreatment.”

Formoreinformationortoreferapatient,contacttheAsianHeartandVascularCenterat(415)885-3678.

Iwaspleasedtohearthatthefocusofthecurrentissueison“waywardphysicians.”Iwouldlike to say that therearenone,but Icannot.However,Icansaywithconfidencethat,thank-fully,theirnumbersatSetonarefew.

Asphysicians,wehavebeenplaced inauniqueposition.Despiterecentchangesinhealthcare,weremaintrusted.Thedoctor-patientre-lationship,ascodifiedintheHippocraticOaththousandsofyearsago,remainssacred.Implicitinthisbondistheunderstandingthatthedoc-torwillworkonbehalfofthepatient—notonbehalfoftheHMO,insurancecompany,orotherthirdparty.

This unique and sacred trust does notcomewithoutobligations.Asphysicians,weareheldtoprofessionalstandardsthatarehighandsometimesdifficulttomaintain.Icansaywithpride that breaching these standards israre.Nevertheless,whentheseviolationsoccur,theentireprofessionisweakenedanditisourresponsibilitytorespond.

At Seton, as with other medical staffs,weareendowedwithanexcellentPhysicians’Well-BeingCommittee.ThisgroupischairedbyTimIsaacs,MD,psychiatristparexcellence.Heresearchesrelevantarticlesonphysicianwell-nessandimpairmentanddistributesthemtothemedicalstaffinthemonthlymailing.Dr.Isaacsisalwaysavailabletothemedicalstaffforpersonalaswellaspatientproblems.Forviolationsthatareconsideredmoreserious,anadhoccommitteeisappointedandajudicialreviewcanresult.Anappealsprocessisalsoavailable.

Again, fortunately, egregious problemsofthisnaturearerareatSeton.Dr.Isaacsandhiscommitteeare liketheMaytagrepairmen,waitingby the telephone for calls thatdon’toftencome.Itisthroughthehardworkofthiscommitteeandthegeneralintegrityofmycol-leaguesinmedicinethat“waywardphysicians”areananomalyatSeton.

SetonStephen Conrad, MD


HoSPiTaL neWS

CongratulationstoDr.JohnMoretto,whowas recently reappointedchairof theDepart-mentofPathologyforasecondfive-yearterm.Dr.MorettoisagraduateofStanfordUniversitySchoolofMedicineandhasbeenamemberoftheCPMCMedicalStaffsince1995.

The CPMC Medical Laboratories atboththeCaliforniaandDaviescampuseswererecentlyawardedaccreditationbytheCollegeofAmericanPathologists.TheCAPprogramisthemostrespectedandrecognizedlaboratoryaccreditationprogramintheworld.

Dr.DonaldFletcher,CPMCDepartmentofOphthalmology, received the “MeritoriousAwardforOutstandingLifetimeContributionsinLowVision”fromtheAssociationforEduca-tionandRehabilitationoftheBlindandVisuallyImpaired.

TheCPMCFacilitiesDevelopmentteamisnowbuildinganewPhilips-StereotaxiscathlabintheKanbarCenter.Targetedforcompletionearlynextyear,itwillbecomeKanbar’sfourthcathlab,helpingCPMCservemorepatientsinanimprovedenvironment.ThisefforthasbeenenabledbytheCPMCFoundation,whichhasraisednearly$2milliontosupporttheworkofourcardiologists.

CEOBrendaYeewaspleasedtoannouncetheoutstandingfinalresultsoftheJCAHO/CALSurveyforChineseHospital:onlyfour“Require-mentsforImprovement.”GiventhatChineseisthefirsthospitalintheBayAreatoexperienceanunannouncedsurvey,itsJCAHOTaskForceshouldbecommendedfor“mobilizingthetroops”with literallyonly twohours’notice.Inaddi-tiontoourleader,Ms.Yee,taskforcemembers

