^ /

January, 2000

Lawrence A. Larson, D.O. (left) turns over the gavel and the PCMS Presidency to Charles Weatherby, M.D. at the 1999 Annual Meeting

See story and highlights beginning on page 3

INSIDE: 3 1999 Annual Meeting - fun and festive 5 David Sparling, MD, recipient of 1999 Community Service Award 6 New Officers and Trustees to lead PCMS in 2000 7 Physicians and staff meet with insurance representatives to air grievances 9 “Retirement - What to Expect,” February General Membership meeting 11 “The Story of French Bread,” by Andrew Statson, MD 13 “The Market is Always Right...Sometimes,” by David Roskoph, MBA, CFP B u l l e t in

PCMS Officers/Trustees: C h a rle s M . W e a th e rb y , D O ...... P re sid e n t Patrice N. Stevenson, M D ...... PresidentEiect S u san J. S alo , M D ...... Vice-President J. Ja m e s R o o k s, M D ...... S e c re ta ry FT re a su re r Lawrence A. Larson, DO ...... P ast P re sid e n t Sabrina A. Benjamin, M D DrevvH. Deutsch, MD KevinK_ Gandhi, MD Michael J. Kelly, MD D o ris A . P a g e , M D E d w a rd I. W a lk le y , M D Yolanda Bruce, PCMSA President

WSMA Representatives: Speaker ofthe House: Richard Hawkins, MD Trustee: David Law, MD AM ADelegate: Leonard Alcnick, MD WAMPAC Chair/6th District: M arkGildenhar, MD W AM PAC 9th District: Don Russell, DO

Executive Director: Douglas Jackman

Committee Chairs: Table of Contents Aging, Richard Waltman; AIDS, Lawrence Schwartz; Bylaws, Richard Hawkins; Budget/Finance, Jam es 3 1999 Annual Meeting recap R ooks; College of Medical Education, W . D ale Overfield; Credentials, Susan Salo; Emergency Medical Standards, Ted Walkley; Ethics/ 5 Community Service Award goes to David Sparling, MD Standards Of Practice, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, W illiam 6 New Board of Trustees to lead PCMS in 2000 R itchie; Legislative, William Marsh; Medical-Legal, Pal Donley; Membership Benefits, Inc., D rew D eutsch; Personal Problems Of Physicians, 7 Insurers and physicians at odds due to complex systems Robert Sands; Public Health/School Health, Joseph W earn; Sports Medicine, John Jiganti. 9 February General Membership Meeting: Retirement: What to Expect The Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce County Medical Society. Deadlines for submitting 10 TPCHD:OperationSuds Handwash Program articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. October 15 for the November issue). 11 The Invisible Hand: "The Story of French Bread"

The Bulletin is dedicated to the art, science and 13 In My Opinion: "Devaluation of the Doc" delivery of medicine and the betterment of the health and medical welfare of the community. The opinions herein are those of the individual contributors and do 14 Applicants for Membership not necessar-ily reflect the official position ofthe Medical Society. Acceptance of advertising in no 15 Special Feature: "The Market is Always Right.Sometimes" way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin and Pierce County Medical Society reserve the right 17 Letter to the Edi tor: " Were You There?" to reject any advertising. 18 Welcome New Members Editors: MBI Board of Directors Managing Editor: Douglas Jackman Editorial Committee: MBI Board of Directors 19 College of Medical Education

Advertising Representative: Tanya McClain 2D Women in Medicine experiences wanted Subscriptions: $50 per year, $5 per issue Letter of Thanks from Dr. Cuevas M ake all checks payable to: MBI 223 Tacoma Avenue South, Tacoma WA 98402 21 PCMSA: The Pulse 253-572-3666, FAX253-572-2470

E-mail address: pcmswa@ pcmswa.org 22 New copying charges for Medical Records Home Page: http ://www.pemswa.org ______23 Classified Advertising

2 PCMS BULLETIN January, 2000 1999 Annual Meeting recap - a fun and festive event

At the PCMS/PCMSA Annual Meeting on December 14, 1999, Dr. Lawrence A. Larson, completed his year as President just as his father, Dr. Charles P. Larson had done 32 years ago, in 1967. Mrs. Margaret Larson had the honor of experiencing both her husband and her son lead the physician organization, formed 111 years ago. Dr. Larson passed the gavel to Charles Weatherby, M.D, w ho will serve as President in 2000. Dr. Weatherby is a family physician in Tacoma. Once again, the Tacoma Y outh Symphony Quartet provided reception and dinner music. The annual raffle was sponsored by the PCMSA with Fran Thomas (William.) and Yolanda Bruce (John) drawing the lucky names. Jan Oravetz, MD won the millennium basket, Patrice PCMS outgoing President, Dr. Lawrence A. Larson with his Stevenson, MD the gourmet basket and Yolanda Bruce mother, Margaret Larson and his wife, Mary Larson was the winner of the monthly fruit basket from the Children's Home Society. Dr. Larson asked for a moment of silence in honor of colleagues that died in 1999. They included Drs. Clarence Anderson, Cletus Stevens, Richard Link, Samuel Adams, Charles L. Anderson, William Mattson, Rodger Dille and Kenneth Sturdevant. Mrs. Fran Thomas gave the PCMSA report noting that the organization has changed to doing primarily philanthropic work such as the Holiday Sharing Card and the Annual Dinner raffle. The Baby Think It Over dolls continue to be in demand from the schools in the county, while their education efforts in domestic violence continue. She thanked everyone for their contributions of gifts for the YWC A Support Shelter. She invited membership and participation from all physician spouses. Dr. Larson introduced Mr. John Ulwelling, Executive 1999 Community Service Award recipient, Dr. David Sparling Vice President of the Foundation for Medical Excellence and and his wife, Barbara. Dr. Sparling is a retired pediatrician former Executive Director of the Oregon Board of Medical Examiners. Mr. Ulwelling spoke on Balancing the Medical Career, and his focus was on various f onns of impairment whether they be mental, physical and/or emotional. He defined impairment as the inability to practice medicine which is normally caused by a mental or physical or drug related incapacity. He shared rules of living that he claims as manda­ tory, 1) show up, 2) pay attention, 3) tell die truth. His closing thoughts were questions and he asked folks to ponder them in relation to their own life. ► What inspired you today? ► What challenges did you experience today? ► What beauty did you appreciate today? ► What are you grateful for today? Highlighting the evening was the presentation of the Community Service Award to Dr. David Sparling (see Newly elected officers, Drs. Susan Salo (left) and Patrice Stevenson. Dr. Salo will serve as Vice President and Dr. See “Meeting" page 4 Stevenson as President-Elect in 2000

January, 2000 PCMS BULLETIN 3 B u l l e t in

“Meeting” from page 3 page 5). Dr. Sparling received a standing ovation from the audience; recognition that his colleagues appreciate his endless work for the betterment of the health of our commu­ nity. Dr. Larson thanked the outgoing Board of Trustee members for their support during the year and thanked the many mem bers who are ac tive with the Society in various ways. He introduced the 2000 President, Dr. Charles Weatherby. Dr. Weatherby thanked Dr. Larson for his service to PCMS, particularly his work with insurers, trauma and access to care issues. He then specified his interest in welcoming new members to the Society, and ensuring that physicians stand together as one body against the many forces that are PCMSA members Fran Thomas (Past-President) and Yolanda working against them in this era of health care delivery Bruce (President) drew names for the raffle drawing. The frustrations .a Alliance sponsored the raffle drawing

Dr. Sian Harris (Past-President, 1997) and Debbie Bowman Dr. Jeff Jacobs, pediatric allergist/immunologist attended the (center) visit with Dr. Maria Mack (Trustee, 1998-99) and her meeting with his wife, Jan. Dr. Jacobs serves on the Public husband, Dennis Mack Health/School Health Committee

Dr. Jim Blankenship, retired Fircrest family practitioner was Tacoma Family Medicine's Dr. Jim Hubband and his wife accompanied to the meeting by his daughter, Beth Rachel attended to meet and mingle with colleagues

^ ore photos page 5

4 PCMS BULLETIN January, 2000 David Sparling, MD, honored at Annual Meeting

Retired Pediatrician receives 1999 Community Service Award at 1999 Annual Meeting

"He is a colleague that most of you know and admire," noted Dr. Lawrence Larson, as he introduced the recipient of the 1999 PCMS Com­ munity Service Award. That recipient, fellow pediatrician, Dr. David Sparling, practiced pediatrics for al­ most 40 years in Tacoma after arriving here in 1960. "He has exemplified the quality and high ethical standard of medical care that is the hallmark of this community," added Dr. Larsoa Dr. Sparling was honored for the numerous ways that he has contributed to the community. He has served on and chaired so many committees and boards over the years "we'd be here Dr. Lawrence A. Larson, (left), PCMS President congratulates Dr. David all night if we named them all," quipped Sparling, recipient o f the 1999 PCMS Community Service Award Dr. Larson. But, he did name a few, in­ cluding, PCMS, WSMA, Pierce Girls, Washington Physicians for Social county's health policies and proce­ County Pediatric Society, Washington Responsibility, and Tacoma Opera dures. For the last seven years, Dr. State Pediatric Society, American Chorus. Sparling has coordinated the activities Academy of Pediatrics, Mary Bridge Dr. Sparling is jus t ending a six of the Mary Bridge-Chelyabinsk con­ Children's Hospital and St. Clare Hos­ year term as the Pierce County Medi­ nection, an exchange of medical col­ pital. Community agencies include cal Society's representative on the leagues with Russia. FamilyService ofTacoma, Children's Tacoma-Pierce County Board of Dr. Sparling received a standing Home Society of Washington, Greater Health. This is a tremendous commit­ ovation from members as Dr. Larson Lakes Mental Health Foundation, ment of time including many meetings congratulated and thanked him for his Pierce County Council, Campfire and major decisions that direct the service.*

Drs. Vita and Ray Pliskow, anesthesiologist and radiologist New member, Dr. Todd Kihara and his wife, Eve. Dr. Kihara respectively. And, both accomplished musicians. is a vascular surgeon with offices in Puyallup and Tacoma

January. 2000 PCMS BULLETIN 5 B u l l e t in

New Board of Trustees to provide leadership for 2000

Charles Weatherby, MD Tacoma. She received her medical (President) is a family practitioner degree from Uniformed Services with MultiCare Medical Group. He University of the Health Sciences and received his medical degree from the practiced several years at MAMC. She University of Washington School of and her husband, Selvius, live in Medicine and completed his internship Olympia and residency atSt. Luke's Hospital in Drew Deutsch, MD practices Milwaukee. He and Iris wife, Shauna, withTacoma Radiology Associates. He live in University Place. received his medical degree from the Patrice Stevenson, MD University of Illinois College of (President-Elect) practices physical Medicine and completed post medical medicine and rehabilita tion in Puyallup. education at Cedar-Sinai Medical She graduated from the University of Center in Los Angeles. He lives with Washington School of Medicine and his wife, Rebecca, in Gig Harbor. completed her internship and resi­ Kevin Gandhi, MD is a dency at the VA Medical Center in Los pediatric/ adult urologist His practice is Angeles. She and her husband, Craig, in Puyallup. He received his medical live on Lake Tapps. degree and completed his internship Lawrence A. Larson, DO and residency at Loyola Stritch School (Past-President) practices pediatrics of Medicine. He and his wife, Kassy, with Pediatrics NorthwestSpecialty live in University Place. Care, specializing in pediatric allergy / Michael Kelly, MD is a family immunology/pulmonology. He gradu­ practitioner in Lakewood. He gradu­ ated from the College of Osteopathic ated from the University of Cincinnati Medicine & Surgery in Des Moines, College of Medicine and completed his Iowa. He and his wife, Mary, live in residency at Oregon Health Sciences Tacoma's north end. University. He and his wife, Bonnie, Susan Salo, Ml) (Vice- live in University Place. President) is a family practitioner with Doris Page, MD is a family Group Health in Tacoma. She earned practitioner at Allenmore Medical her medical degree from tire Univer­ Center in Tacoma. She completed her sity of Washington School of Medicine medical education at tine University of and has practiced in Tacoma for 24 Colorado in Denver and her internship years. She lives with her husband, at Mercy Hospital. She and her Robert, in Puyallup. husband, Cedric, live in Tacoma, J. Janies Rooks, MD (Sec­ Edward Walkley, MD retary/Treasurer) practices practices pediatric emergency medi­ otolaryngology in Lakewood. He cine at Mary Bridge Children's attended medical school at the Univer­ Hospital. He received his medical sity of Miami School of Medicine. He is degree from Harvard Medical School a Fellow in the American College of and completed an internship in Surgeons and American Academy of pediatrics at Children's Hospital. He Otolaryngology/Head/NeckSurgery. and his wife, Kathryn, live in the north He and Penny, his wife, live in end of Tacoma. Pictured from top left, left to right: Drs. Steilacoom Yolanda Bruce serves as Charles Weatherby, Patrice Stevenson, Sabrina Benjamin, MD President of the PCMS Alliance. She is Lawrence Larson, Susan Salo, James practices internal medicine with married to John E. Bruce, DO, Tacoma Rooks, Sabrina Benjamin, Drew Deutsch, Internal Medicine Northwest in Kevin Gandhi, Michael Kelly, Doris Page, emergency medicine physician. They Edward Walkley and Yolanda Bruce reside in Gig Harbor.

6 PCMS BULLETIN January, 2000 Complex system puts insurers and physicians at odds

E d ito r ’s N ote: The following le tte r was A meeting to allow physicians and their office staff an submitted lor comment on the cuixeiil opportunity to ask questions of insurance company represen­ difficulties experienced with plan s. tatives was very well attended, even at 7:30 a.m. Held Decem­ ber 9 at the Landmark Convention Center, the meeting Editor: featured Medical Directors, Drs. Nancy Fisher (Regence); Unfortunately, I have prior commitments on John Lindberg (TransAmerica representing Medicare); Joe December 9th that prevent my personal attendance Nichols (Community HealthInformationSysteiTis); Art at the meeting regarding insurance woes. 1 do not Sprenkle (Premera); and Dick Whitten (Health Care Author­ want to miss the opportunity to contribute my opin­ ity). ion. Attendees got right to business when a local orthopedic Physicians are at an unfair disadvantage when surgeon asked about his "scores of accounts over 90-120 days contracting with insurers. An insurance company past due" and the amazing phenomenon of rejected claims unilaterally declares the rates o f compensation for being returned quickly while authorized claims never get set'vices without negotiation and without regard to paid. Each panel member had a response to the problem and physician expertise. Physicians have all too long ac­ they all admitted there needs to be a solution, but in spite of cepted this. As a result, the insurance industry these admissions, they defended their way of doing business. ratchets back compensation rates and imposes un­ "Claims processing is very complex," noted Dr. Joe compensated burdens, such as pre-authorizations, See "Insurers" page 8 on the physician. When a supplier will accept less for his prod­ uct, a buyer will continue to drop his offer until he cannot purchase the product for the price offered. Eventually, the supplier reaches a point where the offer is unprofitable and says no to the deal. The buyer must raise his offer or lookfor a willing dis­ count supplier. This practice makes sense to busi­ ness managers. Until physicians value themselves, what motivates the insurance industry to value phy­ sicians 'sendees? I call upon every member o f the medical soci­ ety to value himself. Negotiate the line item price of each sendee you provide. Refuse to sign a con­ tract that includes unacceptable points. Dare to be Dr. Dick Whitten, left, Medical Director o f the Health Care an out of nehvork provider. Every time I have Authority (left) answered questions o f many participants dropped an unacceptable contract, my profit margin has increased. Wouldn 'tyou like your profit margin to increase likewise? Dare to be a non-provider o f Medicare. Until enough o f us do, I guarantee that the government will continue to cut back compensation. Do not be a discount supplier with a minimal or losing profit margin. Dare to make a profit. We live in a capital­ ist democracy, not a socialist country. Do not accept clauses that are unreasonable. As an example, ‘ Pre-authorization does not guaran­ tee payment. " Who created such an absurdity’? Why should a surgeon spend valuable time and assume risks without guarantee o f payment? I received a written pre-authorization form United Airlines, self- From left, PCMS President, Dr. Lawrence Larson visits with insured, performed the case and three months later Dr. John Lindberg and Dr. Joe Nichols after the meeting See "Jasper" page 8

January, 2000 PCMS BULLE I IN B u l l e t in

Insurers from page 7

Nichols, PCMS member and orthopedic surgeon previously in private practice in Tacoma. "There are many, many roadblocks along the way and the systems are complex at best." He noted that insurance companies have nothing to gain from stalling claims. They make money from reserves. "There is no solution to the problem until plans and providers sit down together and work it out/' said Dr. Nichols. There was encouragement in the legislative arena as plans will be forced via legislation to pay interest. According to the insurance representatives, this makes things worse as die added burden of paying interest only slows down the Left, Art Sprenkle, Medical Director o f Premera, talks with payment system, just as claims that are submitted more than Ron Robinson, clinic manager for Eye & Skin Associates once place unnecessary burdens. The new OIC rules regarding clean claims turn arounds increases the operating costs and slows down the processing systems, according to the plan administrators. A big issue was customer service. A challenge was made to the health plan administrators that they seriously look at this issue."You need PROVIDER customer service, not member customer sendee," Ron Robinson, office manager for Eye and Skin Associates explained. Dr. Art Sprenkle explained that Premera had over 4,000 provider changes in one month. They now have 1,400 left to do. He said they are continually looking for easier ways to accomplish their work but agreeing with his colleagues, "it is an incredibly complex system." He also agreed that plans and physicians need to work together. "Politicians are creating unrealistic expectations," noted Sprenkle. "We need to work Nancy Fisher, MD, Medical Director for Regence, explained together and all be responsive to market forces or our system to the group that Regence is studying staff workloads will implode into a single payer model," he added. There is no doubt diat frustration abounds. Insurers need to make an investment in the physician community and both 'Jasper from page 7 sides need to consider the perspective and frustration of the other. Bob Pema, WSMA Insurance Specialist summed it up received a denial o f payment. Why are we paying as "plans and physicians are used to being on opposite sides, staff to obtain pre-authorizations required by the in­ now they are both in the middle without realizing it." surer? Increase your expected compensation to ac­ The concensus of the meeting was to work together. count for this cost. Goals such as administrative simplification, claims processing Refuse to accept that disposables, such as efficiency, improved working relationships, standardizing dressings, will not be compensated. Either re-nego- systems as well as making them easier were recognized. tiateyour contracts, or have your patients sign a fi­ We need to simplify the systems and find ways for better nancial responsibility form stating that such items communication, added Dr. Sprenkle, before giving his phone may not be covered by their insurance and that they number to the attendees. will, likely be expected to pay at the time o f service. To contact any of the speakers at this meeting, you may Estimate the charge for them and collect it once call them at: provided. If one must go to the trouble o f collecting a co-pay, why not collect the entire amount? Let Nancy Fisher, MD R egence 253-573-3244 the patient fill out insurance forms and try to collect 206-971-7266 Joe Nichols, MD CHIS I am an expert in my specialty. I value Art Sprenkle, MD Premera 425-670-5832 myself. Do you value yourself? Will you Dick Whitten, MD HCA 360-923-2709 S'msurer?Slde ^ 1 Stand aSainst the mighty Joseph F. Jasper, MD

8 PCMS BULLETIN January, 2000 $(&&€& Q /fie d io a i

February General Membership Meeting

Tuesday, February 8, 2000 Landmark Convention Center Social Hour: 6:00 pm Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm Tacoma Retirement: What to Expect

featuring: Jim Early, MD Bob Ferguson, MD Ken Graham, MD David Sparling, MD

► Financial preparations ► Family/spouse considerations ► Psychological and emotional concerns ► Enjoyment of the “golden years” ► How to reap the benefits of early planning

Name: (please print or stamp) ______

Please reserve______dinner(s) at $ 18 each. Enclosed is my check for $_ OR

Charge my □ VISA □ MASTER CHG CARD #______Exp Date:.

Signature ______

I will be bringing my spouse or a guest. Name for name ta g :______

REGISTRATION REQUIRED by Friday, February 4

Return this form to: PCMS, 223 Tacoma Ave S, Tacoma 98402; FAX to 572-2470 or call 572-3667

January, 2000 PCMS BULLETIN 9 B u l l e t in \ - -...... _ _

The Health Status of Pierce County

Operation Suds Handwash Program TACOMA-PIERCE COUNTY HEALTH DEPARTMENT The Tacoma-Pierce Comity food service establishments in an effort Health Department is encouraging to curtail the rapid spread of the While counties surrounding Pierce County residents to wash their disease. The outbreak subsided and Pierce County are seeing increased hands in order to prevent disease. by 1990 the number of infected cases of hepatitis A, Pierce County is Statistics show this simple procedure individuals was a pproximately forty, well below the average number of creates important results. the yearly average for Pierce County. cases. In 1999, there were only 19 Hepatitis A follows a cyclical reported cases, well below the typical ► According to the U.S. Center pattern, reoccurring about every ten 40 cases annually. This can be attrib­ for Disease Control, "Handwashing is years. The uted to more people tine single most important means of F&CS washing their hands more preventing the spread of infection." Program often. Unwashed hands can spread diseases saw the F&CS Program staff such as hepatitis A, colds, flu, and even threat of a are available to present E. Coli. A study of coughing, sneezing, potential the Operation Suds train sinus trouble, bronchitis, fever, "pink repeat the trainer program. The eye", headache and acute asthma, hepatitis A program includes the abdominal pain, diarrhea, and vomiting ou tbreak as Super Scrub and showed there were 116.5 days of an opportunity absence in a handwashing group for prevention. Bubbles workbook, a versus 175 absences in the comparison In 1998 an handwash curriculum with instructions, songs group. extensive countywide and stories, and the free > In elem entary schools, a handwash campaign began In addition use of a black light box so participants scheduled hand washing four times a to the distribution of the original can see where germs can hid in bright day can significantly reduce absences bumper stickers, the "WASH THEM!" florescent lotion on their hands. The due to communicable illness. Rhinoviral message was delivered through: Operation Suds train the trainer particles (a major cause of colds) are program is appropriate for children or spread more effectively by hand than ► An eighteen month bus adults. by air. In an article in Family Medicine, advertising campaign In addition to the Operation Suds Master says, "Just as we insist that ► Operation Suds, an interac­ program, a self-contained mobile children get immunized, brush their tive handwash curriculum train­ handwash unit complete with two sinks, teeth, ea t healthfully, etc., w e should ing for teachers and school hot and cold running water, soap and insist that they wash their hands nurses by F&CS Food Safety paper towels has been used at several regularly." Specialists community events. The handwash unit ► Super Scrub and Bubbles may be reserved on a first-come, first- A hepatitis A outbreak in Pierce activity workbook served basis as long as the event meets County ten years ago started the ► Handwash activities at criteria outlined by the F&CS Program. department's focus on handwashing. At events and fairs For more information about the its peak in 1989, hepatitis A infected ► Development of a self- Operation Suds program or tine over 800 people. TPCHD's Food and contained handwash trailer for handwash unit, contact Diane Community Safety Program developed countywide events W estbrook atTPCHD, 798-6045. ■ and distributed "Dirty Hands Spread ► The www.gotsoap.net Disease.. .WASHTHEM!" bumper w ebsite stickers to clinics, hospitals, schools, and

10 PCMS BULLE I IN January, 2000 } ^Ptey-ce Q/fle/lical (^focwty __ X

The Invisible H and... by Andrew Statson, MD

The Story of French Bread’

"What do these people want?" "They want bread V our Majesty. They are hungry." "Bread? Can't they eat cake?" A ttributed to M arie Antoinette, Q ueen of France (1798) A ndre ir Statson, MD

Hungerwas amajor motivating The baguettes tasted much better, and interests, but that can only work to a factor for the French Revolution. One people were willing and able to pay certain extent and for a short time. of the first acts of the Revolutionary extra to get them. What finally assured the French their Government was to fix the price of The crescent rolls in France are daily baguette was the industrial bread. Their honorable intention was about one-third the size of the ones in revolution, not the edicts of the to feed the hungry. Hie result was this country. It is not because French Revolutionary Government. In the 18* famine. The price of bread was fixed in appetites are much smaller than ours. century, more than one-third of the tire government paper money, the At one time, their price was regulated workforce was in agriculture. Today it "assignats", which suffered the same as well and the market shrunk the size is about 6%. The changes were fate as our Continentals. The price was to match. Had the size been regulated brought about by mechanization, such that the fanners could not sell also, they would have disappeared fertilizers, irrigation, pest control, seed their wheat, the millers could not grind from the market. improvement, etc. I have doubts about it into flour and the bakers could not The mistake of the French the efficacy of price controls. The bake the bread, and expect to remain in business. Food riots were common in many cities; bakers, millers and farmers were accused of hoarding; stores were "This country is working under an impossible handicap while ransacked and people were killed. trying to solve the problem o f medical care for its people. It is the Eventually, the price controls were belief that equality under the law also means equality in everything adjusted and bread again became else. The only direction in which such equality can be achieved is available on the market. down. We can all be equal only when we all become beggars. ” The bakers were still faced with a problem. They were barely able to survive on the profit they were allowed to make on bread. So, for the Revolutionary Govemmentis an market probably would have done people who could pay a little more, illustration, sadly very common, of the better on its own. But it is possible that, they developed rolls and specialty arrogance of power. To make bread, as inefficient as price controls may breads that tasted better and eventually they needed plows and sickles, and the have been, they may have played a replaced the regular bread in the farmers to work them; mills and the role as a social safety net. As tine market millers to run them; ovens and the general prosperity of the population The price of bread was still bakers to tend them. However, the increased, however, the demand for regulated when I was a student in only tools at their disposal were peasant bread went down, while the Paris, living on a very limited budget. It guillotines; and they drought that these baguettes took over the market. Today came in peasant loaves of five kilo­ were enough. Unfortunately, guillo­ the only reason to want a loaf of bread grams and was a special order. In my tines can only chop off heads. They would be to make French toast. student day s, a loaf like that would see did a lot of that, but couldn tbake a The honorable intention of 2011’ me through several days and it helped single loaf of bread. century government was to take care me make it during some tough times. Of course, people can be and of the sick. In Eastern Europe, under The bakers did not have it on the shelf have been forced at gunpoint to act Communist control, medical care was because there was no market for it. against their will and against their best See “Bread” page 12

January, 2000 PCMS BULLETIN 11 B u l l e t in

its people. It is the belief that equality bread from page 11 Service developed a huge backlog under the law also means equality in with long waiting times for hospital everything else. The only direction in free. I will not bore you with the services. Private hospitals appeared which such equality can be achieved is details. If you have never been there and the people who could afford to pay down. We can all be equal only when you would not be able to imagine the the charges went there. Others went to w e are all beggars. That is the equality private hospitals in Switzerland or in primitive facilities, the pervasive Communism almost achieved in Eastern this country. In France, patients paid for shortages of supplies, the desperate Europe. Almost, but not quite, because office visits up front and were reim­ struggle of physicians and nurses to it fell apart before it could do it. We bursed a centrally determined amount take care of their patients, the crushing must learn from this experience and that, with inflation, rapidly became only burden of controls. For minor prob­ abandon the idea of economic equality. a small percentage of the actual fee. In lems many patients went to the doctor's It is not attainable. the public hospitals, they paid a home after work hours and paid out of A fully egalitarian society cannot percentage of the charges. Many small their pocket the fee for the visit. For sustain itself economically. The private hospitals and clinics, where major problems, those who had private incentive to produce is missing. Human patients paid higher charges and got funds got a permit to go to Western action is motivated by two factors, the better service, coexisted with the public Europe for treatment. The govern­ carrot and the stick. When we all are hospital system. ment was all too happy to let them go. equal, we all get the carrot, whether we This country is working under an In Western Europe, the situation w ork for it or not. It loses its effect. impossible handicap while trying to varied from country to country. In W hat is left is the stick. However, the solve the problem of medical care for Great Britain, the National Health main motivating action of the stick is to induce people to cover their rear. It only marginally can motivate them to produce, and has no effect on motivat­ ing inventions, discoveries, or any other factors that lead to economic and TACOMA RADIOLOGY social progress. Even in prehistoric times, when people lived in the same cave, sat Detect and Monitor around the same fire and ate the same food, they were not fully, totally, Low Bone Density completely equal. There were always some who slept closer to the entrance of die cave; who sat away from the Comfortably, quickly, safely smoke of the fire; and who ate the and precisely better morsels of food, or more of it. I have read statements that multi­ Assess fracture risk tiered health care is immoral. The Detect clinical changes people who advocate that should put their money where their mouth is, Monitor therapeutic response instead of forcing their morality on those who do not share it. Actually,

Heel (Peripheral DEXA) what is immoral is to obtain through Lo w risk screening pressure, frequendy with a gun not far behind. What one cannot get through is the voluntary exchange of one's efforts for the efforts of others. Under current conditions, no amount of laws, regula­ tions or mandates can assure unre­ Tacoma Lakewood Gig Harbor stricted access to high quality medical (253) 383-2038 (253)572-5174 (253) 588-6083 (253) 858-3200 care for all. Only the continued grow th ANenmore Medical Center Frank S. Baker Center Lakewood Office PointFosdick Imaging of our economy can bring the general prosperity to a level at which all of us will be able to afford the medical equivalent of French bread.*

12 PCMS BULLETIN January, 2000 In My Opinion. by Nichol Iverson, MD.

“Devaluation of the Doc”

I'm sorry. I am sic and tired of "It ain't over until the fat lady to invade the privacy of our elected listening to Joey Gallowbladder or the sings; thenit's over." officials, and rummage around in their Big Ugly Unit whine about making Dr. Yo Yo Ma offices, look through their checkbooks only and computers. We will do this ran­ seven domly, without warning and wearing million per wait, nohow. surgical gloves and masks. All the year. In the meantime, we get notices information we collect can be given to Randy like the one I received last week, well respected journals such as the Johnson asking me to send copies of my medical National Ink Wire or "Scar" newspa­ record, along with any necessary makes per. Any money that is being wasted in about five signed waivers, to a Medicare watch­ this random search and seizure will be thousand dog (half German Shepherd, half deducted from our senators, represen­ per pitch Rottweiler). My time, and the time of tatives and president's salaries. my staff, you see, has no value. As our whether it By the time this tripe is published is a strike ivicttui /1 ‘ji'son, MD government wastes bundles of money we will have survived the Y2K bug, or a ball. on projects such as polishing die launched an IPO Doctor Dolittle.com squeaky owl project, or philanderers Guaranteed! Who cares if you can't and created virtual hospitals. Patients win in the playoffs? And all of this for peace, we are stuck wasting our will visit their holographic physicians money is for the terrible and onerous time and energy in order to make some e.g. Dr. Yahoo, HD, and all psychiatric bureaucrat look good. Having the mind task of playing a game. Society has help can be obtained on the Internet at completely lost its sense of values. sharp as an antique adz, I have come www.vouarenuts.nut. Lest all of you Perhaps. up with a scheme to divert attention think that I am a total cynic, you are away from our day to day hassles, and Agents for doctors. Can you invited to apply to my "school ofthe have some fun, too. imagine the kind of money that really future".. .Morons ofMystery,whichis We can demand the opportunity important people, such as superstars or available at the above web site. Presidents would pay if they could access the playing field of "Superstar Doctors of America"? Clearly having the opportunity for physicians to become free agents for somebody like O rgan S^Tissue Paul Ailing, founder of Mindersoft, and owner of the Seattle Freefallers Football franchise. As different teams of doctors around the country begin to assemble and form leagues and divisions, they would need to have some sort of playoff format, competing for the best outcomes. As the competi­ tion to build the best teams begins to increase, we will finally see the Share Your Life. potential for free agency. Physicians Share Your Decision will be traded, and new draft choices from medical schools will be auctioned For more information on organ and tissue donation off and given signing bonuses of ten or please call UfeCenter Northwest twenty million dollars. I can't hardly toll free, 1-877-275-5269

January, 2000 PCMS BULLETIN 13 B u l l e t in

Applicants for Membership

Aversa, Marc L., MD Donner, Charles S., MD Momah, Kingson I., MD Family Practice Gastroenterology C ard iology Practices at South HOI Family Medicine, Practices at Digestive Health Practices at Cardiac Study Center, 1901 390810* St. SE, #200, Puyallup 98374; Specialists, 1901S Union, #B4006, S Cedar, #301, Tacoma 98405; 572-7320 848-5951 Tacoma 98405; 272-5127 Medical School: University of Nigeria Medical School: Brown University Medical School: University of Internship: New York Hospital- Residency: Valley Medical Center Heidelberg Medical Center at Queens Residency: University of Illinois Residency: Montefiore Medical Center Christopherson, Chad R., MD Fellowship: University of Tennessee Fellowship: University of Connecticut C ardiology Fellowship: Stanford University Fellowship: University of Practices at Cardiac Study Center, 1901 Massachusetts S Cedar, #301, Tacoma 98405; 572-7320 Hamill, Lisa V., MD Medical School: University of South Internal Medicine Stegman, Roger J., MD Dakota Practices at2420SUnion, #100, Internal Medicine Internship: Mayo Clinic T acoma 98405; 403-4444 Practices at Lakewood Clinic, 11311 Residency: Mayo Clinic Medical School: Loyola Stritch Bridgeport Way SW, #100, Lakewood Fellowship: Rush University University School of Medicine 98499; 581-6688 Internship: University of New York Medical School: Tufts University Das, Sumit K., MD Health Science Center Internship: Montefiore Hospital Neurosurgery Residency: Hershey Medical Center Residency: Maimonides Hospital Practices at Neurological Consultants Fellowship: Anderson Hospital of Washington, 1802 S Yakima, #306, Lee, Donald, MD Fellowship: University of Washington Tacoma 98405; 627-7338 Internal Medicine Medical School: University of Practices at the Lakewood Clinic, 11311 Taggart, Kevin W., MD Michigan Bridgeport Way SW, #100, Lakewood Family Practice Internship: M t Sinai Hospital 98499; 581-6688 Practices at South Hill Family Medicine, Residency: Mt. Sinai Hospital Medical School: Univ. of Wisconsin 390810* St. SE, #200, Puyallup 97374; Fellowship: Texas Children' Hospital Residency: University of Iowa 848-5951 Medical School: University of Pierce County Medical Society Califomia-Los Angeles Internship: Valley Medical Center Medical Placement Service Residency: Valley Medical Center

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14 PCMS BULLETIN January, 2000 Special Feature by David Roskoph, m b a , c f p

“The market is Always Right...Sometimes”

If you're somewhere in the vicin­ money in our banking system through rates and earnings. All diings being ity of a television or radio you're sure a normal operation that seeks to en­ equal - when interest rates go down, to know that the stock market has sure an expansion of money in pro­ the market becomes a better value. reached an almost magical status, en­ portion to growth in the economy. Conversely, when interest rates go thralling everyone The caution sign reads: too lose a up, the market becomes overvalued. with its prodigious credit policy can create an artificial Thus, when interest rates were cut daily performances. and unsustainable bubble. The latest three times in the summer of 1998, the Rarely does a day go figures on U.S. consumer spending market took off. The Federal Re­ by that something, com show a steady increase in the spend­ serve raises short-term interest rates hasn't quintupled on its ing of disposable income. In fact, con­ to control the growth of the opening day and the sumers are now spending 102% of economy. The curiosity of a rising venerable NASDAQ their disposable income as reported in market against an environment of ris­ indices made another David Roskoph. the September 1999 issue of the ing interest rates raises a caution flag new high. If you're MBA. CFP Economist. The creation of excessive to experienced investors. On the not in, you're lament­ credit and its attendant bloated money earnings front, corporate earnings ing each day that heralds another in­ supply inflates something. The Fed­ have traditionally detennined stock crease in someone else's portfolio. It's eral Reserve is particularly scrupu­ value. The relationship between the up, up and away and with little to noth­ lous about monitoring monetary infla­ price of a stock and its earnings has ing to slow it down because the U.S. tion since they control die money sup­ been reduced to a ratio known as economy has entered a "new era" with ply. The purchasing power of the dol­ price to earnings or PE. U.S. PE's the advent of the Internet revolution lar is not deteriorating through infla­ have historically found their level Right? tion. Consumer price inflation is being between 10 to 15. In other words, if a Every once in a while, including suppressed by the new and viciously company earned $1 it would sell for now, the parameters of our financial competitive frontier of die Internet. $10-$15 per share. As its earnings markets get stretched. The present Wage inflation is being held in check grew, so too would its share price. stretch began when an already exu­ botii by the soothing effect of rising Now, however, it is almost impossible berant stock market met the Internet. pension accounts and the absence of to even measure die PE's of many Not only was the Internet the place to job security. People are not paying tech stocks since they have no earn­ invest, it also became the medium for more for goods, employers are not ings. I estimate the PE of the that investment. A new generation of paying more for labor but investors NASDAQ Composi te at 175 and die investors was introduced to the market are paying more for financial assets. A NASDAQ 100 at about 280. The best through on-line trading. Somewhere in bubble has been created in financial measure ofthe overall market, the the turmoil, traditional measures of mar­ assets through an incredible expan­ Standard & Poor 500 is around 36. ket valuation (once again) became ir­ sion of credit. Financial bubbles are The only explanation that makes any relevant, largely because anything, by nature unsustainable and can only sense to me is that of a lottery mental­ com meantinstantprofitwithoutrisk. be deflated in two ways: 1) a decrease ity. Investors must feel that if they Take a minute to think about the in the asset's value or 2) a substantial buy everything, a few companies will changes in our financial world beca use reduction in interest rates. The Fed­ increase many times while most are things are remarkably different than at eral Reserve is more likely to raise in­ consumed or fade. Either there is a any other time. When were you able to terest rates further in2000 as a result new paradigm or an extremely over­ mortgage 125% of your home's equity? of a booming gross domestic product valued market exists. If more money How about receiving credit card offers (GDP), a 30 year low in unemploy­ keeps poring into financial markets every week or the opportunity to buy ment and rising energy costs, which withoutregard to earnings, these goods with 0 % interest for up to a makes a market correction the odds- trends will continue. If, however, the year? Though ubiquitous now, these on favorite. King feels a draft, look for a rapid are signs of an extraordinary expan­ Without getting too technical, correction. market valuation is tied to interest sion of credit. Creating credit creates Sec “ M arket” page 16

January, 2000 PCMS BULLETIN 15 B u l l e t in

------6 0 “M arket” from page 15 STOCK VALUATION MODEL*M ODEL- -5 5 " (percent, daily) - 50 With popular indexes soaring to ^ 12/14 new levels each day, the media would -45 have you believe that the economy -40 -35 has arrived at a new level of con­ r / / H f : 3 0 - , J 1 I I ■30 sciousness. This argument has been * - v,V , I* 1 ■25 offered before, be skeptical. The 20 stock market has been legitimately ris­ 20 - , /I 'i1 (; (l 15 ing for many years as a result of in­ 1 \W. ; t IMill, fi 10 creasing productivity and tame infla­ 5 - 1 OverpricedO v e r p r i c e d 5 tion. In other words, companies are 0------U------h —------0 5 |Jj i|| UnderpricedUnderpriced more efficient, their profit margins f t / -5 stable and consumption of their prod­ 10 1 V -10 ucts strong. In a bona-fide, sustainable •15 - -15 -20- -20 market advance, however, there is -25 - -25 broad market participation. Market i a n l n t i .t orrr ,30 J ------j------l_ -30 bread th indicates the number of com­ II III IV 1 I II III IV 1 ! II 1998 1999 20 0 0 panies participating in a market's rise. ■ Ratio o( S& P 5 0 0 in d e x to 1/8 /E/S consensus estim ates o( earnings over the com ing 1 2 m o n t h s Until last summer, (a critical intersec­ divided by the 1 0 -year U S Treasury bond yield minus 1 0 0 . tion in U.S. fiscal policy), there was a strong correlation between rising in­

dexes and market breadth. In other 20000 -3700 words, the economic tide was still com­ NASDAQ STOCK M ARKET INDEX VS BREADTH 10000 •3500 ing in and most boats (stocks) were ris­ 0 3300 ing. Then came the anxiety over Rus­ -10000 - 3100 sia, Brazil and the threat of an Asian Vv'\. contagion. In an effort to avert a glo­ -20000 '•A A 2900 bal panic, our Federal Reserve dra­ -300 0 0 V*\ 2700 matically expanded credit by lowering -4 0 0 0 0 - 2500 interest rates three times inrapid suc­ -5 0 0 0 0 - 2300 NASDAQ Breadth* cession. The result was a somewhat -6 0 0 0 0 2100

curious split in the economic tide. A •7 0 0 0 0 . A\ 1900 NASDAQ Price Index growing majority of companies began -80000 1700 to lose buoyancy while a select group -90000 1500

began a meteoric ascension. A global - 1 0 0 0 0 0 - 1300 panic was averted but the breadth of V\ -110000 - U .S. markets began to turn negative 1100 •120000 and the majority of companies were no V. 900 -130 0 0 0 longer getting stronger. 700 Presently a mania grips the mar­ • Breadth is m easured by subtracting the num ber of declines from the num ber of advances ket with an insatiable appetite for and adding the result to that ol (he previous day. duvdnce:*. anything.com. Each day's rise in the popular market indexes stretches eco­ nomic realities further. Since the atmosphere. As of 12/15/99, tradi­ (NYSE) new higlis to new lows as ris­ broad market has been declining for tional measures of value are ing interest rates. By most traditional over a year, the indexes are being stretched well past reason for the measures tliis is a bear market not a pulled higher by an ever-narrower few remaining market leaders, with bull. Be careful before throwing out group of companies. Simply stated, very optimistic growth projected into 100 years of market history in defer­ only a handful of stocks are actually the hereafter. Other traditional mea­ ence to yet another "new era." ■ advancing and their ranks are dwin­ sures of market health are also sour. dling. This can not continue indefi­ Included are the Dow Jones Trans­ DavidRoskoph, MBA, CFP is a nitely; either the broad market re­ portation and Utility indexes, the ra­ fee-based investment advisor in verses or the few meteors re-enter the tio of New York Stock Exchange Gig Harbor

16 PCMS BULLETIN January, 2000 Letter to the Editor by Mrs. Loma Burt

Were You There?