ChineseFred Hom, MD

CPMCDamian Augustyn, MD

includeDr.JamesYan,cochair and MedicalDirectorofPerformanceImprovement;Dr. Jo-seph Woo, Chief ofStaff;Stuart Fong ofRiskManagementandInfection Control;DoloresOng,Directorof Nursing; RebeccaSulpacio,PerformanceImprovement; ElenaTinloy, Director ofClinicalServices;Dr.Wai-LamChan,Direc-torof SunsetHealthServices; Jian Zhang,NP and manager ofSunsetHealthServices;myself,Dr.FredHom,Vice-Chief of Staff;andmostofall,PatriciaChung, JCAHOSur-veyCoordinator.Alsotobeacknowledgedareallthemedicalstaffandhospitalstaffwhotooktimeoff toparticipatein the survey.Thankyoutoallinvolved.

SFMS Symphony Night

Returning this fall!

More information—in-cluding the date—for this SFMS Membership favor-ite will be available soon.

SFMS day at the Ballgame coming soon!

ThiseventwilltakeplacelateSummer/earlyFall.Pleasewatchthemagazine andcheckourwebsite,www.sfms.org, for more informa-tion.


in MeMoriaM

Berdeen Frankel, Md

Dr. Berdeen Frankel (Paul) passedaway on May 18, 2006, at the age of86. She was born on December 5,1919, to Mathilde and Joseph Frankel.ShereceivedaBAinsociologyfromtheUniversityofCaliforniaatBerkeleyandreceivedherMDfromStanfordUniversitySchoolofMedicine in1948, specializinginpsychiatry.Shewasoneofonly threewomen inher graduatingmedical class.Dr.FrankelpracticedpsychiatryinSanFranciscoforover50years,specializinginpsychiatricdiagnosis and treatment,psy-chopharmacology,andpsychotherapy.ShewasanattendingphysicianatStaintFrancisMemorialHospital,whereshereceivedtheDistinguishedServiceAward.ShewasalsoanassistantclinicalprofessoratUCSF.ShewasalifefellowoftheAmericanPsychiatricAssociation,amemberoftheAmericanandNorthernCaliforniaPsychiatricAssocia-tions,andamemberoftheSanFranciscoMedicalSocietysince1953.Sheresearchedandpublishedarticlesonthyroidfunctioninmentaldiseaseandpredictionofperfor-manceformedicalstudents.

Dr.FrankelwasalsoamemberoftheCommonwealthClubofSanFrancisco,theSanFranciscoWorldAffairsCouncil,andtheMetropolitanMuseumofArt.Heravocationsincludednationalpolitics,artsandantiques,world travel, andgourmetdining.Shehadanelegant senseof styleandawonderfulsenseofhumor.Shewasanavidreaderanditseemedtoherdaughtersandthoseclosetoherthattherewasnotawordinthedictionaryforwhichshedidnotknowthedefinition.

Dr.Frankelmarried JosephPaul,apoliticalpublic relationsconsultant, in1956.TheypurchasedahouseonJacksonStreet inSanFrancisco’sPacificHeights,wheretheylivedwiththeirtwodaughters,MimiandMary.

Herhusbanddiedsuddenlyin1972and

Nancy Thomson, MD, SFM Obituarist

Dr.Frankelraisedtheirdaughtersasasingle,workingmotherwithasteadfastdetermina-tion.HerunwaveringeffortsandemphasisontheimportanceofeducationledtoMimiattending andgraduating fromStanfordUniversity,andMaryfromHarvard—bothmadehermostproud.Unfortunately,Mimidied fromanorexia/bulimia inDecember2001.Dr.FrankelsetupanendowmentatStanfordUniversity formedical researchinto the causes and treatment of thesediseases; contributions in Dr. Frankel’smemorymay be made to the BerdeenFrankelPaulEndowmentforAnorexiaandBulimiaNervosa,c/oRichYates,StanfordUniversity,DirectorofPlannedGiving,FrancesC.ArrillagaAlumniCenter,326GalvezSt.,Stanford,CA94305-6105.

Dr.FrankelissurvivedbyherdaughterMaryPaulBrown(Martin),formersons-in-lawVincentAllioandAndrewNash,fourgrandchildren,herbrotherandsister-in-law,andthreenephewsandnieces.