Editor's Note: The following letter wax were there to hear their analysis of Doctors are now referred to as submitted after the November GeneraI what is happening in the field of "health care providers." A mother who Membership Meeting by Mrs. Loma medicine and what they know about bandages a child’s skinned knee is a Burt, wife o f Retired Member. Dr. HMOs condescending to give doctors heal tli care provider and she didn't Robert Burt more freedom of choice in the treat­ spend 15 years going through college, ment of their patients. medical school, internship and specialty A stunned silence swept over the The garbled responses were training! assembled audience of doctors and inadequate in my opinion and we were Once, in the past, before most guests at the PCMS general member­ a disappointed group who left the present doctors were bom, Tacoma ship meeting onTuesday, November meeting. had a trauma center and one of the 9. It was time for the program they Once home, I couldn't sleep. I finest health care systems of the time. wished that Emily Walker, who was a were anticipating. Pierce County Hospital (now Puget "Nice turnout," one doctor reporter for the News Tribune many Sound Hospital) was Tacoma's commented as they arrived for the years ago as "Our Gal in Washington Harborview. It was staffed with meeting and gathered by the bar. "It's D.C." could have been there. Emily excellent nurses, interns, residents and the free food," said another. One of the spent many years in our nation's capital staff doctors representing every "golden age" doctors lamented that and kept us informed of what was specialty. These doctors gave freely of really so few of the 700 or so physi­ going on in matters of health care. She their time for the poor, who couldn't cians in Pierce County were there and feared that something was happening pay, and gave immediate attention to all that he missed the rapport, the competi­ to reduce our fine medical care system; trauma victims. tive spirit, and camaraderie of his era. a socialist movement, which she called, But along came the "great President Larson introduced the " the camel's nose under the tent." society" and the government decreed it speakers, three editors from the News I was President of the Auxiliary was not dignified for the poor to be in a Tribune, who shall remain nameless for (now the Alliance) at the time and we county hospital, therefore welfare and the purpose of this article. They, in could see it coming. There were health poor patients should have the same turn, re-introduced themselves, research organizations around the privilege as others and be allowed to explained their particular jobs at the country. We sent a representative to go to private hospitals at tax payers paper and that was all. They simply meetings held in Tacoma to find out expense. asked, "Are there any questions?" what it was all about. She reported that Perhaps the doctor's dilemma of The quiet was deafening. Finally, these health care organizations were the present cannot be changed, but the one person in the back of the room gatheringinformationand statistics and stranglehold on die doctor's position as spoke up for all of us and told them we were frantically trying to spend all of far as using their judgment in the the government grant money so they management of patient care, allowing could get more; therefore they were more hospital time, etc. could be eased. producing reams of non-essential So, rally around, you M.D.s.. .you do TACOMA/PIERCE COUNTY paperwork. Our "goldenage" doctors have a voice and it is called the Pierce were too busy caringfor patients to see Outpatient General Medical Care. County Medical Society. This is YOUR whatwas happening. organization. Attend the meetings and Full and part-time positions I feel sorry for this younger work together to better your position in available in Tacoma and vicinity. generation of doctors - giants in stature; the medical community and give your Very flexible schedule. Well suited but helplessly caught in a spider web patients the best care. Why not make for career redefinition for from which there seems to be no Tacoma an exemplary city in health GP, FP, IM. extrication. In this kind of situation care for others to follow. Give the perhaps a certain apathy sets in and a newspapermen something worthwhile Contact Andy Tsoi, MD (253) 752-9669 resignation to be eaten in small bites by or Paul Doty (Allen, Nelson, Turner & to write about. Make your voice the spider takes over. Assoc.), Clinic Manager (253) 383-4351 heard.. .USE IT,.. .DON'T LOSE IT.«

January, 2000 PCMS BULLETIN 17 New Members

Becker, Nicole R., MD Hoefle, Stephanie F., MD Petrin, James H., MD P ediatrics Family Practice Dermatology Practices at Pediatrics NW, 316 MLK Practices at MultiCare, 225-176th St. S., Practices at Puyallup Dermatology, Jr. Way, #212, Tacoma 98405; 403-1419 Spanaway 98387; 552-4777 1706 S Meridian, #140, Puyallup 98371; Medical School: University of Medical School: Louisana State 841-2453 Pennsylvania School of Medicine University Residency: Texas Tech Medical School: Univ. of Washington Internship: Children's Hospital of University Health Science Center Internship: University of Washington Philadelphia Residency: University of Washington Residency: Children's Hospital of Johnson, Anthony G., MD Philadelphia Family Practice Rynes, Richard I., MD Fellowship: University of Washington Practices at 9332 Bridgeport Way SW, Rheumatology Fellowship: Rush Children's Hospital Lakewood 98499; 403-4460 Practices a t4905108™ St. SW, Medical School: University of Lakewood 98499 Edgoose, Jennifer, MD California Irvine Medical School: Univ. of Pennsylvania Family Medicine internship: University of California at Internship: University of Michigan Practices at Community Health Care, Davis Residency: University of Michigan 9112 Lakewood Dr. SW, #230, Residency: University of California at Graduate Training: Harvard Lakewood 98499; 589-7030 Davis University School of Medicine Medical School: Columbia University Internship: University of Washington Residency: University of Washington Dates Program Directors) Cardiology for Primary Friday, January 21 Gregg Ostergren, DO Personal Problems Care of Physicians Wednesday - Sunday CME @, Whistler Richard Tobin, MD February 2-6 Medical problems, drugs, alcohol, retirement, emotional, Advances in Women's Friday, February, 11 John Lenihan, Jr., MD or other such difficulties? Medicine Thursday-Friday Internal Medicine Robert Corliss,MD Your colleagues March 9 & 10 Review 2000 want to help Monday - Friday CME @ Hawaii April 10-14 Mark Craddock, MD

*Robert Sands, Chair 752-6056 Saturday, April 29 Surgery Update 2000 Virginia Stowell, MD Bill Dean 272-4013 F. Dennis Waldron 265-2584 Asthma, Allergy & Friday, May 5 Pulmonology for Alex Mihali, MD Primary Care Confidentiality Nuts, Bolts & Assured Friday, June 2 Innovation: Gary Taubman, MD Gastrointestinal Richard Tobin, MD Disease V

18 PCMS BULLE I IN January, 2000 COLLEGE Continuing Medical Education MEDICAL ***** (Five Star) Hapuna EDUCATION Hotel is site for Hawaii CM E The Hapuna Beach Prince Hotel, 2000. Reservations can be made by on 32 acres edging on Hapuna Beach calling the Hapuna directly at (800) at the Mauna Kea Resort,(hailed as 882-6060. You must identify yourself "one of the world's 10 best"), is the site as part of the COLLEGE OF MEDI­ for the CME at Hawaii program for the CAL EDUCATION group. Cardiology CME year 2000. The College was able to se­ Those planning to attend should cure a "world-class resort" at greatly also secure air transportation. To as­ registration open reduced rates. Registrants may benefit sure you are able to secure seats and from our negotiated group rates for get a reasonable price, vve urge you Registration remains open for the ocean view rooms starting at $180. A to make your reservations NOW. A College's fifth annual program featur­ second adjoining room for children small refundable deposit will hold ing subjects on cardiology for the under 18 is available at $50 below the your seats. primary care physician. The program group rate. The College is working with will be held on Friday, January 21. The To take advantage of these sav­ Marilyn at Olympus Travel (565-1213). course director is Gregg Ostergren, ings, you must make your reservations Olympus has booked some seats at DO. soon. THE COLLEGE'S RESERVED group rates and has access to other Call the COME at 627-7137 to BLOCK OF ROOMS WILL BE RE­ special options at the bestrates. Call register. LEASED AFTER FEBRUARY 9, Marilyn today.

"First” Advances W m m m w m z. in Womens Medicine CME '-yrj set February 11 J’L W ^ ^ ^ Sy 'ft? The College of Medical Education's "first" program focusing on 9 women's medicine is scheduled for Friday, February 11,2000. Dr. John Lenihan,Tacoma O b/G yn, is the program director. This one day program will ad­ dress a variety of timely subjects rela­ tive to contemporary medicine for women. Designed for the primary care physician, this new CME program will feature issues related to diagnosis and treatment advances in treating ill­ Whistler CME registration open ness in women. Registration continues to be open conference is scheduled for February The program brochure will be for the College's popular CME at 2-6,2000. Can the COME at 627-7137 out in mid-January. Whistler/Blackcomb program. The for more information.

January, 2000 PCMS BULLETIN 19 B u l l e t i n

Women in Medicine experiences wanted

The University of Washington is models who have gone before them to seeking your experiences of what i t see how they have patterned their has been like to be a woman physician. lives and how they have made their III What professional challenges have choices. you faced? How have you balanced This book will focus directly on career goals with family needs? the field of medicine, as opposed to the Dr. Eduardo Cuevas, Via request from Eliza Chin, MD multitude of works addressing the internist in Tacoma, and his an Assistant Clinical Professor of experiences of motherhood, childcare, family wishes to extend Medicine at Columbia University, they career and marriage. their deepest appreciation to are collecting stories, poems, personal The deadline for publication is anecdotes, essays and words of advice February 28,2000. Please submit both a colleagues and friends for for publication in a book. hard copy and disc, including the their unselfish support, Dr. Chin believes that women face author's name, address, phone number prayers and encouragment unique challenges, in such an all- and e-mail address. Contributions will during his recent battle consuming profession, particularly be acknowledged by e-mail or post­ against cancer. He is when balancing work and family card. responsibilities. She says she regularly Send to: Eliza Lo Chin, MD expected to fully recover encounters medical students and Asst Clinical Prof of Medicine and be back to work soon. residents who are grappling with Columbia University competing concerns of career and 16 East 60th Street, Suite 330 family. And, they are looking to role New York, NY 10022

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20 PCMS BULLETIN January, 2000 0^iewee ^Qowithj- oM eduxd Q ^ociet^

The Pulse PCMS Alliance Presidents YWCA thanks PCMS and PCMSA Message The YW CA of Tacom a-Pierce C ounty thanks Pierce C ounty Medical Society & Pierce County Medical Society Alliance for their generosity and love at this season of caring Membership is down to seventy four and volunteerism is at an all time low. The board is pondering the future The YWCA thanks you for your the YWCA transitional housing of the Alliance and it's role in our support of our Holiday Giving Pro­ program community. As Medical Society gram. Your contributions give warmth ♦to fill a void for women and membership increases, the Alliance and a sense of a shared community to children who have left everything membership is decreasing. It is YWCA clients. behind in their escape from domestic extremely difficult to plan projects and The donations you have made will violence programs without the support of our be used to brighten the holidays of In the spirit of holiday giving and members. It is obvious the Alliance is women and children alike. Your the next century - and in the tradition failing to meet the interest of its donation might be destined: of New Year's resolution, we ask you members. The board will meet on ♦to be chosen by a young child to continue volunteering your time and Tuesday, January 18 at 9:30 a.m. at the for her mother spirit to the YWCA of Tacoma and PCMS office to evaluate the problem ♦to be chosen by mom for her Pierce County during the first 11 and seek solutions. Please plan to young son months of the year. attend. If you are unable to attend, ♦to be given to a single woman We thank you for your generosity please e-mail your thoughts and reclaiming her life this holiday season and look forward to comments to me [email protected], ♦to be given to a family that is in you being part of the YWCA family fax to 253-265-8298 or call me at 253- next year. 265-8190. It is imperative that we hear from you, especially from members who made the decision not to renew their membership. Help us change the Holiday Sharing Card update direction of the Alliance. A big THANK YOU to the have a feeling when this young lady Yolanda Bruce members of the Alliance and the reaches her peak your Alliance card PCMS President Society for so generously supporting may turn out to be quite valuable! our annual fund raiser. Once again it Thank you volunteers: Yolanda was a great success. The total amount Bruce, Nikki Crowley, Mary Cordova, Annual Meeting raised was $14,890, with 231 families Fran Thomas, Dot Truckey, Rubye participating. Ward, Loretta Macha, Kris White, raffle drawing Donations received after the Helen Whitney, Sue WuLfestieg and November deadline: Alice Yeh. raises funds Tim & Lael Duncan Many of your donations were Nichol & Joanne Iverson accompanied by cards and notes of PCMSA raised $436from the sales George & Helen Kittredge appreciation for the work we do. of raffle tickets at the Annual Meeting Ja me & Hugh Moore Those of us who remain active in on December 14. Raffle items included Cecil & Denise Snodgrass Alliance are very grateful for the a gourmet basket, a millenium basket, Steven & Doreen Yamamoto support we receive from the medical two wine baskets and a monthly fruit community. basket. Each year we strive to have On behalf of my colleagues on the The meeting was a festive way to quality art work for our card. This year board of the Alliance...Thank you! begin the holiday season. If you were in particular many of you were unable to attend this year, hopefully we impressed with the talent of Miss Mona Baghdadi, Co-chair will see you next year. Laura Yu. Hold on to your '99 card. I Holiday Sharing Card

January, 2000 PCMS BULLETIN 21 V B u l l e t in

Did You New copying charges for medical records Effective July 1,1999 pursuant to WAC 246-08^00 and RCW 70.02.070, the fees Remember? that physicians can charge for searching and duplicating records cannot exceed:

Copy charges: $.79 per page, first 30 pages

.60 per page, all other pages

Clerical fees: $18.00maximum

Certification of Record: $200

WAMPAC Editing by the physician personally: Basic office visit charge (when required by statute) Washington Medical Political Action Committee Under the Uniform Health Care Information Act, a Washington statute govern­ ing access to and disclosure of a patient's health care information, physicians must 1800 Cooper Point Road SW release a copy of tine patient's records to the patient or any other health care Bldg 7, Suite A provider, except under certain conditions, when the patient has signed a release Olympia, WA 98502 form. 800-562-4546- (360)352^848 For a copy of the statute, call PCMS, 572-3667.

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22 PCMS BULLETIN January, 2000 fooim ty Q/Uedical Society

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Specializing in treating movement and ...a multi­ mobility problems, as occur in Stroke, MS, Allen more disciplinary Head Injury, and Parkinson’s Disease. jSL Psychological behavioral Paul D. Hansen, Ph.D., P.T. health group Associates, P. S. that works 1105 Regents Blvd, Suite C with physicians Fircrest, WA 98466 ■ 752-7320 ■ (253) 565-7796 Do you have patients with difficult emotional Fax: (253) 565-7836 and stress-related problems? Psychiatric and Email: [email protected] psychological consultations are available. 1-Hesseetal. Arch Phys Med Rehnbil 1994;75:1087-1053 2-VisLntin et al. S tro k e 1998.29:1122-1128 Union Avenue Professional Building ______1530 Union Ave. S.. Ste. 16. Tacoma

January, 2000 PCMS BULLETIN 23 B u l l e t in

er Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether it’s a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and in the future, is to help physicians, clinics, and hospitals remain successful. ■P Physicians ■" Insurance Western Washington 1-800-962-1399 A Mutual Company Eastern Washington 1-800-962-1398 Oregon 1-800-565-1892 hmuIc, W A (O Physicians Insurance 1999

Pierce County Medical Society PRESORTED 223 Tacoma Avenue South STANDARD Tacoma, WA 98402 U S POSTAGE PAID TACOMA, WA PERMIT NO 605 Return service requested

24 PCMS BULLETIN January, 2000 February, 2000

Board Retreat brings health care leaders together

From left, Drs. Don Russell, Susan Salo, Jim Rooks, Len Alenick and Mike Kelly

See highlights beginning on page 5

INSIDE: 3 President’s Page: “Medicine in the Millennium” 4 In Memorium: Dr. & Mrs. Hazelrigg pay tribute to Dumont Staatz, MD 5 Board of Trustees leam from Pierce County health leaders at January Retreat 9 “Viral Hepatitis in Pierce County,” are you informed? 11 L & I Task Force working to improve claim process 15 “The Health Status of Pierce County,” by Health Director Federico Cruz-Uribe, MD 23 PCMS Alliance Board recommends disbanding to their membership B u l l e t in

PCMS Officers/Trustees: VPie/Ke 'flofm lij Q/Heduxd (Society CharlesM . Weatherby, M D ...... P re sid e n t PatriceN. Stevenson, M D ...... President Elect Susan J. Salo, M D ...... Vice-President J. James Rooks, M D ...... Secretary /Treasurer Lawrence A. Larson, DO ...... P a st P re sid e n t Sabrina A. Benjamin, MD February 2000 Drew H. Deutsch, MD Kevin K. Gandhi, M D M ic h ael J. K e lly , M D D o ris A . P a g e , M D Edward 1. W alkley, MD Yolanda Bruce, PCMSA President

VVSiVIA R e p r e s e n ta t iv e s : Speaker of the House: Richard Hawkins, MD Table of Contents Trustee: David Law, MD AM A Delegate: Leonard Alenick, MD WAMPAC Chair/6th District: M arkGildenhar,M D 3 President's Page: Medicine in the MHennium W AM PAC 9th District: Don Russell, DO

Executive Director: Douglas Jackman 4 In Memoriam: Remembering Dumont Staatz, MD

Committee Chairs: 5 Retreat offers education for PCMS Board of Trustees Aging, Richard Waltman; AIDS, Lawrence Schwartz; Bylaws, Richard Hawkins; Budget/Finance, Jam es R ooks; College of Medical Education, W . D ale 9 Viral Hepatitis in Pierce County Overfield; Credentials, Susan Salo; Emergency ] Medical Standards, Ted Walkley; Ethics/ 10 February General Membership Meeting Standards Of Practice, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, W illiam R itchie; Legislative, William Marsh; Medical-Legal, 11 L&I Task Force has worked to improve claims process Pal Donley; Membership Benefits, Inc., D rew D eutsch, Personal Problems Of Physicians, Robert Sands; Public Health/Scliool Health, Joseph 12 Go shopping on Support/WyAssocia tion.com W earn; Sports Medicine, John Jiganti. 13 The Invisible H and:" Fee for Service" The Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce County Medical Society, Deadlines for submitting 15 TPCHD: The Health Status of Pierce County articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. 16 1999 Physician Directory changes October 1 5 for the November issue). How to recycle used PDRs

The Bulletin is dedicated to the art, science and Safe Handgun Storage brochure available delivery of medicine and the betterment of the health and medical welfare of the community. The opinions 17 InMyOpinion...."MeetDr. Rocker" herein are those of the individual contributors and do not necessarily reflect the official position of the Medical Society. Acceptance of advertising in no 18 Fee Policy recommended by Medical/Legal Commitee way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin 19 hrMyOpinion..."Finding Beauty in Annie" and Pierce County Medical Society reserve the right to reject any advertising. 20 WSMA Physician Leadership Conference set for May Editors: MBI Board of Directors WSMA thanks you for your membership Managing Editor: Douglas Jackman Editorial Committee: MBI Board of Directors 21 College of Medical Education: Get ready for Hawaii Advertising Representative: Tanya McClain Subscriptions: $50 p e r y e a r, £5 p e r issu e 22 Legislative Health Clinic needs volunteers

Make all checks payable to: MBI 223 Tacoma Avenue South, Tacoma WA 98402 23 PCMSA: Alliance to vote on dissolution 253-572-3666, FAX253-572-2470 25 MD License Renewal and CME Requirements change E-mail address: pcmswa@ pcmswa.org Home Page: http://www.pcmswa.org______27 Classified Advertising

2 PCMS BULLETIN February, 2000 Presidents Page by Charles Weatherby,

Medicine in the Millennium

What do we have to look forward to in the coming years? The AMA House of Delegates has endorsed the unionization of practicing physicians. The National Labor Charles Weatherby, MD Relations Board (NLRB) has let it be known that they are PCMS President going to support the unionization of interns, residents, and fellows. With the steady decline of hospital admissions and inpatient care days, hospitals are becoming more involved with outpatient care services. As a result of this situation, hospitals spent the past several years employing physicians and acquiring private practices. Recently, however, the pendulum is swinging the other way, with physicians returning to private practice. We are also starting to see the merger of multiple heal tli insurance companies. The contracts that we are being asked to sign are becoming more complicated and more one­ sided. (To the benefit of the health insurers, of course.) It seems that physicians are always being "asked" to take a decrease in our reimbursements. These contracts are requiring us to have MBAs or JDs just to interpret them or are requiring us to hire people with those degrees to interpret the contracts for us. My medical training didn t prepare me for this. Some physician specialty groups are refusing to sign some of these contracts. Do their refusals, in effect, invalidate some of these contracts because the necessary specialty panel required by the State Insurance Commissioner doesn't exist? Can the office of the State Insurance Commissioner enforce the regulations regarding the pool of physicians necessary for a health insurer to operate within a specific geographic area? Will this requirement force the heal th insurers to interact more posi tively with physicians? Our state legislature is considering legislation regarding a patient "Bill of Rights." This will even permit patients to sue their HMOs. Our WSMA is preparing for its CURE campaign. This is a media program that will promote physicians to the public in a very positive light. What does all this mean? It's going to become more difficult to practice medicine "in the old way." Physicians are going to have to become more knowledgeable and cognizant of the forces that determine how physicians practice. Unfortunately, our busy practices preclude our involvement in dealing with some of these important issues. However, our voices need to be heard. That is why it is very important that we continue to support organized medicine; AMA, WSMA, our own PCMS as well as our respective specialty organizations.*

February, 2000 PCMS BULLETIN B u l l e t in

IN MEMORIAM

DUMONT STAATZ, MD

Those who knew Dr. Dumont Staatz personally nearly always described him as energetic and a man in a hurrv. He was impossible to pigeonhole though because he was also a man of contrasts so divergent as to be startling. Professionally, Dr. Staatz was a well established orthopedic surgeon who was highly respected by his colleagues. He was interested in rehabilitation orthopedics and especially in helping patients who suffered from the effects of polio. He was president of the Northwest Orthopedic Association and a member of the Tacoma Rotary Club. He traveled repeatedly to India and Ethiopia and on the ship Hope teaching local physicians orthopedic technique. Dumont was an avid sailor. He also spent many happy hours restoring his antique Pierce Arrow. His personality was vivid. He had a bluff hearty exterior but expressed an inner sympathy for his fellow beings by sharing his skills. He cared for his invalid wife for several years prior to her death. He loved world travel but at the same time he was a solid member of the community, serving on the Advisory Committee of the Centre at Norpoint. He was highly distinguished professionally but at the same time he played Santa Claus with relish since 1994 for Norpoint's Annual Santa Breakfast. He was a serious thinker but loved the bonmot and apt witticism In the neighborhood he was noted for small kindnesses. He gave many rides to and from the airport, he took out neighbors garbage cans and brought in neighbors mail. When the awesome task of buying a wedding present fell to him, bluff Dumont courageously braved the china department and bought our daughter's gift. Seeing the gift and knowing Dumont brought tears to her eyes. Those of us who live on the same road remember him roaring down the street drag strip style. "Here comes Dumont!" someone would say. Yet if he saw my husband in tire yard, surprisingly, he would slam on the brakes and pass the time of day, seemingly unhurried. The conversation over, his car would lurch ahead resuming speed and disappearing over the hill. We would stand there a moment and someone would say, "There goes Dumont" It seemed somewhat of an oxymoron that Dumont was a twin because he was definitely one of a kind- intelligent but funny, competentbutkindly, eminent but unassuming. Dumont became unexpectedly incapacitated with a heart ailment on Tuesday and by Thursday, he was gone. We couldn't believe it. We had just talked to him. We had plans with him for the future. We reminisced abou t a friendship that spanned 45 years and eventually somehow his departure began to seem consistent with his flamboyant style. He had a full life. He had a highly recognized career, a dear wife and five wonderful children And whenit was time to go, true to form, Dumont had simply left in a hurry.

Jim and Carol Hazelrigg

4 PCMS BULLETIN February, 2000 'ipw /nty oM edim l (^fouefoj,

Retreat offers healthcare education for PCMS Board

PCMS Board hears about the future of healthcare from local hospital leaders

At the 2000 Board of Trustees Retreat held on Satur­ day, January 8 at Fircrest Golf Club, representatives of each hospital system gave, from their perspective, an overview of the future of health care in Pierce County. Panelists George Brown, MD, VP Acute Care, MultiCare; Mark Gregson, CEO, Puget Sound Hospital; Ed Miller, CEO, Good Samaritan Hospital and Joseph Wilczek, President & CEO, Franciscan Health System agreed on several issues, one being the changes in hospital/ physician relationships as well as the shift in the competition for dollars. Many hospitals believed tha t they could work with primary care providers (PCPs) to direct health care and with From left, hospital administrator panelists. Joe Wilczek and payers to get better reimbursement rates. This did not occur Mark Gregson representing Franciscan Health System and and "we are now paying more to monitor the system than the Puget Sound Hospital, respectively system is saving," according to Joe Wilczek. He said, Franciscan Health System, his employer, purchased Western Clinic, developed an infrastructure, and secured 98,000 capitated contracts that initially lost $6.5 million and ultimately $38 million. Today, they have decreased their losses from $142,000 per physician to $40,000, and hope that by 2001 will meet the break-even point. "We will be joint venturing with specialists," but it is clear, noted Wilczek, "physician deals will be dissolved over the next three to five years." Good Samaritan Hospital's CEO, Ed Miller, agreed, "hospitals will be pulling back from employing physicians, no doubt," he said. Hospital/physician relationships have changed, with more hostility and competition, and he believes that "as long as reimbursement ra tes remain low, competition for dollars will continue." With physicians needing to be more efficient and From left, hospital administrator panelists, Ed Miller, Good withdrawing from hospitals, hospitalists are helping to cover Samaritan Hospital CEO, and Dr. George Brown, Multicare, patients. Mark Gregson explained, "providers will be pushed VP Acute Care to keep up with growth in all specialties, more hospitalists induded." And, there continues to be bad news for an industry already in trouble. In 1999,21 hospitals/health systems had their bond ratings down graded, which decreases their access to capital. Margins have dropped, with the average hospital operating with a 1.2% margin. "You need afour to six percent operating margin to do good business," noted Wilczek. "Things will get worse," he added. Competition and challenge were words used freely throughout the discussion Panelists agreed that the Internet will provide additional competition as consumer expectations are increased. Both referral advice and office visits will try to be replaced by on-line services. "Providers will be pushed to remain competitive," said Gregson. Challenges will be numerous, as each presenter discussed several, including PCMS President, Charles Weatherby, MD, consults with Dr. Lynn Hankes, MD before his presentation at the Retreat See "Retreat" page6

February, 2000 PCMS BULLETIN 5 B u l l e t in

Retreat from page 5 county, could be frankly detrimental to their outcomes," he issues such as reimbursements, medical mistakes, a new noted. For the remainder of patients, this system creates sig­ trauma system, pain management, Wall Street, staffing, nificant problems for continuity of care and social support training/ technology and federal government regulations, structures. particularly fraud & abuse vulnerabilities. George Brown, He believes MD believes that significant challenges will be "providing f: that Pierce County measurable outcomes that can be shared in efforts to hold the I provides him with a public's trust" and " the challenge to re-invest in our own t "golden oppiortu- facilities." He added that the competition of billing and coding :; nityW ith a govern­ will be significant and that anyone that" doesn't get" billing and mental mandate, a coding will be in trouble. political mandate and Creativity' and change were words frequently used in a popular mandate summary. There is no doubt that these leaders believe that he sees an opportu­ the status quo will not remain. "There will be more changes nity to create some­ ahead," noted Gregson, while Miller believes "we have to thing of lasting value develop new relationships and creative ways of working in this community. together." Dr. Brown sees "shared risk and equity models," as | "With the pieces all the next step, because you " have to watch the bottom line in gathered, the chal­ addition to outcomes." But hopefully, physicians can hold one Robert Winchell, MD lenge will be figur­ change at bay because Wilczek believes, "economic ing out how to put credentialing would be disastrous." them all together," he said. New trauma director looking forward to In response to questions from participants, Dr. opportunity in Pierce County Winchell admitted that he had never seen a community that had the luxury of saying no to tine provision of trauma care. Dr. Robert Winchell addressed the Board of Trustees at The situation is "unusual, going on unique," he quipped. For­ their retreat after just five days on his new job as Director of tunately, the mandate for the development of a trauma system Trauma Services for the Pierce County Adult Trauma Sys­ is larger than the few who oppose it. tem. He began big, philosophically, with an overview that pic­ He compared and contrasted the San Diego system tured medicine as an industry versus medicine as a ministry. with Pierce County. He explained that in San Diego County, As an industry, a person with an injured spleen and an empty trauma patients are a " target population." Due to the prevail­ wallet should be left on the street. As a ministry, everyone ing medical economics, their care is relatively well-reim- gets all the care they need provided for them regardless of bursed compared to other populations. With such a closed fi­ the cost. "In fact, the current approach is not going to work in nancial market, provision of trauma care has been profitable the long run," he added. "As a society we have some very dif­ for the hospitals involved. In San Diego, physicians don't ficult decisions to make. What is the industry piece, what is the avoid being on the trauma panel, they fight to be there. For ministry piece and how will we all support that," he said. many physicians in Pierce County the financial rewards are A self-described "trauma zealot," Dr. Winchell said he not perceived to be worth the efforts. Another obstacle for could cite numerous reasons why trauma needs to be ad­ some surgery sub-specialists is ending up with full responsi­ dressed as a public health issue. Trauma is the leading cause bility for the patient s care from the time they do surgery. Dr. of loss of life and productivity in the young, and a major Winchell leassured participants that the new trauma delivery health care issue across all age groups. An organized system system will take full responsibility for the patient from the time approach to trauma care has been shown to reduce prevent­ ey are transported until they go to rehab. If a sub-specialty able deaths and improve outcome. Dr. Winchell just left a sys­ surgeon is called in, they will be expected to evaluate the pa­ tem in San Diego County, with five adult hospitals (one Level tient, perform the required medical procedure, and provide I, four Level II) serving 3.5-4 million people, that is arguably appropnate follow-up, but will not be responsible for continu­ one of the best long-standing county operated systems in the ing inpatient care. The trauma team will provide the inpatient country.. continuity of care. "To say that Pierce County does not have a trauma sys­ "There is no question that a trauma system will change tem is not correct," he said. "There is a trauma system, but it is than'13*" w3fa''ten^f neuro orthopedic surgeons more sub-optimal. For 7-10% of trauma patients, this system, which ^an ^ybody said Dr. Winchell, when asked about trauma includes long transport times to a trauma center outside the coverage for these two specialties. "Tlus can be a blessing or

See " Retreat" page 7

6 PCMS EULLETIN February, 2000 o4iedical (Sfocieihf-

Retreat from page 6 a curse depending on what their individual practice looks Washington Physicians Health Program like," he added. We axe working with the various expanding, becoming more proactive, and subspecialists to arrive at an optimum solution. focusing on stress related issues "One of the blessings for me is that the hospitals are working on ways to provide incentives for sub-specialists to participate," said Dr. WincheU. "It is not an insolvable prob­ Lynn Hankes, MD, reviewed the successes and failures lem," he added. during his tenure as Director of the Washington Physi­ When asked about the effects of Pierce County's trauma cians Health Program (WPHP) and discussed current system on Harborview, Winchell noted, "We anticipate build­ trends. He is ing a co-operative relationship with Harborview, which re­ beginning his eighth mains our tertiary referral center. As envisioned in the Wash- year of assisting ingtonState plan, Pierce County's trauma center and troubled physicians Harborview each have primary responsibility for their own in Washington State. geographically separate region. Our trauma center will pro­ The program vide a level of patient care that is second to none." began in 1986 and has evolved over the years. In 1999 Director of Health speaks on Health there were 539 Department activities and ‘health’ of participants in the Pierce Comity program, with 179 under contract and Federico Cruz-Uribe, MD, MPH, Director, Tacoma 360 cases in devel­ Pierce County Health Department, gave his perspective on opment. The vast the health of Pierce County, particularly in light of the majority of the disastrous effects that Initiative 695 had on the Health professionals under Department's budget. "MVET (motor vehicle excise tax) contract are MDs. Of caused the loss of 50% of our general fund," he lamented. "At the 179,143 are MDs, 23 are PAs, 3 are DOs, 2 are DPMs, the Health Department, we're not so concerned with market and 8 are DVMs. WPHP offers a five year contract and then forces, butpolitical forces," he explained. clients have an option to stay in the program voluntarily on a Not one to be discouraged, however, Dr. Cruz said they year to year basis. About 60% choose this option. Of the 179 are the same agency, just smaller. "We spent just ten percent contracts, 150 are voluntary and 29 are mandated by a on prevention when I first came and we continue moving Commission or Board. toward 90%, but we're not quite there yet," he noted. The In 1999 there were 108 inquires to the WPHP compared Department continues work on their three priorities, which to 93 in 1993." While steady, this is not what we predicted," are violence, tobacco and alcohol within their operational said Dr. Hankes. "We thought that health care reform with its framework of assessment, prevention and partnerships. attendant stress would generate a lot more calls," he said. Dr. Cruz believes they are proving that partnerships Although the number of calls have not changed, the charac­ work. They turned over their Tuberculosis Clinic medical ter of the calls has. They added a category to their roster for care to Infections Limited while they continue to provide "difficult doctor" about a year and a half ago and in 1996 prevention services, and they have partnered with several began treating physicians with just pure mental illness, community clinics to provide direct care. CHC, SeaMar, without any chemical involvement. These two categories CCPC and the PLU Wellness Center now make up the have skyrocketed wi tin psychiatric calls doubling and difficult choice of community clinics for underinsured and uninsured doctor calls tripling in the last year. WPHP is not funded to Pierce County residents. The clinics totaled 26 providers in implement a program for these " difficult doctors" but is 1999 as opposed to just nine in 1995. exploring resources. Dr. Cruz reviewed statistics on access to care (See Between January, 1993 and December, 1999 total TPCHDpage 15).These statistics have helped his staff tailor program participants have increased 254% from 152 to 539, programs and activities within the realities of Pierce County. including a 75 % increase in contract cases and a 620% "The most difficult aspects of setting a prevention framework increase in cases in development. "We continue to expand," is to use tactics that you know will work and to know the he noted. realities of your own community," noted Dr. Cruz. Unfortunately, he reported the bad news as well." On See "Retreat" page 8

February, 2000 PCMS BULLETIN 7 B u l l e t in

Retreat from page 7

my watch, we've had three deaths, I'm sad to say," said Dr. Hankes. Two occurred after program discharge. "We know we are not going to win them all but when we don t, it is very sad," he added. Dr. Hankes expressed two major concerns. One is the extremely high level of discontent among physicians. "Physicians frequently tell me, 'If I could do something else, I would'" he said. The second is the adverse relationship which currently exists between hospitals and physicians. Mental illness is surfacing, chemical dependency relapses might be increasing, health-care change is difficult to handle, and many doctors are angry and abusive. Physi­ From left, Drs. Jim Rooks, Len Alenick and Mike Kelly study cians know very little about self-care as they are their packets in preparation for the day's speakers trained to take care of others. He said, "Asking for help and providing it are almost mutually exclusive." WPHP is trying to become more proactive and focus on stress related issues. "The program has recently signed a new contract with the state for almost six years." This will allow us to develop long-range strategic plans," said Dr. Hankes. Additional speakers at the day long retreat included John Coniff, Deputy Insurance Commissioner, Managed Health Care, and John Gollhofer, MD, WSMA President. Mr. Coniff said the Office of the Insurance Commissioner (OIC) has little power as to how insurance companies do business. The OIC does review contracts and will continue to do so and he sees no reason why plans can t have standard provisions. He noted that they are working to get a handle on ■' # ■ network adequacy. The way it currently works is that each plan must publish their ownnetwork adequacy. The Office of From left, Board members, Drs. Lawrence A. Larson, David the Insurance Commissioner (OIC) monitors them to make Law, Kevin Gandhi, Drew Deutsch, and speaker, Dr. sure they comply with their own requirements. Federico Cntz- Uribe

He believes physicians should demand: what i t would provide: ♦ impartial and quick review of disputes ♦ access to health care for those who need it ♦ competent reviews ♦ heal tli care financing that rewards quality ♦ external reviews for big cases ♦ health care delivery that honors diversity ♦ the right to sue plans ♦ more money spent on care than on management ♦ a new process for cutting edge medicine Dr. Gollhofer spoke of common problems and needs for Patients should demand: solutions shared by all physicians. He noted that physicians, ♦ right to choose care more than ever must not become adversarial, but recognize ♦ enough health care professionals the need to focus on common issues. He reported that the ♦ care in the right place economics of medicine is the worst ever as many practices are ♦ providers with the right skills going broke, particularly in rural areas where it is very ♦ the power to make decisions difficult to say no to patients." The WSMA CURE campaign is working to help with several issues of concern to physicians," The regulatory role should include saying NO to bad said Dr. Gollhofer. The CURE campaign will work to plans, bad networks, bad practices and bad contracts and YES decrease the cost of transactions and increase the cost of to putting consumers first "We must spread the risk without payments, and will accumulate data on physician income to hurting access to care," added Coniff. give to payers to give them perspective that perhaps they In closing, he outlined an ideal health care system and have been unable to see, he added.*

8 PCMS BULLETIN February, 2000 Viral Hepatitis in Pierce County

by Alan Tice, MD; Karen Mottram, R]N; Frank Lyons, MD; Tim Schubert, MD; James DeMaio, MD

Viral hepatitis is not a new disease ment, which has been a "sentinel site" liver disease-such as acetaminophen, but it is emerging as one of the most for the study of viral hepatitis by the lipid lowering agents, and cardiovascu­ significant infectious diseases in our CDC for over 20 years. Information on lar medications. community. Recent methods of identi­ viral hepatitis in Pierce County has If they appear to have active fying the viruses responsible and the been published in many prestigious liver disease and are interested in potential for effective treatment as well journals. treatment, further investigations with a as interruption of transmission to others What does viral hepatitis mean to measurement of viral load and possibly make it worthy of review. you as a practitioner? First, make sure a liver biopsy may be indicated. De­ In brief, hepatitis A, B or C vi­ you and all of your staff are vaccinated pending on those findings, the age of ruses cause most hepatitis. Hepatitis A is epidemic and usually self-limited. Fortunately, there is a good hepatitis A “When it comes to patient care, think more of asking vaccine available for those at risk and with chronic liver disease. Chronic patients about whether they ever used parenteral hepatitis B causes cirrhosis and hepato­ drugs or inhaled cocaine - even if it was 30 years ago mas but is being controlled by vaccine and they never had a clinical case of hepatitis. Also ask use. Hepatitis C was only recently if thev ever had a blood transfusion before 1992...” identified by a blood test which became available in 1992. It appears to infect about one in a hundred Americans and is only now surfacing as a major public against Hepatitis A and B if they are at the patient, the genotype of the virus, health problem in the population who risk. Also be sure you have instituted and the insurance company, treatmen t abused drugs or received contami­ procedures and protocols to prevent with interferon or antivirals for a year nated blood transfusions over the last and to manage needle sticks or punc­ may be indicated. 20 or 30 years. Hepatitis C is now ture wounds when they do occur. Referral to local specialists may known to cause chronic disease like When it comes to patient care, also be helpful to obtain advice about hepatitis B but usually without any his­ think more of asking patients about therapy and possibly obtain medica­ tory of an acute illness. It usually pre­ whether they ever used parenteral tions that may not otherwise be avail­ sents when a patient develops cirrhosis drugs or inhaled cocaine-even if it was able. New oral agents and long-acting with it's complications of encephalopa­ 30 years ago and they never had a interferon injections (one shota week) thy, intestinal bleeding or ascites. Cir­ clinical case of hepatitis. Also ask if may soon become available on re­ rhosis may develop without consis­ they ever had a blood transfusion be­ search protocols. It is also of value to tently abnormal liver function tests. In fore 1992 when the blood banks began enter patients into these studies so that addition, there are complications with screening for hepatitis C. Some blood we may promptly assemble the data and patients who are co-infected with mul­ had a 10 % chance of being contami­ learn more of what treatments are most tiple agents such as Hepatitis C, Hepati­ nated a few years ago. Also check valuable and how we should best use tis B, HIV and Hepatitis D virus in addi­ your chemistry screening panel for el­ the med ications we have. tion to other medical problems which evated liver function tests, especially If you have any questions about may contribute to liver disease or com­ alanine amino transferase (ALT). Even hepatitis, please contact the health de­ plicate therapy. minor abnormalities may be significant partment or your local gastroenterolo­ What is also new is the potential as it is a slow, smoldering infection gist or infectious diseases specialist. ■ to treat hepatitis B and C through sev­ which may go unnoticed until cirrhosis How to contact the authors: eral oral and parenteral medications or hepatic encephalopathy appear. Dr. Tice or DeMaio: that have become available. Unfortu­ If you find a patient with viral Infections Limited, 627-4123 nately, the medications are expensive hepatitis, ask about continued alcohol D r. L yo n s: and often toxic. Fortunately, there are or drug abuse, which are essentially Digestive Disease Center, 272-8664 a number of resources in our county, contraindications to the potentially Dr. Schubert: which can help with patient evaluation toxic and expensive medications avail­ Digestive Health Specialists, 272-5127 and management. This includes the able. Also check for medications they Karen Mottram, RN: Tacoma-Pierce County Health Depart­ may be receiving which may cause TPC Health Department 798-6546

February, 2000 PCMS BULLETIN 9 V B u l l e t in

invites you and your spouse/guest to the

February General Membership Meeting

Tuesday, February 8, 2000 Landmark Convention Center Social Hour: 6:00 pm Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm Tacom a

Retirement: What to Expect

featuring:

Jim Early, MD Bob Ferguson, MD Ken Graham, MD David Sparling, MD

► Financial preparations ► Family/spouse considerations ► Psychological and emotional concerns ► Enjoyment of the “golden years” ► How to reap the benefits of early planning

Name: (please print or stam p)______

Please reserve______dinner(s) at $18 each. Enclosed is my check for $ OR Charge my □ VISA □ MASTER CHG CARD # c _ ------Exp Date: Signature ______

I will be bringing my spouse or a guest. Name for name tag:

REGISTRATION REQUIRED by Friday, February 4

Return this form to: PCMS, 223 Tacoma Ave S, Tacoma 98402; FAX to 572-2470 or call 572-3667