Benjamin Gross, Md

Dr. Benjamin Gross, longtime psy-chiatrist in San Francisco, passed awayApril 17, 2006, of prostate cancer athis home in Sebastopol. He was 84. He was born March 1, 1922, in SanFrancisco’sFillmoredistricttoPolishJew-ishimmigrantparents.HegraduatedfromLowellHighSchoolin1938,receivedaBAinliteraturefromUCBerkeleyin1942,andearnedhisMD fromUCSF in1946.Heworked for thePublicHealthService fortwoyears inEurope serving inHamburg,Germany,andRotterdam,theNetherlands.Aftercompletinghisresidencyinpsychi-atryin1954,heopenedhispracticeinSanFrancisco.Healsosawpatientsatclinicsrunbythecity.HewaspsychiatricconsultantforSanFranciscoSuicidePrevention inthelate1960s,trainingpeoplewhofieldedemergencycalls.Hewasalsooneofthefirst

psychiatricconsultantsadvisingtheGoldenGateBridgeDistrictonwhethertoputupasuicidebarrier.

Helikedtorecounthow,attheageofone,hebecameillandthephysicianwhocametothehousequicklysurmisedthefam-ilycouldnotaffordtopayforthemedicineheneeded.Insteadofmakingafussaboutit,thedoctorslylylefttheneededsumundertheprescription form.Dr.Grossworkedfor30yearson the facultyof theUCSFpsychiatric institute andwas responsiblefornamingitLangleyPorterafterthedoc-torwhohadhelpedhimandhisfamilysomanyyearsbefore.

He also pursued his interest in lit-erature, teachingaclass in literatureandpsychology atSanFranciscoState for adecadeintheheightofstudentunrest inthe1960s.He taught the samecourseattheFrommInstituteatUSFuntilthelate1990s.Hewon theU.S. amateur seniorchesschampionshipin1989,andnaturallythepsychologyofchesswasoneofhisfa-voriteteachingtopics.Hemayhavebeentheonlyprofessor to linkchesswith theRussiannovelistFyodorDostoevsky,accord-ingtofriendsandcolleagues.Aftermedicalschool,hedrovetoWashington,D.C.,totrain forhis jobwith thePublicHealthService,survivingonalargesackofdates.However,hisinterestinliteraturegotthebestofhiminSt.Louiswhen,browsinginabookstore,hefoundacompletesetoftheworksofWilliamShakespeare,andblewtherestofhistripmoneypurchasingit.HehadtotakeajobunloadingsacksofBoraxdetergentfortwoweeksinordertofinancetherestofthedrive.

Hiswifeof61years,Anita,saidhewasverybrilliantandalsovery sensitive:“Hewas suchanall-aroundman.”He isalso survivedbyhis son,his sister,RuthHipshmanofSanMateo,andtwogrand-children.



in MeMoriaM Malcolm S.M. Watts, Md

Dr.MalcolmS.M.Watts,PastPresidentoftheSanFranciscoMedicalSociety(1961),passedawayonJune8,2006afterashortill-ness.Hewas91yearsoldandwassurroundedbyhislovingfamilyatthetimeofhisdeath.HewasborninNewYorkCityonApril30,1905.HeattendedTrinitySchool,Har-vardCollege,andHarvardMedicalSchool.While serving in theU.S.ArmyduringWorldWarII,hevisitedhislabpartnerfrommedicalschool,Dr.HerbertMoffitt,whoin-troducedDr.Wattstohiscousin,GenevieveMoffitt,whomhemarriedafter thewar.Heembarkedonatriplecareerofprivatepractice, teachingandadministrationatUCSF,and,communityservice.AtUCSFhe was a popular professor of internalmedicine,constantlyupholdingthevaluesof“old-timedoctors”andstressingtheim-portanceoftreatingthewholeperson.HealsoactedasAssistantDeanandAssistanttotheChancellor.UCSFhonoredhiscon-tributionswiththeUCSFMedalin1983.Dr.WattswasactiveintheSanFranciscoMedicalSociety, theCaliforniaMedicalAssociation, and theAmericanMedicalAssociation.Hewas editor of California Medicine, eventually expanding it intoWesternRegionalJournalofMedicine.Hewrotehundredsofeditorials.Hewasalsoeditorof theJournal of Continuing Education in the Health Professions.Heservedondozensofothercommitteesandboards,bothcharitable andprofessional, at thecivic,professional,state,andnationallevels.Healso servedaspresidentof theAmericanSocietiesofInternalMedicine.