10 PCMS BULLETIN February, 2000 Qdbduxd ofow tff

No Medical Input to Dept, of Labor and Industries

The following letter was written by Dr. tional rehabilitation. In December, In 1999 the enthu siasm of the task William Ritchie, MD, Tacoma ENT. Carol Britton, RN, the 1ME project di­ force members declined and only four who has chaired the PCM S L& l Task rector and nurse consul tant with tire meetings were held. Tine same con­ Force for the last three years. The Department of Labor and Industries, cerns that had been aired previously letter was sent to M aty Kay O 'Neill, gave a broad overview of the proce­ were re-discussed. Mr. Pema informed MD, Chair, WSMA Industrial dures for the annual 32,000 IMEs per­ us of the new WSMA Physicians Com­ Insurance and Rehabilitation formed in the state. plaint Fonn. I personally submitted two Committee. As a result o f the letter, The task force met only five times separate complaints that illustrated a Drs. Ritchie, David Judish, Jeff in 1998. Dr. Franklin attended the April fru s tra ting proced u re used by tine De­ N acht and Mark Tomski will be meeting and discussed the difficulties partment. Tine response by the Depart­ meeting with the WSMA Committee on with the independent medical evalua­ ment, in effect, stated, "That's the way it February 16. All of them have served tions. His particular concerns were the is," with apparently no understanding on the PCMS L&I Task Force since its quality of IME exams, the training and that a change in procedure would alle­ inception. The letter addresses the certification of examiners, tine appro­ viate the problem. frustration the Task Force members priateness of the IMEs, and the fee In our lastmeetingof 1999, the have with L&I. schedules. He did remind the task question as to tine future direction of force of the magnitude of trying to cre­ the task force was raised. Tine consen­ Dear Dr. O'Neill: ate change within the bureaucracy of sus was, the task force had few, if any, the Department of Labor and Indus­ substantive accomplishments. Procur- In the fall of1996, discussions with tries. In June of 1998, Dr. Lee Glass ingan updated phone list of personnel Helen Vandergriff, a Nurse Consultant was introduced to the task force, and to contact at tine Department, and get­ for the Department of Labor and In­ we were encouraged when he indi­ ting acquainted with tine nurse consul t- dustries in Pierce County, led to the cated that he would like to bring the ants and supervisors have been help­ formation of a task force group that at­ medical perspective back into its ful, but committee members were frus­ tempted to improve communication and proper role at the Department of Labor trated with their inability to be more the working relationship between the and Industries. A significant attempt to useful. This is why we requested tine Pierce County medical community and improve communication between medi­ opportunity to present to your commit­ the Department of Labor and Indus­ cal offices and the Departmentwas ini­ tee our frustrations with the system. tries. The group was comprised of in­ tiated. A poll of tire offices in Pierce Our frustration is not directed at the terested physicians, medical office per­ County indicated tha t a t least 25 to 30 personnel of the Department of Labor sonnel, and representatives of the De­ individuals felt it would be informa­ and Industries. There are many well- partment, including Helen Vandergriff tional if medical office staff could meet informed and helpful employees work­ and A1 Dunham. Hie first meeting was on a one-to-one basis with the Depart­ ing with physicians and physicians' of­ held on October 1,1996, and several is­ ment of Labor and Ind us tries staff, in­ fice personnel. Tine problem is that sues and concerns were identified. cluding claims managers, in an attempt many procedures and policies of the These included IMEs, consultations, to leam Department procedures and Department do not made medical pre-authorizations for procedures, bill­ improve communication. Tine individu­ sense, and delay treatment of injured ing issues, access to claims managers, als were willing to travel to Tumwater. workers and makes tine claims adjudica­ coding problems, and the volume of The Department rejected this idea be­ tion process difficult. Changes to poli­ claim loads for claims managers. Two cause they were too busy training new cies and procedures of tine Department more meetings were held in 1996. claims managers. are needed. We do not pretend to The task force met eight times in On December 7,1998, Bob Perna, know how these changes can come 1997. The problems were discussed, Doug Jackman, and Dr. Ritchie trav­ about, but changes mu st be made to im­ and a great deal of time was spent on eled to Tumwater and met with Assis­ prove the treatment of injured workers return to work delays and IMEs. In tant Director Doug Connell and sev­ in this state. March, Bob Pema attended the meet­ eral members of the Department staff. ing and helpfully informed the task Dr. O'Neill and Dr. Stockbridge were ACTIONS: force about the activities of the WSMA in attendance. A discussion on numer­ This task force strongly believes L&I Committee. Dr. Stockbridge at­ ous problems was held, but nothing of that there needs to be an increase of tended a meetinginNovember of 1997 substance occurred because of this and was helpful in explaining issues, in­ medical influence in the claims process. meeting. cluding a provider bulletin on voca­ See L&t page 26

February, 2000 PCMS BULLETIN 11 =— B u l l e t in

Go shopping on SupportMyAssociation.com

ATTN: PCMS MEMBERS: each purchase made by their member. With ONLY 24 hours in PCMS Membership Benefits, Inc., For your office supplies compare (MBI) the Medical Society for-profit the costs at Office Max, Staples and At subsidiary recently affiliated with Your Office. At Your Office has free the day, WHEN do SupportAA-Assodation.com (SMA). At next day shipping on any order over this website you will find PCMS's $25 and a best price guarantee. YOU SHOP? customized area. It takes only seconds AtYourOffice.com is considered by to register, hi the "My Shopping" area, many to be the best source for office over 200 of the world-wide-web's top supplies available. merchants are consolidated into one, Check out companies such easy to use shopping portal. As a as Dell Computer, JCrew, member, you receive an array of PetsMart, Priceline, Barnes & promotions and specials. Noble, DrugStore, 800 Flowers Every time you make a purchase, and more. If you don't see your PCMS/MBIwill earn a percentage of favorite merchant you can go to each qualifying sale. the "Suggest A Site," area and A sampling of the categories of recommend it. items available through SMA include You may also access apparel, auctions, auto, baby, books, SupportA^'Association.com via the business / careers, computers, electron­ PCMS home page. Go to ics, appliances, financial, flowers, wine, [email protected] and click health / beauty, gifts, hobbies, home / on the SupportA^ Association.com garden, office, pets, music, recreation, logo. sports and fitness, travel and toys and Online shopping is the future games. Need a book? Over six of retail. SupportMyAssodation.com bookstores to choose from. You can provides PCMS the opportunity to compare prices with competitors in take advantage of this trend. PCMS minutes and have it delivered right to leadership understands the If you have any questions or would your front door! importance of non-dues revenue like additional information about Each association has their OWN to forestall increases in dues, SupportMyAssodation.com, please call shopping site and will receive a and voted to align with SMA as a the Society office, 572-3667. commission (based on vendor) for trial venture. Happy Shopping! ■

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12 PCMS BULLETIN February, 2000 The Invisible Hand.. by Andrew Statson, MD

“Fee for Service”

There have been many criticisms of fee for service, but hardly any defi­ "Every abuse ought to be re­ nitions of just what is being criticized. formed, unless the reform is more The major objection has been the per­ dangerous than the abuse itself." verse incentive. It claims that physi­ Andrew Statson. MD cians have the incentive to perform Voltaire (1764) more services, even though not needed, so they can get paid more. costs, but are not fully responsible for they pay the same amount for each Very little mentionhas been made of them. However, the patients have a visit, no matter how extensive it may the patients who request, and expect to strong incentive to keep the costs be. gettheseservices,no matterhowmuch down, because the higher the charge, No copay. The patients pay noth­ they may cost, when they do not have the more money they have to pay. ing. The insurance pays up to the maxi­ to pay for them. Insurers have discov­ Therefore they have the incentive to mum allowable. Hie main question ered that the restrictions imposed on shop around for the best price and the these patients have about any treatment patients have not been well accepted, best quality they can get. Compared to is whether it will hurt. They don't care so they decided to shift the burden and simple fee for service this system in­ how much it may cost the responsibility to the physicians. creases the demand for medical ser­ The criticisms of fee for service They used the gate keeper approach, vices and their price. There are two are directed to the last three types, and which did not work well, and now the reasons for this. First, the patients value only marginally, to type 2. Simple fee capitation approach, which will not the services according to their out-of- for service is a free market transaction work well either. pocket expenses. That determines of value for equal value. When the There are five types of fee for their decision to purchase a service. transactions are distorted by insurance service, and the difference between Since they get some reimbursement, payments, there is room for misuse and them is significant The common com­ their personal expenses are lower, so fraud. That may be on the part of the ponent of all is that the physician per­ their demand for services goes up. physicians, who may attempt to get what forms a service and gets paid a fee. Their demand for better quality ser­ they consider a more reasonable com­ The variable aspect is in w hat the pa- vices rises also because they are better pensation by using higher codes for tientpays. able to afford them. Second, the higher their services than warranted. It also Simple fee for service. The physi­ demand tends to increase the price. may be on the part of the patients, who cians treat, the patients pay the fee. Percent copay. Typically the in­ w ant tests, procedures or medications There is no third party. The patients surance pays 80% of the fee up to a on the basis of what they have seen on are aware of the costs and are directly maximum allowable, the patients pay television or read in the popular maga­ and fully responsible for them. The pa­ the balance. Hie patients are aware of zines. Since their monetary cost is very tients determine, on the basis of their the costs, but their incentive to keep little, and frequently does not depend wishes and their resources, what and them dow n is at the 20% level. They on the cost of the treatment they get, how much will be done. These transac­ are more likely to want a service, since they tend to request the more expen­ tions consist in the exchange of value they only pay one fifth of the cost. sive tests, procedures or medications for equal value. If the physicians Flat copay. The patients pay a set withou t having a dear indication for charged more than the services were amount. The insurance pays the bal­ them. The factors that make them limit worth to the patients, they could look ance, up to a maximum allowable. The their utilizations are the risks, side-ef- for a better value someplace else, or patients usually are not aware of the fects and complications; the pain and decide to forego the service. costs of any one service and have no disability; and the time they^ will have to Upfront payment with reimburse­ incentive to shop for lower cost, or to spend in connection with the treat­ ment. The patients pay the fee and file request a lower level of service. They ments. a claim. The insurance reimburses a flat may want to cut down the number of Yes, such a system is subject to amount. The patients are aware of the visits, but not their complexity, since See "Service" page 14

February, 2000 PCMS BULLETIN 13 B u l l e t in

Service from page 9 functions like a statutory law system. complex, dynamic, fairly predictable Societies are complex, dynamic organ­ abuse. A simi lar problem exists with and adaptable. The judges rule on the isms, both orderly and chaotic at the manufacturer warranties and car insur­ basis of the knowledge and the circum­ same time. The possibilities are end­ ance. There must be outright fraud by stances of any individual case. There is less. No laws or regulations can cover repair shops, charging for things they an oversight mechanism. When they did not do. I don't know how common them all. There will always be unfore­ judge wrong, it affects only one case. seen situations, new developments, un­ that is. Much more common, I suspect, Statutes are not only more likely to be expected individual variations and odd is the repair of defects, dents and wrong, but when they are, they affect loopholes. This is even more likely in scratches that people usually would not die entire society and cause much die field of medicine than in society at have done, except when the charges more damage. are paid by someone else. large. The basic problem with the cur­ One of the greatest contributions The problem with health care is rent system is that it squeezes people more complex, because there is a large England has m ade to civilization is the who are honest, while encouraging the development of a working modem gray area, where a wide range of op­ others to cheat. Patients c a n get care if conimonlaw system. The origin of com­ tions are acceptable. The insurance they scream loudly enough that diey companies have tried to limit services mon law goes back to biblical times (" In need it. Since there are no laws without to what is medically necessary, but the those days there was no king in Israel; loopholes, cheats can still play the sys­ definition of medical necessity has everyone did what was right in his own tem and grow rich. A system that en­ eluded them. They have devised eye"-Judg21:25). The beauty of the courages such behavior and penalizes elaborate systems of coding and cross­ commonlaw system is that it matches honesty cannot survive for very long. checking. They have studied distribu­ the characteristics of society itself. It is It is on the road to self destruction. ■ tion curves of diagnoses, and related them to services. A whole industry lias grown around the development of pro­ grams to track health care services. At the same time another industry caters to TACOMA RADIOLOGY die education of physicians, their staff and hospital personnel on coding and billing requirements, so that they can Detect and Monitor get paid for what they do and avoid trouble widi the law. Low Bone Density The recent fraud investigation in California is j ust one example of how vulnerable such a system can be. In or­ 1999 Physician's Guide to der to prevent abuse it is forced to es­ Prevention and Treatment tablish detailed rules, which make it of Osteoporosis cumbersome and inefficient. At the

same time it has to be suspicious of ev­ by the N a tio n a l Osteoporosis erybody, including the majority of phy­ Ffnimiution in coifuborarioii with .Aiiii.*nuin Acu.tarty uf OrthnfMc.-iiiL Sirfrgeims sicians and patients, who are honest, .\iTUTkcm AuiJiiTn P/ivsum/ jVlaiiiJiU’ looking on them as guilty, expecting irni /u'/u.iMjidfinu A w v u tin n 0/ Gin/La! EnJi them to be able to prove at any time Ci 0/ O/ytanVfWtis that they are innocent. The overhead I.ij K,nlf'olii£y costs of such a system are staggering. (..id/cji*! Of ft/luumuM/ory GiTwmcs Vn'ift} Recently United Healthcare admitted Saeu'ty/i.jr l !Lict\ quests alone cost them over one hun­ dred million dollars per year. What about their other costs? How mudi Tacoma does it cost on our end? Lakewood (253) 383-2038 Gig Harbor This system, largely established (253) 572-5174 (253) 588-6083 Allenmore Medical Center (253) 858-3200 by law and loaded with regulations, Frank s. Baker Center Lakewood Office Point Fosdick Imaging

14 PCMS BULLETIN February, 2000 The Health Status of Pierce County

In January 2000, the Director of race or ethnicity shows that the largest the Tacoma-Pierce County Health group (17%) are people who are black TACOM A-PIERCE COUNTY Department, Federico Cruz-Uribe, (non-hispanic). Approximately'10% of MD, MPH, made a presentation to the uninsured are white (non-hispanic). HEALTH DEPARTMENT Pierce County Medical Society. The Hispanic people make up about 8% of foH owing summarizes thattalk. uninsured people. The focus of the Tacoma-Pierce In three different surveys, cost death and illness. Prevention priorities County was the number one reason given for include: tobacco use reduction alcohol Health not accessing healtli care. This was misuse reduction, and violence Department followed by concerns about getting an prevention. has changed appointment, hours of services, and not The prevention work is multi­ from knowing where to get care. Transpor­ faceted, informed by research and is providing tation problems created a slight barrier, population-based rather than consisting limited as did personal beliefs and language. of one-on-one services. The Health clinical When asked how long it had Department's work is sustained services to: been since their last routine check-up, through the communi ty, including Assessment about 65% of Pierce County residents private providers. Federico of commu­ surveyed reported it was less than one Highlights of each prevention Cruz-Uribe, MD nity needs year. About 10% said it had been more priority plan include the following: and assets, than five years since their last physical. The Tobacco plan will increase the prevention of illness and death, In Pierce County, almost 70% of effectiveness of current tobacco laws partnerships with community organiza­ residents surveyed said they go to a and policies; reduce tobacco experi­ tions. physician's office or private clinic if mentation among youth; reduce What's the health status of Pierce they are sick or need health advice; exposure to environmental tobacco County within which the Health almost 10 % use an HMO or prepaid smoke; and decrease the smoking rate Department is doing this? One area to group; about 5% said they access care among adults and you tin. Providers can consider is access to health care. The through a community/ migrant clinic. participate in this plan by holding brief, following statistics cover the 1995-1998 Community health centers in in-office interventions with smokers. time period. Pierce County are critical partners with The Alcohol Plan will reduce the In Pierce County, almost 60% of the Health Department to address the availability of alcohol to underage insured residents surveyed are needs of the indigent. There are four youth; reduce the incidence of covered by insurance paid by their clinic systems, each governed by a drinking and chiving: develop and employer; about 20% are covered by local board: Community Health Clinics, strengthen community networks; and Medicare; Medicaid covers another Community Clinics of Pierce Coun ty, increase screening and brief interven­ 5%; 5% of individuals buy their own SeaMar and Pacific Lutheran Univer­ tions. Private providers can participate insurance; and 10% are covered by sity. In the twelve clinic sites across the in the alcohol plan by identifying military or Indian Health or some other county within the systems, the provid­ alcohol misuse among patients and insurer. ers are on salary. The Health Depart­ referring them to cessation programs. About 11% of Pierce County ment has invested clinical care funds in The Violence Plan will promote residents have no health insurance the systems and has seen a steady the increased use of the Domestic coverage, approximately 8% of women growth in their capacity to serve Violence Helpline; promote safe and 13% of men. For those households indigent clients. Over the last three storage of firearms; support early without insurance, 25 % have an annual years, their clinical load has almost childhood and family programs and income of $15,000 or less. doubled. services; and strengthen efforts to People who are 18-24 years old This investment and partnership reduce adolescent suicides. Private make up 25% of uninsured people. in community health centers has providers can help by identifying and Those who are over 65 years old make allowed the Health Department to referring victims of domestic violence up less than 5% of uninsured people. operate a prevention framework, to and by referring patients who have Comparing uninsured people by change those behaviors which lead to guns to places where locking devices are sold. ■

February, 2000 PCMS BULLETIN 15 B u l l e t in

1999 Physician How to recycle Safe Handgun Directory used PDRs Storage changes Does your office have old A new brochure about the Physician Desk Reference (PDR) importance of safe handgun storage is Thomas Irish, MD books that you no longer use or need? now available through the Health change suite to #202 If so, the Medical Society office will be Department. The four-color brochure happy to recycle them for you. shows a Joseph Jasper, MD We receive numerous requests picture of a (as of February 1,2000) from school nurses for the outdated bedside stand 1628 S Mildred, #105 and #110, books. They use them in their health with a "door." Tacoma, 98465 office for reference. W hen the door is Phone:253-564-2009 To recycle your used books, you opened, there is a Fax:253-564-7420 may bring them to the Medical Society picture of a handgun Accounting Services: office, 223 Tacoma A venue South or inside with the words, “If you PO Box 97115, T acoma, 98497 call 572-3667 and leave your nam e and were curious enough to open it, Phone: 253-588-7911 ■ address. We will pick them up if that is just think about your child.” On more convenient. ■ the back is infonnation about the importance of handgun locking and storage, the availability of push-button lock boxes and a toll-free number to call for more inforxnatiorL If you would like copies of the brochure for your Personal Problems office, please contact Fran Wood at of Physicians 798-6426.-

Medical problems, drugs, ■■ alcohol, retirement, emotional, or other such difficulties? ER^SE Your colleagues w a n t to help THAT TATTOO WORRIED ABOUT WHAT YOUR SPOUSE, YOUR FRIENDS OR EVEN YOUR BOSS *Robert Sands, MD, Chair 752-6056 THINKS ABOUT YOUR TATTOO? Bill Dean, MD 272-4013 OR ARE YOU JUST TIRED OF Tom Herron, MD 853-3888 LOOKING AT IT? Today’s newest Alexandrite laser, Bill Rocs, MD 884-9221 will remove your tattoo F. Dennis Waldron, MD 265-2584 with minimal discomfort &

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16 PCMS BULLETIN February, 2000 C om ity Q/Medical Society,

In My Opinion.... byNicholIverson,M.D.

Meet Dr. Rocker

"If the! @#$ % A &* public @#$ % A &* wants @#$ % A &* care, then @#$% A&* do it or @#$% A&* 'em!" Dr. Offiz Rocker Nichol Iverson, MD Unbeknownst to most of you, Dr. that they, on a good day, had the brains Rocker was known for his nefarious of a @#$% A&* monkey. Rather than brief medical career. Little did the personality as a surgeon before dealing with his threat of"I'll rip your world know that he had passed through making the big leagues. Being a @#$% A&* off, and stuff them up your the greatest training ground for precocious student, he entered @#$% A&*," the administration made egregious behavior — medical school Southern Red Neck University a t the him captain ofthe hospital softball team. and a residency program. Learning the age eighteen, and graduated in three Baseball scouts discovered him when skills of medicine, especially empathy, years summa cum louder. During his he was observed to throw a softball caring, loving and sensitivity, were left residency he was observed to throw a through the backstop from center field to his later encounters with umpires, pair of metzenbaum's under a scrub after catching a routine fly ball for the managers and understanding New nurses armpit, through an open third out. When "Dr. Offiz," as he was York baseball fans. Had Dr. Rocker window where it imbedded itself into a proudly nicknamed, found out that he not been required to take 57 credit coconutpalm one hundred and could make much more money playing hours per quarter during school, then seventy one yards from the hospital. baseball, he went on to make a brave work 117 hours per week during his On a separate occasion, he was donkey look intelligent. residency, he likely would have been observed jumping up and down on a In a recent Sport Illustrious one of the best loved relief pitchers on patient's bed screaming to the nurses article, little mention was made of his the Island of Atlantis. Unfortunately, his patterns of behavior had been pretty well compressed into his pea brain, shamefully being expressed to the consternation of Ted and Jane, precipitating their separation. PCMS The lesson from John Rocker is MEDICAL PLACEMENT SERVICE simple. We can't tolerate his behavior on the baseball diamond, and we can't * Qualified applicants tolerate his behavior if he returns to * Ethical, effective, responsive medicine. Those of us who were not * Controlled by a physician board of directors fortunate to make the big leagues of - We fill all clinical & administrative positions baseball, need to listen to the public - We test applicants outcry surrounding the statement of this fallen "star." Creating a Code of - We screen and interview applicants Cooperation among heal thcare - We verify references workers is going to be a necessary part - We arrange interview times for you of reengineering medicine. Failure to call us today for the correct poor communication skills in MOST QUALIFIED APPLICANTS thefrustratingenvironmentof medi­ cine 2000 will inevitably lead to a 5 7 2-3709 deterioration of our profession, and we WE WILL DO THE REST will be @#$% A&*ed. ■

February. 2000 PCMS BULLETIN 17 B ulleTIN

Fee policy recommended by Medical/Legal Committee

The PCMS Medical/ Legal Advi­ Below is a sample template that can receive is regarding misunderstand­ sory Committee recommends that all be used in your office. PCMS will pre­ ings of fees. It is very helpful to inform physicians prepare a professional pare your docum ent for you if you fill professionals what the fee will be prior charges fee schedule. This will help in tine blanks below and submit itfor to the transaction. tremendously in making arrangemen ts formatting. Please call PCMS, 572-3667 if you for work performed for other profes­ The Medical/Legal Committee would like assistance preparing your sionals, particularly attorneys. finds tine number one complaint they fee schedule.

Professional Chargeso Fee Schedule NAME: _____ PHONE:__ SPECIALTY: FAX: ___ ADDRESS: TAX ID#: ► Review of Patient's Records _.00 Per Hour ► Special Reports/Letters _.00 Per Hour ► Attorney Conference Time (telephone or in person) _.00Per Hour ► Deposition _.00 First Hour and ...... ’ ' ‘ land _.00 Second Hour and thereafter

space can be secured) ► Office Setup Time for deposition $__ .00 Per Hour ► Court or Arbitration Testimony $__ .00 Per Hour ► Courtroom Waiting Time $__ .00 Per Hour ► Travel Time $__ .00 Per Hour ► Copying of Physician's Records $ .00 Clerical Fee $ ■ First 30 pages $ • thereafter ► Charts greater than six months old may be in storage and will add a retrieval fee of: $___.00 (In accordance with Washington State tax law, medical record copies are considered goods and are subject to local sales tax)

NOTE: Fees may be higher depending on complexity of case.

LATE CANCELLATION POLICY - 48 HOUR NOTICE REQUIRED Cancellation of less than 48 hours will be billed at:

► Conference $ .00 ► Deposition $---- '00 Each Hour Scheduled ► Court or Arbitration Testimony $ .00 Please understand that Dr.______. carries a full schedule of patients daily, to weeks in advance. Rescheduling appointments within weeks for the above may be difficult or impossible to accommodate. If you have questions or concerns, please call the office at the above phone number

18 PCMS BULLETIN February, 2000 In My Opinion.... b y Teresa Clabots, M.D.

“Finding Beauty in Annie”

Annie walked into our clinic with more children and immediately went her new insurance card. Prior to that out and received a tubal ligation. This she had never received care from a was actually not true advice and at that pediatrician, only from a school nurse time Turner's was not considered and occasionally the mobile health genetic, although 10 years later in my Teresa Clabots, MD clinic. practice I had another case where the She was short, funny looking, child was a Turner's patient and the and had coke bottom glasses. She was mother turned out to be Mosaic. not a pretty child. Her mother was a Serendipity worked in that case and the high school prom, and actually danced frail elderly woman who was very hard partfor thatfamily to accept the with a boy. She was so excited. We concerned about her daughter, socially Turner's diagnosis was that they were joked that there was at least ONE and because she was so short. Mormon, placing a huge burden on the advantage to being short - she could A complete workup including child to continue to procreate and get to dance with all the boys since cardiology, renal and growth hormone evaluations would giver her a diagno­ sis she would carry the rest of her life: “I wanted to continue caring for her, and Turner Syndrome. A referral to an received a M edicare application form...... endocrinologist and growth hormone I pitched the partically filled out application shots she received didn't really help into the trash. It was insulting and degrading.” her since she was diagnosed so late. Annie wanted a "girl doctor" arid she insisted on becoming my pa dent. become a mother. they were all taller than her. She wanted to talk about her hopes, I gave Annie the advice that I Now Annie is 18 and she has SSI her dreams, and one day she ended up had given thatfamily, that if at 63 years insurance, and Medicare. I wanted to on my schedule and we talked for a of age, an old Italian woman can bear continue caring for her, and received a long time. We talked about the future children after menopause, thanks to Medicare application form. After the 6“' of a Turner's patient. We talked about hormonal intervention, I saw a terrific of approximately 40 blue pages, being the sadness she experienced on being future ahead for her. God only knew if asked yet again whether I had commit­ told she could never be a mom. She in 20 years the technology would be ted a felony, or fraud, or whether any told me about her future hopes - she such that she would be able to carry an of my staff had committed felonies, or wanted to get rid of her glasses. We implanted fetus. I told Annie not to frauds, I pitched the partially filled out talked about why depth perception and worry about it, that we would work on application into the trash. It was mathematics was so hard for her and getting her contact lenses. This made insul ting and degrading. her probable inability to drive in the her very happy, and we worked about I see Annie for free now. On her future. We talked about entering her getting her a pair of twins (our joke for last physical, I praised her for her into a tutoring program and also last but getting boobs). When Annie left I grades, her grooming, her dental not least getting her on DSHS and SSI. dictated a 3 page letter eliciting all of hygiene, her personal appearance. She was on Healthy Options (managed her past medical history, complications, She was beaming. She has joined a care), and I was sick of doing referrals. and future diagnosis. We applied for Tumer's club, and went camping for I told Annie that when I was a SSI and incredibly for me we got it on the first time in her entire life. med student in Kansas, one of my the first try for her. Her first goal was to Her mother paid me in the only expectant mother's had twins. One was get contacts. thing she could. A tiny little African a Turner's patient and one was not. Annie came in, she had on a little violet blossoming under a thick bush of She was then told by a senior pediatric bit of make-up and contacts. Now an ugly leaves. It seemed it was a little resident that she should never have "acceptable" date, she had gone to her Annie in itself. ■

February, 2000 PCMS BULLETIN 19 B u l l e t in

WS M A Physician PCMS and Leadership WSMA thank Do we have your e-mail Conference set you for your address? for May 12-13 membership The WSMA Leadership Confer­ WSMA Annual Membership dues ence has been scheduled for May 12- statements were mailed in November 13 in Chelan. Physicians who are for the 2000 dues year. Don't let your delegates, officers of county medical membership lapse! please send societies, state specialty societies, Did you know that 73% of hospital medical staffs, group practices your WSMA membership dues it to us at: and other organizations should plan to are tax deductible as an ordinary attend. The conference will be held at and necessary business ex­ Campbell's Resort, p en se? The program will include plenary A nd , if you have professional sessions addressing trends affecting liability coverage from Physi­ pcmswa@ the current and future environment of cians Insurance, you receive a medicine as well as break-out sessions $200 discount on your premium. pcmswa.org on interview techniques, speech PCMS is a unified county making writing, interpreting financial state­ sta te membership mandatory. T o ments, and much more. belong to one organization you must The program is offered with no belong to both. registration fee and will be accredited If you have questions about your for Category I CME credits. WSMA membership status, call A conference brochure and WSMA's membership department800- registration information will be mailed 552-0612 or email [email protected]. ■ in February. For more information, Did You contact John Arveson, at the WSMA Check out the WSMA legislative Seattle office, 800-552-0612, email: priorities on the WSMA website, [email protected]. ■ Remember? www.wsma.org

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20 PCMS BULLETIN February. 2000 W ’tmce ^(ocimhf Q /dedim l (Society

COLLEGE Continuing Medical Education MEDICAL Timely topics addressed in EDUCATION Womens Health CME Subjects scheduled to be The College of Medical Education's "first" program focusing on covered include: women's medicine is scheduled for ♦Estrogens, Anti-Estrogens & February 11,2000. Dr. John Breast Cancer Risk Lenihan is the program director. February 9 is ♦New Hormone Therapies This one day program will Hawaii Hotel address a variety of timely subjects ♦New Contraceptive Choices relative to contemporary medicine for ♦Incontinence reservaton deadline women. Designed for the primary care ♦Menstrual Migraines & Other physician, this new CME program will H eadaches feature issues related to diagnosis and The College’s reserved ♦Genetics of Reproductive treatment advances in treating illness in block of rooms for CME at Ha­ Cancer: Who & How to Screen women waii will be RELEASED AFTER ♦New Pharmacologic Approaches FEBRUARY 9, 2000. Reservations to the Management of Obesity can be made by calling the hotel di­ rectly at (800) 882-6060. You must iden­ tify yourself as part of the COLLEGE Dates Program Directors) OF MEDICAL EDUCATION group. The Hapuna Beach Prince Ho­ Wednesday - Sunday tel, on 32 acres edging on Hapuna CME @ Whistler Richard Tobin, MD Beach at the Mauna Kea Resort February 2-6 (hailed as "one of the world's 10 best"), Advances in Women's is the site of the CME at Hawaii pro­ Friday, February, 11 John Lenihan, Jr., MD gram for year 2000, which will be held Medicine April 10-14. The College was able to secure a "world-class resort" at greatly Thursday-Friday Internal Medicine Robert Corliss,MD reduced rates. Registrants may benefit March 9 & 10 Review 2000 from our negotiated group rates for ocean view rooms starting at $180. A Monday - Friday second adjoining room for children un­ CME @ Hawaii Mark Craddock, MD der 18 is available at $50 below the April 10-14 group rate. Saturday, April 29 Surgery Update 2000 Virginia Stowell, MD Those planning to attend should also secure air transportation. To as­ Asthma, Allergy & sure you are able to secure seats and get a reasonable price, we urge you to Friday, May 5 Pulmonology for Alex Mihali, MD make your reservations NOW. A small Primary Care refundable deposit will hold your seats. The College is working with Nuts, Bolts & Marilyn at Olympus Travel (565-1213). Innovation: Gaiy Taubman, MD Olympus has booked some seats at Friday, June 2 group rates and has access to other Gastrointestinal Richard Tobin, MD special options at the best rates. Call Disease V Marilyn today.

February, 2000 PCMS BULLETIN 21 B u l l e t in

Legislative

health clinic O rgan S^Tissue needs volunteers U O N A T I O N

Physicians are needed to staff the WSMA Legislative Health Clinic dur­ ing this legislative session. The clinic is open weekdays 8:30 a.m. to 12:30 p.m. This year's session is scheduled until MarchS. Being a legislative physician for a day provides a perfect opportu­ nity to get to know your legislators. There is a full-time clinic nurse for Share Your Life. your assistance. You may take your family and visit the legislature in ses­ Share Your Decision.™ sion as you will be given a beeper. Parking is provided. All physicians For more information on or«-an and tissue donation are invited to participate. For more information, contact Su­ please call LifeCenter Northwest san Peterson at the WSMA Olympia of­ toll free, 1-877-275-5269 fice, 800-5624546 or email [email protected]. ■

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22 PCMS BULLETIN February, 2000

V B u l l e t in

r a i / e lL e r d Health Service A service of Northwest Medical specialties, PLLC INTERNATIONAL TRAVEL CAN BE HAZARDOUS TO YOUR HEALTH • PRE-TRAVEL CARE • POST-TRAVEL CARE HOURS CALL EARLY WHEN PLANNING MON - FRI 9-5 253-428-8754 or 253-627-4123 A SERVICE OF INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph's Hospital)

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24 PCMS BULLETIN February, 2000 i‘^Piwce- 'fpotmty o4iedkal Society

MD License Renewal and CME Requirements change

With the year 2000, came a change licensure is $400 plus $50 for the hours every two years. Prior to 2000, in the license renewal and continuing substance abuse monitoring surcharge, PA requirements were 50 hours medical education (CME) reporting which is the same rate as was charged annually. requirements for MDs. (DO license for one year renewals. License renewal and reporting renewal and CME reporting require­ Reporting cycles for CME have requirements for DOs remain un­ ments remain unchanged). The also changed. Physicians who will changed at one year for renewal and reporting cycles have changed renew their license for two years in 150 hours of CME every three years from 150 hours every three 2000 will not be required to report for CME. years to 200 hours every four CME until their renewal in 2004. At this For a copy of the Rule Making years. time they will be required to report 200 Order and Washington Administrative As of January 1,2000, MDs whose hours. Physicians renewing their Codes (WAC) please contact PCMS, birth year is an even number will license for one year in 2000 will only 572-3667 and they will be faxed to you. renew their license for two years report CME if due. If not due, they will If you have questions on the rather than one year. For those MDs not be required to report 200 hours transition, you may contactSusan with an odd number birth year, the until 2005. Anthony, Washington State Depart­ license renewal period is for one year Physician Assistant (PA) require­ ment of Heal tli, 360-236-4787 or Mavis in 2000, then for two years beginning in ments have also changed. Their Pless at 360-236-4786 or PCMS. ■ 2001. The renewal fee for the two year reporting requirements will now be 100

MultiCare Health System Franciscan Health System Diagnostic Imaging Northwest Tacoma Radiology B u l l e t i n

IMEs need to be developed. A review nicate. This could be helpful by having from page 11 of the quality of exams, the quality of a common Physician Initial Report form The proper treatment of injured work­ examiners, the quality' of the panel for both the department and self-in­ ers in Pierce Countv and the State de­ companies, and the charges of the sured. mands this. The following actions panel companies needs to be instituted. There needs to be continued would be a startto bring this about: Giving the nurse consultant authority review of the timelines of payments for “► Claims managers decisions to authorize IMEs would be cost effec­ services. Payments for the original need greater medical input. Claims tive by reducing the number of unnec­ medical evaluation needed to file a personnel wi thout med ical training are essary IMEs. claim are usually delayed until the claim making decisions that affect the treat­ "► There needs to be a clarifi­ is closed - often for months to years. ment of injured workers. There needs cation of the communication lines be­ Changes in policy result in retroactive to be more authority placed on nurse tween physician's offices and the de­ retraction of payments. Disagreements consultants. Denied requests for a partment. Who do you call for what? between em ployer responsibility delay medical procedure or a consultation The claims manager? The provider payments for services. need a swift and easy appeals process. line? The bill payer? Periodic educa­ Thank you for your attention to An appeals procedure in­ tional meetings between claims manag­ our concerns. The task force does not volving; medical directors should be in- ers and office personnel could be desire an adversarial relationship with stituted if there is a disagreement be­ helpful. Timely responses from claims the department. The department mem­ tween a nurse consultant's recommen­ managers are still a problem. bers on o u r task force have been ex­ dation and an attending physician. -► There needs to be better tremely helpful in explaining policies ”► An ongoing review of inde­ coordination between self-insurers and and procedures and why things are pendent medical examinations needs the department. Especially on occupa­ done the way they are. The task force to be instituted. There are far too many tional diseases there is great confusion desires that a collaborative effort can be IMEs performed and the quality needs as to the responsible employer and made on behalf of injured workers for a improvement- Criteria for ordering where tine physician needs to commu­ better working relationship between the departm ent and providers of sendee. ■

Will a disability put you out of commission?

As you know, disability insurance policies for physicians are changing i apidly and not for the better. High claims have caused manv major carriers to limit the most important benefits.

At Physicians Insurance Agency, there's still time to secure the specialty- specific coveiage you need. In addition, we can help you find superior life and long-term-care coverage for you and your family.

To discuss the ways you can best protect your future income, call Physicians Insurance Agency today: (206) 343-7150 or 1-800-962-1399. PHYSICIANS INSURANCE ■ ~~ AGENCY A wholly owned subsidiary of Physicians Insurance

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26 PC'v'iS BULLE I IN February. 2000 VPwce bounty Q/dedkal Society

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Tacoma/Pierce County outpatient Lakewood medical space avail­ Transcription specialists are general medical care at its best. Full and able. Two suites 750 square feet each. eager to provide prompt, accurate, and part-time positions available in Tacoma One suite 2900 square feet. Excellent professional transcription. Free pick-up and vicinity. Very flexible schedule. location and visibility. Close to many and delivery. Daily turnaround. Well suited for career redefinition for schools and residential areas. 8509 Excellent references and exceptional G.P., F.P., I.M. Contact Andy Tsoi, MD Steilacoom Blvd. Call Dr. Ken Ring at background in all specialties. 253-925- (253) 752-9669 or Paul Doty (Alien, 584-6200 or 582-5856. 3276. Nelson, Turner & Assoc.), Clinic Manager (253) 383-4351. New office space available. Up to 5500 sq. ft. or 1000-2200 sq. ft. Will GENERAL Beautiful San Juan Island - finish to suit. 1310 S. Union. Close to WashingtonState. Full-time salaried hospitals. Convenient parking, ground Medical Records Storage Space position for Board Certified Family level. Call Dr. Michael Lovy at 756- at 2201S 19th Street. Easy access, Physician Good benefits including 2182 or 721-5512. individ ual locking units. Please call vacation, CME time (with stipend) and Kellis Commercial, Inc. a t4754363. sabbatical. Full range of practice Summit View Puyallup, specialty including emergency medicine. Must space. 1500 sq. ft. minimum, adjacent to have strong skills and ability to make Summit View Clinic, diagnostic imaging, independent decisions. Send CV to physical therapy. Fax 535-5432 or e- David M. Gimlett, MD at drgimlett mail [email protected]. ©rockisland.com, fax 360-378-3655 or call 360-378-2141, ext. 24. Puyallup medical office space VOLVO available. One unit is 1200 sq. ft. with Practice opportunity for a part- three examination rooms, a consultation time BC Internist witli an IM/Geriatric office, and a laboratory. Another BMW group in Tacoma. Evening/week-end building is 2400 sq. ft. and can be hours are an option. Flexible hours/ remodeled to suit tenant. Offices are SERVICE & REPAIR benefits. Please submit resume to Jan 1 / 2 mile from Good Samari tan Hospital. Brame, Administrator, 316 ML King Jr Contact Paul Gerstmann, MD 253- (253) 588-8669 Way, #304, Tacoma, WA 98405 or by 845-1761. www.volvorepair.com fax to 253-272-5643. New Puyallup office space Boyle’s Foreign Car Repair available. 1500+ sq. ft. Will finish to suit. 7202 Steilacoom Blvd SW Near Good SamaritanHospitai Call Rose 848-4215 or 840-0480.

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Outpatient General Medical Care. HIGHLINE COMMUNITY HOSPITAL HEALTH CARE NETWORK Full and part-time positions www.hchnet.ora available in Tacoma and vicinity. SEATTLE, WA - excellent opportunities for BE/BC family practice, internal medicine, and Very flexible schedule. Well suited occupational medicine. Enjoy practicing in a progressive hospital setting with an extensive network of health care providers and specialists throughout SW King County. Minutes from for career redefinition for downtown Seattle, the shores of Puget Sound and the Cascade Mountains. W e offer GP, FP, IM. state-of-the-art resources, equipment and expertise to provide outstanding care for your patients. Competitive package. For details, call or write us: Gail Mumma, Highline Contact Andy Tsoi, MD (253) 752-9669 Community Hospital Health Care Network, 137 SW 154lh Street, Seattle, W A 98166. or Paul Doty (Allen, Nelson, Turner & Phone (206) 619-9069 • Fax (206) 431-3939 Assoc.), Clinic Manager (253) 383-4351 e-mail: [email protected]

February, 2000 PCMS BULLETIN 27 V. B u l l e t in

Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether it’s a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and in the future, is to help physicians, clinics, and hospitals remain successiul. f T Physicians ■" Insurance Western Washington -800-962-1399 A Mutual Company Eastern Washington -800-962-1398 Oregon 1-800-565-1892 Seal tie, WA © Physicians Insurance 1999

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28 PCMS BULLETIN February, 2000 March, 2000

PCMS members, from left, Drs. David Law, Nick Hamill, Len Alenick, Lisa Hamill, Charles W eatherby and David Sparling in front of the State Capitol on Legislative Day

See highlights on page 7

INSIDE: 3 PCMS retired members advise colleagues about retirement issues 7 PCMS members participate in Legislative Day and meet with their elected officials 8 James M. Wilson, Jr., MD appointed to Pierce County Board of Health 10 Pierce County Hospital CEOs will speak at May General Membership Meeting 11 Professional Charges Fee Policy recommended by Medical/Legal Advisory Committee 15 In My Opinion: “Goodbye Regence” - local surgeon ends relationship with insurer 23 Whistler CME program pictures — education and vacation for participants PCMS Officers/Trustees: Charles M. W ealhcrby, MD P re sid en t Patrice N. Stevenson, M D ...... I''resident 1 Meet S u san J. S alo. MID...... Aice-President J. Ja m e s R o o k s. M D ...... S ecretary T re a s u re r Lawrence A Larson. DO - Past President Sabrina A Benjamin. MD Drew H - I X'utsch. \ 1D M arch 2000 Kevin K. Gandhi.M D M ichael .1. Kelly. M D D o ris A . P ag e, IVID lidward 1. W alkley, MD Yolanda I iruce, PCM S A President

WSMA Representatives: Speaker**! the House; Richard Haw kins, M D T ru stec: 1 )a \ id L a w . M D AMA Delegate: Leonard Alenick. MD W AM P AC Chair 6th District: Mark Gildenhar, MD XVAMPAC'OthDistrici: Don Russell, DO lable of Contents

Executive Director: Douglas Jackman 3 "Retirement and What to Expect" Committee Chairs: Aging. Richard Waltman: AIDS. Lawrence Schwartz; Bylaws. Richard Haw kins: Budget'Finance. Jam es (i Absentee Ballot Application Rooks: College of Medical Education. \Y. D ale Legislate e Health Clinic seeks volunteers Overfield; Credentials. Susan Salo: Emergency Medical Standards, led Walkley; Ethics/ Standards Of Practice, David l.ukens: Grievance. 7 Legislative Summit provides opportunities to be heard Law rence A. Larson: l.ubor & Industries. W illiam R itchie. Legislative. William Marsh; Medical-Legal. 8 Janies M. Wilson. Jr.. MD appointed to Board of Health Pat Donlev: Membership Benefits, Inc.. Drew f-uet \\ itness \ . Expert Witness: reimbursement issues D eutsch; Personal Problems Of Physicians. Robert Sands; Public Health/School Health. Joseph \ \ cam : Sports Medicine. John Jiganti. 9 TPCHD: Tuberculosis Reporting

The Bulletin is published monthly by PCMS 10 May General Membership Meeting Membership Benefits. Inc. I'or members of the Pierce County Medical Society. Deadlines for submitting articles and placing ad\ertisements in The Bulletin 11 Professional charges lee policv template are the 15th of the month preceding publication (i.e < Jctober 15 for the November issue h 12 WSMA organizes Medicare Fraud Work Group The Bulletin is dedicated to the art. science and delivery of medicine and the betterment of the health 13 "1 he Invisible Hand; \ alue ior Ei.|ual Value" and medical w elfare of ihe community. The opinions herein are those of the individual contributors and do not necessarily reflcct the official position of the 14 Go shopping on ^SiipportA/yAs.soeiation.eom" Medical Society. Acceptance of advertising m no wav constitutes professional approval or endorse­ I? In My Opinion: -Hex Nurse." by Nichol Iverson. MD ment of products or services advertised, The Bulletin and Pierce County Medical Sooctv reserve the right to reject any advertising. lf> State MAA office searching for chief medical consultant

Kditors: M (31 Board o! Directors 17 In My Opinion: "Goodby Regence," by Chris Jordan, MD Managing Editor: Douglas Jackman Editorial Committee: MB! Board of Directors 18 COME: Whistler program educational and fun Advertising Representative: Lanya McClain Subscriptions: S50 per year. S5 per issue 19 C OME. C alendar and program acti\ ities

Make all checks pay able to: MBI 223 Tacoma Avenue South. Tacoma W A 98402 3.1 W SM.A Pin sieian Leadership C onference set for May- 253-572-3666. FAX 253-572-247* > 21 PCMSA Philanthropic Update l>mail address: pcmswaCaipcmswa.org I lome Page: http://vvwvv-pcmsvva.org______2? Classified Advertisinc bounty Q /ti^d^di Sfocmty.'