Someofhisproudestachievementsin thepublic realmwereassisting in theestablishmentoftheUCSFMedicalCen-terinFresno,administeringtheCaliforniaAreaHealthEducationCentersprogram(AHEC)formedicallyunderservedareas,helping to establish the San FranciscoConsortium,andcontributingtoallaspectsofcontinuingmedicalhealtheducation.HealsoadvisedtheU.S.governmentonhealthpolicy.Hewasalwaysproudthatthepub-

liclyfinancedprogramshe administerednever incurredoverruns,muchtotheas-tonishmentofgovernmentauditors.

Healsogreatlyenjoyedhismember-shipsat theUniversityClub, thePacificUnionClub,and theMedicalFriendsofWine.

In spiteofallhisprofessionalactivi-ties,Dr.Wattswascompletelydevotedtohiswifeandfamily,supportingthemintheupsanddownsoflife.HeenjoyedrelaxingintheNapaValleywithfamilyandfriendsand traveling around the world.In hiseighties,heputalifetime’sexperienceintoanautobiographyandphilosophicalwrit-ingsforhisfamily.Evenattheend,atSanFranciscoTowersandHospicebytheBay,hetaughtaboutfacingdeathwithdignity,opennessandhischaracteristicdry senseofhumor.

Hewasprecededindeathbyhiswife,Genevieve, and his son Malcolm S.M.WattsII.HeissurvivedbyhissonJamesWatts,hisdaughtersPaulineWatts andElizabeth Thompson-Watts, and fivegrandchildren. He was father-in-law toMary-MichaelWatts,AldonaWatts,PeterThompson,andthelateCharlesTrinkaus.

risk forproviding lower-qualitycare.Be-causeof this growingbodyof evidence,webelievethattherealriskstothepublicsafetyoutweighanytheoreticalconcernsforindividualphysicians.

Thedevelopmentof auniformandvalidatedassessmentofhealthandgeneralcompetency forallphysicians licensed inCaliforniawhowish tocontinueactivelypracticingmedicinebeyondage65or70seemstobea reasonable responseto thisproblem.Weproposethatsuchaprogrambecreatedandimplementedbytheprofes-sionandnotmandatedbylegislation.Thecompositionofsuchaprogram,aswellastheageatwhichitshouldberequired,shouldbeevidence-basedtotheextentpossible,andshouldincludeinputofallthestakeholders.

Althoughthegoalisuniversalcompetencyscreening, we acknowledge that such aprogramwouldbea“shock”tothecultureofourprofessionintheUnitedStates,andtherewouldbemanysignificantandjusti-fiedconcernsabout it.For those reasons,wesuggestthat,atleastinitsfirstfewyears,while it isbeing studied, theprogrambevoluntary,confidential,andnonpunitive.Overtime,suchaprogramwoulddomuchtoensurethepublicsafetyandenhancethetrustthatourpatientsinvestinus.

Reprinted with permission from the California Medical Board’s Action News.The content of this article represents the views of the author and should not necessarily be construed as representing the views of the Medical Board or the San Francisco Medical Society.

Continued from page 19...

SFMS Membership Mixer

6:00 to 8:00 Thursday, August 24

Togonon Gallery (www.TogononGal-lery.com) located at 77 Geary Street, 2nd floor in San Francisco.