February General Membership Meeting Recap by Jean Borst “Retirement and What to Expect”

It’s a likely assumption that most in Dr. Ferguson’s road to retirement attendance at the February 8 General was fairly interesting. “I began talking Retirement preparation tips Membership meeting could relate in to a medical m anagem ent consultant in from AOI.s Money.com some way to the evening’s program the late ‘70s, but I didn’t heed his ad­ topic. Regardless of age or years prac­ vice,” he said. “Skydivers jump out of 1.The rules fo r retirem ent success are changing. Retirees are living longer, staying perfectly good airplanes. In 1985,1 ticing medicine, everyone thinks about more active and likely to spend 30 years or retirement - at least the process of get­ jumped out of a perfectly good prac­ more in retirement.The standard of living you'll ting there. The group was fortunate to tice." Dr. Ferguson turned his practice maintain during your Golden Years will depend hear from four of their own, a panel of over to another physician and became in large part on how well you take advantage of tax-deferred savings options like 401 (k) medical director of United Pacific in­ retired PCMS members who shared plans and IRAs and how skillfully you invest their insights, personal experiences, surance company. When the company your money. and concerns about retirement. was sold in 1990, he found himself out Drs. Jim Early, Ken Graham of a job. He returned to practice at 2. Set a savings goal. The only way to know whether you're on track toward a Community Health Care, doing locum and David Sparling retired in 1997, comfortable retirement is to project your while Dr. Bob Ferguson retired in tenens and also as ship physician on a retirement expenses, and then calculate how 1994. Each has been very involved in few cruises. “It was quite an odyssey,” much you must save to accumulate a the PCM S, all are active in their com ­ he recalls. Official retirement came in retirement nest egg large enough to supplement Social Security and other sources 1994. munities, and all still maintain connec­ of income. Retirement planning software and tions to the medical profession. And, it Dr. G raham started “thinking” web calculators can help crunch numbers. appears, they all are enjoying retire­ about retirement at about age 65. He ment. notes that having younger partners in 3.Think stocks for long-term growth. Over long periods, stocks have the best track Do they have all the answers for his practice made the process of phas­ record for boosting the size of your retirement those among the membership consider­ ing out possible. “Talk with a financial nest egg. Even more important, stocks are ing retirement, either now or down the consultant about retirement planning more likely to keep your retirement savings _ road? Of course not. But their candid and work ahead,” he suggested. growing faster than inflation, increasing the future purchasing power of the money you “I don't know if there is a right and relatively informal discussion pro­ sock away today. vided some interesting fodder for their tim e,” Dr. Sparling added, “but I sug­ audience. gest you prepare yourself for when 4 .There's no single "correct" mix of the time does com e.” stocks and bonds. How you decide to divvy up your retirement portfolio between Should I? When and How? Each panelist offered the Internet stocks and bonds will depend for the most part There are three big questions to as a valuable resource regarding re­ on your tolerance for risk and how long you consider when thinking of retirement: tirement issues. have until you plan to retire. A reasonable “Should I retire?”; “When should I re­ starting point for investors whose retirement is Some options to consider..... 20 or more years away is 70% stocks and 30% tire?”; and “How should I do it?” No bonds. If you feel comfortable shooting for simple task to answer any one of the So, now you’ve made the decision higher gains despite the risk of short-term queries, much less all three. to retire from practice. Is there any losses you can increase your stock holding a “One day I knew,” offered Dr. reason to keep your license? Dr. Gra­ bit, or ratchet them back a bit if you're uncomfortable with the prospect of volatile ham encourages it. “It keeps you con­ Early. “For 35 years, I was passionate stock prices. about medicine. But I started to enjoy it nected to the medical community - gels less. It was taking tim e away from the you to the meetings and in touch with 5. Avoid the urge to move too heavily things I liked doing. If you have other other physicians. If you have hopes of to bonds once you retire. In search of steady income, many retirees stash most of things you want to do, and you can af­ doing any volunteer work in medicine, their entire portfolio in bonds. Unfortunately, ford to do them, that’s a pretty good in­ you are either required to have a li­ over the course of 10 to 15 years, inflation can dication that it might be a good time to cense or you must carry your own li­ easily erode the purchasing power of bonds' retire. And consider this - the average ability insurance at an exorbitant fee.” interest payments by a third or more. Even investors in the'70s and'80s should probably age at death for a man is 83 and for a One of the first things Dr. Graham keep 20% or more of their holdings in equities. woman it is 85. That helps put things wanted to do when he retired was to See “T ips''page 5 into perspective.” See “Retirem ent" page 4

March, 2000 PCMS BULLETIN B u l l e t in

Retirement medicine in some way. One concern, they must adhere to certain principles - he cautioned, is all the rapid change in the law requires insurance carriers to m edicine. be solvent. Individual health insurance volunteer at the WSMA clinic. He is a problem because there aren’t couldn’t without liability insurance. How to fill the time...Keeping enough individuals to spread the risk, While none of the panelists chose active and keeping involved and many of them are older.” this option, many physicians like to con­ "The minute you retire," said Dr. “Look into the options,” Dr. Gra­ sider part-time practice alter retire­ Sparling, "people think you have all the ham urged. “There are companies out m ent. "F or m e," Dr. Early notes, "1 was time in the world to there offering long-term health insur­ volunteer." ance. You need to be prepared. For Dr. Early, W e’ve all heard the horror stories, and once the word was out many of us have friends who have had that he was retiring, to deal with catastrophic illness.’’Dr. the requests for his Graham recalled a close friend whose time began pouring in. wife had Alzheimer’s Disease. Her "There are so many condition deteriorated to the point that worthy things to do, she ended up in Western State Hospi­ but that doesn't neces­ tal. The catastrophe completely sarily mean that you drained the couple’s retirement. are the one to do them all! Remember, when Retirement and Changes in you retire, you Finally L ife sty le...... have ihe chance to do I've found that my greatest Left, Dr. Stevens Dimant and his wife. Sheila, visit with what you really en­ achievement in retirement is getting to speaker and retired internist, Dr. Jim Early joy." the point w here I d o n 't w orry about my patients." said Dr. Early. “But 1 do miss Financially them. When I get lonely, my wife tells speaking...... me to go to our local Safeway store. Fra “ You have to sure to run into several former pa­ realize that you're not tients," he said. going to be as finan­ “My patients have been very con­ cially well off as when siderate about my retirement," Dr. you were in practice." Sparling added. “And by leaving a Dr. Early noted. group practice, f had the satisfaction of In addition to knowing my patients were in the hands early retirement plan­ of my other partners." ning, each physician "One ofthe most important lifestyle agreed that there are changes you experience is that you no major financial con­ longer have to feel hurried every cerns that go with re­ minute of the day worrying about pa- From left. Dr. Mian Anwar aiul Dr. Thomas Bageant tirement. "The cost of tienls, telephone calls, etc.," Dr. visit with speaker, Dr. Bah Ferguson health insurance is a Sparling noted. “You have the time for major consideration," friends and for doing the things you re­ so happy once 1 made the decision to said Dr. Sparling, "Individual plans are ally love." Last summer, he spent two retire, that I became as passionate out of sight, and many individual poli­ weeks helping build a house for Habi­ about retirement as 1 had been about cies have been eliminated. This is a ma­ tat for Humanity. “There is no lack of my practice. Part time was not an option jor topic of discussion in Olympia right interesting and different things to do.” form e." now. 1 hope the situation will improve, Dr. Sparling hasn’t had much of a Dr. Sparling offered locum tenens soon.” chance to consider boredom in retire­ as a good opportunity to consider in re­ The issue of insurance was much ment. In addition to retiring, he mar­ tirement. “This is a great option,” he discussed among the panelists. “All in­ ried, built a new house and experi­ noted. "I have several friends who surance companies want to sell insur­ enced major cancer surgery - all over have done this. It’s an excellent oppor­ ance," Dr. Ferguson continued, “but a period of just three years. tunity for those who want to continue in See “Retirement” page 5

4 PCM S BULLETIN M arch,2000 Retirement Internet is a great resource) l i p s

"I suppose the experts would think all ►Spend your time doing what you truly 6. Contribute the max to your 401K. that would cause too much stress.” love One of the surest ways of boosting the value Many retirees find they finally of your retirement savings is stashing as much as you can in a 401 (k) account.You have the time to fulfill get an immediate tax deduction of as much their travel dreams. as $10,000, the possibility of a matching The Sparlings are contribution from your employer (typically planning future half of what you contribute to a maximum of 3 % of your salary, although some firms are Elderhostel trips more generous), and tax deferred growth on and will be visiting your savings.There are few no-brainers in life, France in April. For but this is one of them. Dr. Early, on the other 7. Check out IRAs. After a 401 (k ), an hand, travel is not a IRA is typically your next best choice for priority. Both he and retirement savings. Choosing among the his wife traveled three basic flavors - a traditional deductible, a extensively when they nondeductible and a Roth IRA - may require a bit of thought, and possibly some serious were in the Air Force. number crunching. But any effort you put into With the exception of a deciding among these plans today will pay off wonderful trip to Ire­ in a more comfortable retirement down the land (a surprise retire­ Dr. Sumner Schoenike, right, greets Dr.David Sparling; road. ment gift from his w ife). he now sees many of Dr. Sparling's former patients 8. Make tax-efficient withdrawals the Earlys simply want from your nest egg.The less you have to to stay put. “Except for pay in taxes on the money you pull out of those few weeks in the your retirement savings, the longer your money will last. Pulling money from taxable winter when you can accounts first as much as possible and letting reach up and touch the tax-advantage accounts continue to clouds, we think the compound can stretch the life of your nest Pacific Northwest is egg by several years. the greatest place to 9. Consider working in retirement. be,” he said. More than 80% of baby boomers polled by the AARP last year said they plan to work full Some Good or part-time after they retire because they find Advice.. work stimulates them and keeps them socially engaged. Working even occasionally Overall, the during retirement can benefit you in two other following pretty ways: it reduces the amount you have to much collectively sum­ save before you retire, and income from a job lowers the amount you must withdraw from marizes the panelists £)r Mian Anwar, right, retired anesthesiologist, asks your retirement savings, which reduces the conclusions about speaker. Dr. Ken Graham a question after the presentation chances that you'll run out of money before retirement: you run out of time.

♦Consult with a financial advisor. 10. Look for creative ways to stretch Early retirement planning is essential your retirement assets. You may not be ♦And enjoy it! ikIt\s a nice feeling to able to save more in retirement, but you can probably get more mileage out of whatever wake up in the morning and Ihe big ♦Stay connected to the medical you've managed to accumulate.One community decision to make is where to go possibility: Relocate to an area with lower hiking,” Dr. Early said. “ Happiness is a living expenses. Such a move can easily save you 20% or more. Another option is to ♦Get involved with old and new journey, not a destination,” Dr. Sparling transform the equity in your home into offered. “It’s important to remember friendships, your church or syna­ monthly income by taking out a reverse gogue, and the community at large that your satisfaction depends more on mortgage.Hie money you receive from a desires and interests than on reverse mortgage isn't taxable because its considered proceeds from a loan, and you ♦Explore all your opportunities (The acquisitions." ■ don't have to repay the loan as long as you continue to live in the house, i

March, 2000 PCMS BULLETIN 5 B u l l e t in

ABSENTEE BALLOT APPLICATION

If you h tvt rtquesM in jbsenfe* billot or hive t permintnt nquest tor u 1 $bs*ntae billot on Mt, prt«i do not submit mother application. To be filled out by applicant Please print In Ink.

Registered Name:. M all this absentee ballot Street Address:— request form to your county auditor o ra faction departm ent C ity:------. Z IP C o d e : See previous page for your county's mailing address. Telephone: (Day). (Eve.)

For Identification purposes only (optional): Voter registration number if known ------This application is for: Birth D a t e ______Have you recently registered to vote7 Yes O No PJ Presidential Primary only I hereby declare that I am a registered voter. February 29. 2 0 0 0 l! Date _ Permanent Request S ig n a tu r e ______AH f'j'.wo Elections H To be valid, your signature must be Included

Send my ballot to the following address (If different from above): For office use only Precinct Code Mailing Address:______Lew C ode______

C ity :------S t a t e : ______Ballot Code.

Z IP C o d e . . C ountry: Ballot Mailed.

To vote absentee, in the privacy of your own home, complete the form above and mail to: Pierce County Auditor, 2401 South 35th Street, Room 200, Tacoma, WA 98409.

Did You Legislative health clinic needs Remember? physician volunteers

Physicians are needed to staff the WSMA Legislative Health Clinic during this legislative session. The clinic is open weekdays 8.30 a.m. to 12:30 p.m. This year’s session is scheduled until ✓ March 8. Being a legislative physician for a day provides a per­ fect opportunity to get to know your legislators. WAMPAC There is a full-time clinic nurse for your assistance. You may Washington Medical Political take your family and visit the legislature in session as you will be Action Committee given a beeper. Parking is provided. All physicians are invited to participate. 1800 Cooper Point Road SW O lvm niI*10**- lnformation> contact Susan Peterson at the WSMA Bldg7, Suite A Olympia office, 800-562-4546 or email [email protected]. Olympia, WA 98502 800-562-4546 (360)352^848

6 P C M S BULLETIN March,2000 W}u:rce % ounty r’ liedtcat cim ety

Legislative Summit provides opportunities to be heard

Approximately 160 W SMA mem­ tion allowing naturopaths to call them­ ing the House Health ( ’are Committee bers marched to Olympia to hear and selves physicians and grant them pre­ or touring I he capitol campus. talk about the priority issues for the scriptive authority. And WSMA will op­ 2000 legislative session prior to meeting pose efforts by pharmacists to assert with their individual legislators. Priority themselves in the physician/patient re­ The following PCMS members legislation developed through the lationship attended I lie WSMA February 25 House of Delegates and the Interspe­ 4) Preservation of funds from to­ I .egislative Summit in ( (lymia.Tlicy are: cialty Council includes: bacco settlement agreement for to­ Leonard Alenick 1) Access to care bacco prevention ami control pro I't'derico Cruz-llribe 2) Strong support lor the "Patient grams. During the 1999 session, the Nick llamill Bill of Rights,"Senate Hill 6199 and Washington State Legislature dedi­ Lisa Ilainill House Bill 23 3 1. cated $ 100 million of I lie tobacco sell le­ Sidney Kase 3) Opposition to increasing the nient proceeds to fund prevention and Lawrence A. Larson scopes of practice of other healthcare cessation activities by the state. Al­ David Law providers. WSMA will actively oppose though the money has been allocated Joe Mancuso allowing optometrists to determine I heir for these purposes, the legislature did Nick Rajacich own scope of practice through a "as not formally appropriate I he money. Don Russell taught" legislation. They're also seek­ Due to severe cutbacks as a result of I- Cecil Snodgrass ing to increase prescriptive authority 695, some are fearful that the monies Dave Sparling and seeking to use the term physician may go to repair"poiholes." Patrice Stevenson as well as allowing optom etrists to per­ Attendees at the meeting spent the (Jeorge Tanhara form surgery. afternoon visiting with their personal Charles Weatherby WSMA will again oppose legisla­ legislators oil I he above issues, attend­

I.Ll-T: Drs. Lawrence /A. I.arson, l.rn Alenick. Seattle Internist. John \’asset, Charles Wetuhcrhx anti George Tanlnira

RIGHT: Dr. Nick Rajacich (center I anil l.en Alenick talk with Rep. Roger Hush, iR- 2) left

LEFT: Dr. Joe Moneuso greets form er WSMA I’resi- i/enl, Dr. Marl Adams

RIGHT: Drs. Nick Rajacich, l.en Alenick, ( 'hartes Wcathcrhx, David Sparling. David Law anti Nick and Lisa ilainill Umr the grounds " ft B u l l e t in

James M. Wilson, Jr., MD Fact Witness appointed to Board of Health Expert Witness

Dr. James M. Wilson, T aco m a one. The board meets once a month, One of the most common areas of Internist, has replaced Dr. David and often deals with major issues, such dispute between attorneys and physi­ Sparling, who retired January 1. on as HIV reporting. Pierce County cians is reimbursement for providing the Pierce County Board of Health. landfill issues, tobacco regulations, etc. testimony. Very often physicians are He was appointed to the three year Dr. Federico Cruz-Uribe. H e alth reimbursed the smallest amount or term by the Director for the Tacoma-Pierce nothing at all. PCMS Board of County Health Department answers to The attorneys sitting on the Trustees, who the board for the operations of the Medical-Legal Liaison Committee have was asked to Department. crafted forms to petition the court as an select a fs' Dr. Wilson is well prepared for the intervener to get expert witness fees representative job. He has been very active in the established for the subpoenaed from the medical community. particularly PCMS. physician’s testim ony. medical He served as president in 1998 and The Committee members agreed community. president-elect in 1997, he has chaired that once a couple of these orders have T he B oard Jomes M-Wihon. MZ> the Grievance Committee and the been entered in favor of the physician is comprised of Aging Committee, he was Vice Presi­ establishing a fee and a body of orders two representatives from the Tacoma dent in 1996, Secretary-Treasurer in are available to future physicians to rely City Council, three from the Pierce 1995 and served as a Trustee in 1992- upon to address this, you are probably County Council, one from the Pierce 1993. going to face a much easier time in County Cities and Towns, and one is As PCMS President he testified for Superior Court getting this issue at-large, typically from the medical numerous health issues, including resolved. It may take retaining an community. before the Board of Health on the attorney the first couple times, but all The commitment is a significant AIDS reporting issue.■ agreed that in the long run it will be worth it. Please call the Medical Society office, 572-3667 for a copy of the Motion, Affidavit and Order.* ER^SE THAT TATTOO WORRIED ABOUT WHAT YOUR SPOUSE, YOUR FRIENDS OR EVEN YOUR BOSS AMERICAN LUNG ASSOCIATION,. THINKS ABOUT YOUR TATTOO? of Washington OR ARE YOU JUST TIRED OF t LOOKING AT IT? Today’s newest Alexandrite laser, I-800-LUNG-USA will remove your tattoo with minimal discomfort & less than 1 % risk of scarring. Lung Information dull tnduyfor more iiifhmuttion Service Line PIERCE COUNTY LASER CLINIC Providing patient Dirccior I’cier K. M.'irsh M.l). education materials (253)573-0047

8 PCM S BULLETIN March, 2000 ^Pl& Ke, C om ity* oM edical (Society*

The Health Status of Pierce County W

At their January 5,2000 meeting, countries where TB is very common: the Tacoma-Pierce County Board of many ofthe immigrants are also Health adopted a resolution to economically disadvantaged, live in TACOMA-PIERCE COUNTY require physicians, clinics and crowded conditions, and have limited other health care facilities to HEALTH access to medical care. DEPARTMENT report to the Tacoma-Pierce • Increased poverty, injection County Health Department drug use, and homelessness may also medical protocol. positive skin tests for tuberculo­ lead to more cases of active TB as In the state of Washington, sis. This regulation takes effect progression to active disease is more medical providers are required to March 1, 2000. The regulation likely if one's overall health is poor or report over 60 communicable diseases also requires pharmacists to the immune system is weakened by to local health departments. There, report to the Health Department alcoholism or drug use. nurse epidemiologists and communi­ when they dispense any anti­ • People with latent TB who are cable disease control staff investigate tuberculosis medications. homeless or abuse drugs may not the reports to assure that the index Why the change? The purpose of adhere to treatment regimen. Not only patient receives the needed treatment the regulation is to identify individuals do these individuals run the risk of and follow up and that contacts are at risk for and assure prevention of active disease, they may develop a screened and treated, thus breaking active tuberculosis. By reporting the drug resistant strain ol'TB and infect the chain of transmission. names of people who are being others. Reporting positive TB skin tests screened and treated for latent TB In 1997, there were 43 to the Tacoma-Pierce County Health infection, active TB can be prevented active TB cases in Pierce Department will contribute to increas­ in many patients. In addition, the Health County. Of this number. 65% were ing community wide prevention. The Department's tuberculosis control foreign born and 39% were age 65 or information gained will also offer a program will be able to learn the extent older. In 1998, 36 people in more complete picture of populations of latent tuberculosis infection in the Pierce County had active TB, of at risk and how they are being man­ community to gather a complete picture whom 39% were foreign born and 22 aged in the medical care system. of populations at risk in order to were over age 65. Staff in the Tuberculosis improve screening and prevention Pierce County patients with Control Program at the Tacoma- efforts. suspected or confirmed active tubercu­ Pierce County Health Depart­ Tuberculosis causes more losis arc referred to Northwest Medical ment are available to assist deaths worldwide than any other Specialties (formerly called Infections private doctors and other clini­ infectious disease. Approximately Limited) if they do not have a primary cians with questions about whom one third of the global population is care provider or insurance. The to screen and how to most infected each year, causing eight Health Department subsidizes care at effectively offer prevention million to develop active TB and three Northwest Medical Specialties for all therapy. Reports of positive TB million to die. patients with active tuberculosis who skin tests can be made to our 24 Tuberculosis has re-emerged in cannot pay or do not have third party hour Disease Reporting Line at the United States in recent years, coverage. In addition. Health Depart­ 798-6534. The preferred method probably because of several contribut­ m ent staff work in partnership with of reporting, however, is to use ing factors: Northwest Medical Specialties staff and a fax form especially developed • The HIV/AIDS epidemic, with physicians by providing nurse case for this purpose, which you can the resulting decreases in immune management and directly observe obtain by calling the Medical function, leaves people who are HIV therapy for persons with active TB. Society office, 572-3667. positive more susceptible to latent The directly observed therapy For more information about infection and increasingly at a risk for component of care involves delivering screening for tuberculosis and NIH active infection. the medications to the patient and prevention therapy, please contact the • There are increased numbers observing the patient swallow the Network Nurse who visits your office, of immigrants to the United States from medication to insure adherence to the or call 798-7671. ■

March, 2000 PCMS BULLETIN 9 B u lletin

announces tneth<

May General Membership Meeting

Tuesday, May 9, 2000 Landmark Convention Center Social Hour: 6:00 pm Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm Tacoma

Pierce County

B i ^ f a p i a c i

* 0 ( H f health care

fe a tu rin g :

► George Brown, MD; VP Acute Care, MuItiCare ► Mark Gregson, CEO; Puget Sound Hospital ► Ed Miller, CEO; Good Samaritan Hospital ► Joseph Wilczek, President & CEO, Franciscan Health System

-MARK YOUR CALENDAR- Watch your mail for registration information

10 PCMS BULLETIN March, 2000 VPime cJ'leJica! (Society-

Fee policy recommended by Medical/Legal Committee

The PCMS Medical/Legal Advi­ Below is a sample template that can receive is regarding misunderstand­ sory Committee recom m ends that all be used in your office. PCMS will pre­ ings of fees. It is very helpful to inform physicians prepare a professional pare your document for you if you fill professionals what the fee will be prior charges fee schedule. This will help in the blanks below and submit it for to the transaction. tremendously in making arrangements formatting. Please call PCMS, 572-3667 if you for work performed for other profes­ The Medical/Legal Committee would like assistance preparing your sionals, particularly attorneys. finds the number one complaint they fee schedule.