This will be a wonderful oppor-tunity for SFMS members to meet and mingle with SFMS leadership and CMA amidst an exciting exhibit of art from Myanmar (formerly Burma) with beverages and hors d’oeuvres, art and collegiality, plus live jazz! New members are especially encouraged to attend. In order for us to get an accurate catering count, we would appreciate an rsvp to Therese Porter, Director of Membership at (415) 561-0850, extension 268 or [email protected] by August 4th


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Recently the San Francisco Medi-cal Society’s Fellowship and WellnessCommittee merged with its PhysicianMembershipServicesCommittee. ThememberdoctorsandstaffofthisrevitalizedandnewlyexpandedMembershipServicesCommitteearecommittedtofindingwaystomakemembershipmoremeaningfulandusefulformemberphysiciansatallstagesoftheircareers,frommedicalschoolthroughretirement.Atthemostrecentmeetingofthecommittee,manyideaswerediscussedthataddressbothprofessionalandpersonalconcernsinphysicians’lives.

Recruitment of new members, andretentionofexistingmembers,requirein-novativethinkingandpassionate,directedaction.TheCommitteeisatanearlystageofdevelopingaprogramtowelcomenewmembers—students, residents andphysi-cians at every career stage—by havingexistingmembers reachout anddirectlycommunicatetopotentialnewmembersinaformofsponsorship.Theideaistomakephysiciansfeelbothwelcomedandinspiredtoparticipateintheactivitiesofthemedi-calsociety.

Announcements

One of the most profound benefitsofSFMSmembership is collegiality, theopportunity to interactwithpeersacrossthe spectrum of career stage, specialty,andpracticemilieu. As away to fosterandenhancethisexperience,manysocialeventsareintheplanningstages, includ-ingarevivaloftheSFMSnightattheSanFranciscoSymphony,anoutingtoalocalbaseballgame,museumandgalleryevents,and other “mixer”-type events that getmembersmeetingandtalking.

Thecommittee iscurrently facilitat-ingapilotprogramofDr.LindaClever’sRENEWprogramthissummer.RENEWwasdeveloped tohelpphysicians regainandsustaintheirenergy,motivation,andenthusiasmthroughallareasoftheirlives,andDr.CleveriseagertodevelopaprogramthatwillspeaktoSFMSmembers’specificneeds.

Over the next several months, thecommitteewillbediscussinganddevelopingideaswithaprofessional focus, includingtheproductionof informational seminarson topics suchaspracticemanagement,professionaldevelopment,andthedemands

oflivingandpracticinginSanFrancisco.Itemsrelatedtophysicianhealthandwell-beingthatwillbeaddressedinthemonthstocomemayincludehealthclubmemberships,personaltrainingprograms,family-friendlyactivities,andwaystosharetherichhistoryofSFMSwithitsmembersandthecityatlarge.—Therese Porter

JackLewin,MD,vicepresidentandchief executiveofficer for theCaliforniaMedicalAssociation,hasbeenchosentoactaschiefexecutiveofficeroftheAmericanCollegeofCardiologystartingthisfall.Dr.LewinwillremainwiththeCMAthroughOctoberandthenrelocatetotheWashing-ton,D.C.,area.HisfirstdaywiththeACCwill beNov.13,2006.Congratulations,Dr.Lewin!

Good News from the Membership Services Committee

Let MIEC take care of the malpractice pressures soyou can focus on your practice.

The doctors that formed this company established a business structure and philosophy that means you never have to ask yourself if you are insured with the right company.

■ We have a ZERO profit motive■ MIEC is 100% owned and governed by the doctors it insures■ 31 years of continuous service to California doctors ■ Claims Expertise. We have now resolved over 24,000 malpractice claims

and lawsuits reported by our policyholders over the past 31 years. Nearly 90% are closed without payment.

■ We carry one of the highest security ratings of A- {excellent} issued by AM Best’s

Next Steps:For more information or download an application: Go to www.miec.com "Applications & Forms" to download an application or click on “Why MIEC” to better understand our philosophy and structure.Call us: at 800-227-4527. Ask for Phanelia Hill ([email protected]) our California underwriter or Diane Major ([email protected]) / Lauren Kielian ([email protected]) our Underwriting Managers.

Does it feel like the world is closing in on you?

6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com

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MIECOwned By The Doctors It Protects.

July 2006

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Transcript of July 2006