Professional ChargesO Fee Schedule

NAME: PHONE:__ SPECIALTY: FAX: ___ ADDRESS: TAX ID#: * I Review of Patient’s Records $___ .00 Per Hour * > Special Reports/Letters $___ .00 Per Hour * I Attorney Conference Time (telephone or in person) $___ .00 Per Hour * \ Deposition $___ .00 First Hour and (Please inform if videotape deposition and $___ .00 Second Hour and thereafter number of people attending so adequate space can be secured) \ Office Setup Time for deposition $___.00 Per Hour > Court or Arbitration Testimony $___.00 Per Hour I Courtroom Waiting Time $___.00 Per Hour I Travel Time $___.00 Per Hour \ Copying of Physician’s Records $ .00 Clerical Fee $ . First 30 pages $ . thereafter ** I Charts greater than six months old may be in storage and will add a retrieval fee of: $___ .00 (In accordance with Washington State tax law, medical record copies are considered goods and are subject to local sales tax)

NOTE: Fees may be higher depending on complexity of case.

LATE CANCELLATION POLICY - 48 HOUR NOTICE REQUIRED

Cancellation of less than 48 hours will be billed at:

> Conference $___.00 > Deposition $___.00 Each Hour Scheduled > Court or Arbitration Testimony $___.00

Please understand that D r.______carries a full schedule of patients daily, lo weeks in advance. Rescheduling appointments within weeks for the above may be difficult or impossible to accommodate. If you have questions or concerns, please call the office at the above phone number.

* Billed at 1 hour minimum, then billed in 15 minute increments ** Billed at 4 hour minimum, then billed in 15 minute increments

March, 2000 PCM S BULLETIN 11 B u l l e t in

Medicare Fraud WSMA Seeking Council/ group organizing Committee Members

Dr. L e n Alenick, L ak ew o o d The Washington State Medical Association is asking for suggestions for Ophthalmologist, has agreed to members to its councils and committees. If you have an interest or questions participate in W SMA’s new Fraud regarding any of the following, please call the Medical Society office at 572-3667. Work Group. Openings exist on the following Committees: The primary goal of this work group will be lo create a forum for I Bylaws Committee physicians and representatives of > Emergency Medical Services Standards Committee HCFA and the Medicare carrier to k Finance Committee examine concerns related to alleged ) Industrial Insurance and Rehabilitation Committee and substantiated fraud and abuse I Judicial Council behaviors. "We hope to develop an I Medical Education Committee overview of what they are calling I Medical Practice Committee fraud, and how they are defining it in k Medicare Liaison Committee what could be ordinary' misunderstand­ I Membership Promotion/Retention & Services/Benefits Committee ing of billings." explained Dr. Alenick. I Organized Medical Staff Section Governing Council “There are always gray areas and little I PACE Issues Advisory Groups differences that need to be under­ t PACE Program Steering Committee stood.” he added. I Private Health Plan Liaison Committee Dr. Alenick sits on the WSMA t State Health Plan Liaison Committee Board of Trustees and is an AM A > Women in Medicine Committee Delegate for WSMA. If you would like to be involved in this work group, please call Bob Perna at WSMA. 1-800-552-0612.

r a i / e lL e r d Health Service A Service of Northwest Medical Specialties. PLLC INTERNATIONAL TRAVEL CAN BE HAZARDOUS TO YOUR HEALTH PRE-TRAVEL CARE • POST-TRAVEL CARE HOURS CALL EARLY WHEN PLANNING MON-FRI 9-5

253-428-8754 J(Marl«fpan)')| or 253-627-4123 A SERVICE OF INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph's Hospital)

12 PCM S BULLETIN March, 2000 r0^iew ce, ^Q ou/nby' o M ed ica l {S o ciety

The Invisible Hand.. by Andrew Stetson, MD

<£Value for Equal Value”

‘' There is nothing nameable but that some men will, or undertake to, do it for pay.” Herman Melville (1891) Andrew Statson, MD

During the past few years there ing. is drying up. Who is going to step in have been many pronouncements pro­ Health insurance is a 20"’ century now to bail out the government? The claiming the im m inent demise o f fee for development. It probably started in taxpayers? The patients? The physi­ service. The most recent one I read some high risk industries with company cians? It looks like it will be all of the was by Dr. Hunter, a public health offi­ sponsored plans of workmen’s com­ above. cial in Los Angeles, who said, “P P O ’s pensation for accidents and injuries on Insurance is attractive because it are the last gasp of fee for service”. I the job. Prior to that, particularly in En­ spreads the risk of catastrophic losses don’t know what is the basis for such gland, mutual help associations of for­ horizontally, over a large number of statements. It cannot be historical. Be­ esters and miners took care of their people. Actuaries can project reason­ hind the Iron Curtain fee for service members who got hurt on the job. The ably well the expected loss per number existed side by side with free medical churches in Europe and America acted of people insured. At the cost of a rela­ care. Even though it was ideologically as extended families, helping the sick. tively small surcharge for overhead we abhorrent to their system, one of the The first big jump in health insur­ can budget our expenses and protect most oppressive in human history, fee ance enrollment occurred during the ourselves from big losses. for service could not be abolished. So Great Depression. The second came The problem with health insur­ what makes some people think that it during and after WWII. The system ance is that the overhead costs have could be destroyed in this country? I we have today is the logical result of grown excessively. In other lines of in­ wonder whether they believe that if those early beginnings. surance, such as fire or casualty, the they said it loudly enough, and wished The move away from community overhead is probably of the order of it strongly enough, it would come to and industry based mutual help associa­ 5% , if that m uch. The m ost efficient pass. tions was brought about by the socialist medical plans now' spend 15% of pre­ Simple fee for service (the physi­ spirit of the 20lh century. It was based miums on overhead. The average for cian treats, the patient pays, no third on the belief that the government can the industry is probably 25%. Add to party) is not subject to abuse. It is the and will solve all our problems. The that the budgets of the federal and state only true system of fee for service. It Great Depression frightened and agencies that administer and subcon­ has been with us for many centuries. It scarred the generation that lived tract the health care programs, the cost appeared with the birth of Economic through it. The requests for help over­ to the tax collecting agencies to get the Man, and will not die until all humans whelmed the resources of the private money from the taxpayers and the cost vanish from the universe. It is at least as relief organizations. Pressure built up to the employers and other taxpayers old as the world’s oldest profession. As for the government to step in. That to prepare their returns. Then, there is long as someone is willing and able to worked well for a while. Money flowed the cost to employers and individuals in pay for a service, someone else will be into the health care system, hospitals signing up for health insurance. The willing and able to provide it. Some ser­ expanded, the development of new' large companies have whole depart­ vices have been declared illegal by medical technology exploded, there ments in their personnel offices that rulers and proclaimed immoral by was no lim it to w hat we could and did handle the health insurance problems priests, but legal or not, out in the open do. We have now reached the point of their employees. Finally, there is the or in hiding, fee for service has always where the government resources have processing cost to physicians, hospitals existed. Its demise is only wishful think­ been overwhelmed. The money spigot See “Value" page 22

March, 2000 PCMS BULLETIN 13 B u i X b 'l 'iN

Go shopping on SupportMyAssociation.com Personal Problems of Physicians PCMS members may now enjoy With ONLY 24 hours in Medical problems, drugs, the benefits of shopping online with alcohol, retirement, emotional, over 200 of the world-wide-web's the day, WHEN do or other such difficulties? top merchants, all consolidated into one, YOU SHOP? Your colleagues easy to use shopping portal. Through a want to help Free Next Day Shipping is recentaffiliationwith Support^’Associa- 1 \ granted on all orders over *Robert Sands, MD, Chair 752-6056 tioncom, PCMS will Nx?$25-\^r To get started, go to the Bill Dean, MD 272-4013 benefit by receiving a PCMS homepage, Tom Herron, MD 853-3888 royalty from every' www.pcmswa.org and click Bill Roes, MD 884-9221 purchase made from on the active F. Dennis Waldron, MD 265-2584 the numerous mer- "SupporiMyAssodationoom" chants. It is a win-win. SupportMy Assoria- logo. Click on Association Members C onfidentiality tion.com (SMA) members will receive and find Pierce County Medical Society' - M em bership Benefits, Inc. A s s u r e d various promotions and specials. Shopping is easy and prices are Log in your email address and you are competitive. Best Price Guarantee and on your way.*

J lf t e r b r e c iit s u r g e r y . MultiCare/3 ll ii n h D iz2l} -P iz 24 Arid Dizzy. . .Differential Diagnosis of- u i . Tuesday, March 21, 2000 f| Union Avenue Pharmacy & n Allenmore Hospital Classroom % Corset Shop t ' 8 :3 0 pm (Refreshments will he served) Formerly Smith's Corset Shop >\ 2302 S. Union Ave 752-1705 i: Speaker: Charles Soulicre, MD, Tieoma Ear & Balance Clinic Karen Pen, MS, PT, MultiCarc Vestibular anJ Balance Clinic A comprehensive review of the mechanisms of balance, causes of dizziness, diagnostic studies and treatment options. This lecture is designed for physicians, nur>e practitioners, nurses and physical therapists involved specifically in ihe diagnosis and treatment of balance disorders. V O L V O Diflerentiatmc between central and peripheral nervous system disease, toxicities and various metabolic disorders can be very complex. The attendee will acquire an understanding of the available diagnostic and BMW treatment plans appropriate to the patients they frequently encounter. Neu programs available include Posturography. The audience will be shown SERVICE & REPAIR a demonstration of this technology, av ailable at the MultiCare Vestibular (253) 588-8669 and Balance Clinic. www.volvorepair.com For reservations, call 1 -8 0 0 -3 4 2 -9 9 1 9 MultiC&re Center Boyle’s Foreign Car Repair For Advanced 7202 Steilacoom Blvd SW Neurosciences

14 PCM S BULLETIN March. 2000 "tyimx %>untf Q-Medical ofoadif

In My Opinion.... by Nichoi Iverson, MD

“Hey Nurse’

“Hey, Nurse! Can you please help Where have all the nurses gone, me?” “Yo, dude, you be so old you long time passing...? ' Ivcr.suii, Mil stink. Wutcha makin me git up fo; there Florence Nightingale ain’t nobody gonna be here ‘til the sun comes up anyway. Shuddup and come to expect medical care to be a yet suffered enough to change. goadda sleep." Not in my wildest right, and has increased the demands As we experiment with different dreams did I expect to spend my and expectations of the ability of us to forms of healthcare and reimbursement, eightieth birthday sucked into the produce miracles and cures. One does one aspect of our system is being hospital as a vacuum cleaner robot not need to be a rocket scientist to overlooked. Nurses. Nursing schools victim, and have to put up with figure that increased costs of nursing, have fewer graduates. Nurses are inhumane treatment by some high technology, the aging of the popula- leaving their time honored profession. school dropout at three in the morning. When was the last time you wondered why nurses were so difficult to find? We are in the m idst o f the One does not need io be a rocket sciential to nurse reduction conspiracy. Our central government is secretly herding nurses figure that increased costs of nursing, technology, away from a vocation that has had more the aging of the population, expectations of the than its share of heroines and heroes. In the absence of nurses, how much public and bureaucratic o farsight hove

March, 2000 PCMS BULLETIN li B u l l e t in

State MAA office Hematology Oncology Northwest. P.C. searching for chief is pleased to announce medical consultant the association of .T he State of Washington is search­ ing for a Chief Medical Consultant for Andrew S. Sandler, MD tire Department of Social and Health Medical Oncology/Hematology Services, (DSHS), Medical Assistance Administration, (MAA), Disability De­ termination Services. 1624 South I Street #405 Requirements for the position in­ Tacoma, WA 98405 clude a medical license to practice in and the U.S., six years of clinical experi­ ence, one year of administrative expe­ 34709 9lh Avenue S, Suite B-200 rience in a health care program, board Federal Way, WA 98003 certification in a primary care specialty, and advanced writing skills are de­ (235) 383-3366 sired.

(Dr. Sandler will officially begin his practice at this office on March 13, 2000) The Director will manage the state-wide Medical Policy Program to assure compliance with Social Security Administration s regulations and poli­ cies. Administrative oversight of 67 ■ part-time Medical Consultants is in­ cluded. Tire position pay range is rACOMA RADIOLOGY $95,000 - $104,030, w ith office head­ quarters in Tumwater. For a copy of the job announce­ m ent call PCMS at 572-3667, ■

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16 PCM S BULLETIN March, 2000 'W^ievce bounty Q-lbdical Qrociefy

In My Opinion.... by Chris Jordan, MD “Physician leaving Regence A Letter to Patients”

Editor's Note: The following letter was submitted by Dr. Chris Jordan. Dr. Jordan is a general surgeon who practices in Tacoma. He is sending this letter to his patients to inform them that he will no longer be accepting Regence patients

Deal' Valued Patient: tion. It has finally reached a point My records show that you may be where Regence reimbursement rales insured by Regence Blue Shield. I are unacceptable. Chris Jordan, MT) want to notify you of a change in my I would like to continue to provide relationship with Regence. Effective surgical services for you outside of the April 15.2000,1 have cancelled my Regence network. There are various If you would like to let Regence contract with Regence. ways to do this and my office would be know that they need to come to a fair This has not been an easy deci­ happy to discuss this with you. agreement with surgeons, you can caf sion. Over 150 surgeons in the Seattle- If your employer offers a choice Regence Customer Service at 1-800- Tacoma area have also cancelled their of other health insurances, you may 328-7273. Your feedback is very contracts. Regence will not engage in a wish to choose a different plan. I am important. meaningful negotiation on their new contracted with Premcra, First Choice, contract. Surgeons have been working Cigna, One Health Plan and Sound Sincerely. Chris Jordan, MD longer and harder for less compensa­ Health.

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March, 2000 PCMS BULLETIN 17 B u l l e t in

Whistler CME program - education AND vacation

The CME al Whistler course, the of educational subjects of value to all College of Medical Education's winter specialties. Conference attendees resort program, was very successful particularly enjoy the opportunity to this year, providing excellent medical have in-depth discussions about clinical education, great skiing and even good situations. w e a th e r,' When not in the classroom, Pierce County physicians that participants and their families enjoyed attended the program, held at the great skiing, resort activities and lots of British Columbia ski resort, were sun and snow. joined by other physicians from around The program was directed by the country. The program not only is Rick Tobin, MD and will be offered known for excellent CME opportuni­ again next year at the Whistler resort ties. but also for family vacationing. area. The program featured a potpourri Whistler CME leader and speaker, Rick Tobin, addresses the audience

1 earn faculty

Dr. Mark Craddock, and wife Jinny, enjoy the sun after a ft. Di. I hi! Ctaven answers a question about infectious great day of skiing diseases posed by a participant

PCM S BULLETIN March, 2000 'V. dtyeKe ^(Myihy Q'ftedical (Society

COLLEGE Continuing Medical Education OF MEDICAL Internal Medicine Review 2000 EDUCATION scheduled for March 9 and 10 The Tacoma Academy of Internal ♦Update in the Diagnosis & Treatment Medicine's annual two day CME of Osteoporosis program is open for registration. The ♦Management of Type II Diabetes program offers a variety of limely ♦What's New in Alzheimer’s Disease Hawaii CME internal medicine topics and has been ♦Primary Care Management of organized by Robert Corliss, MD. Parkinson's Disease registration The program offers 12 Category I ♦Psychiatric Issues in the Management CME credits and is available to both of the Geriatric Patient remains open Academy members and all other area ♦Antimicrobial Update in the physicians. The program will be held at Treatment of Respiratory Infections Space is still available to join your the Washington State History Museum ♦Thromboembolism in Medical colleagues and their families for spring in Tacoma. Patients vacation in beautiful Maui, during the To register or for more informa­ ♦Where are we with Lipids in the New College’s “resort" conference April 10- tion please call the College at 627-7137. Millennium? 14,2000. This year's program includes ♦Dietary Management of Vascular Reservations can be made on a presentations on the following topics: Target Organ Disease space available basis by calling (800) ♦Cardio-Renal Connection: Micro 882-6060. You must identify yourself as ♦Intractable Pain in the Community Albuminuria as a Predictor of part of the College of Medical Educa­ Setting Cardiovascular Disease tion group. ♦Progress in Hepatitis C Treatments To help with airline reservations to Maui, the College is working with Marilyn at Olympus Travel (253)565- 1213. For additional information or a program brochure, call the College at Dates Program Director^) (253)627-7137. Thursday-Friday Internal Medicine Robert Corliss,MD Allergy, Asthma March 9 & 10 Review 2000 Monday - Friday CME @ Hawaii Mark Craddock, MD & Pulmonology April 10-14 CME - May 5 Saturday, April 29 Surgery Update 2000 Virginia Stowell, MD

The College’s CME program Asthma, Allergy & featuring subjects on allergy, asthma & Friday, May 5 Pulmonology for Alex Mihali, MD pulmonology is set for Friday, May 5 at Primary Care St. Joseph M edical Center. The course is under the medical direction of Alex Nuts, Bolts & Mihali, MD. Innovation: Gary Taubman, MD A brochure with details regard­ Friday, June 2 ing the conference is scheduled to be Gastrointestinal Richard Tobin, MD mailed in late March. Disease V

March, 2000 PCM S BULLETIN 19 B u l l e t in

WSMA Physician Leadership Conference set for May 12-13

The WSMA Leadership Conference has been scheduled for May 12-13 in Chelan. Physicians who are delegates, officers of county medical societies, state spe­ cialty societies, hospital medical staffs, group practices and other organizations should plan to attend. The confer­ ence will be held at Campbell’s Resort. The program will include plenary sessions address­ ...a m ulti­ dfijj Allenmore disciplinary ing trends affecting the current and future environment of behavioral medicine as well as break-out sessions on interview tech­ ■fiSJy Psychological health group niques, speech writing, interpreting financial statements, Associates, P.S. that works and much more. with physicians The program is offered with no registration fee and 752-7320 ■--- will be accredited for Category I CME credits. Do you have patients with difficult emotional A conference brochure and registration information and stress-related problems? Psychiatric and will be mailed in February. For more information, contact psychological consultations are available. John Arveson, at the WSMA Seattle office, 800-552-0612. e mai I: j v a @ w s ma. o rg. Union Avenue Professional Building ______1530 Union Ave. S.. Ste. 16. Tacoma------

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20 PCM S BULLETIN March, 2000 Q /iie d ic a l

The Pulse PCMS Alliance

PCMS Alliance Philanthropic Update

On January 31, Alice Yeh, is GAMBLE - the new learning module and Yolanda Bruce Fran Thomas dealing with using drugs or alcohol $4,(XX) YW CA met to plan the distribution of the during pregnancy. The module Women’s Health Program Holiday Sharing Card proceeds. After includes a drug-affected baby and a the expenses FAS manikin plus a seven day curricu­ $3,800 Trinity Neighborhood Clinic were subtracted lum and supplies for activities - a great from the net learning tool. $1,500 PLU Wellness Center money collected,4 PCMSA thanks you again for there was $12,900 your generous support. $ 500 American Lung Association to distribute. Asthma Camperships The PCMS Fran Thomas Alliance Baby Philanthropic Chair $ 500 P.C. AIDS Foundation Think It Over Basic Needs Program program continues. Four of the latest The money will be distributed to model dolls were ordered for Dorothy the following organizations in the $2,538 Baby Think It Over Hudson’s Family Life classes at W ilson amount indicated: Hiah school in Tacoma. Also ordered

please send it to us r - pcniswafr CHAPEL HILL - Traditional Townhome Community in Downtown Gig Harbor. $274,000 - $295,000. pcmswa.org For more information or for a private showing, please contact Sean L. Watson at 253-858-2927 or Toll Free 888-858-2927. Windermere Windermere Real Estate/Gig Harbor

March, 2000 PCMS BULLETIN 21 The medical savings accounts, by ployer, but when they want care, they from page 13 Value their nature, would be best for young will look for something better than what people, who will have time to build a their insurance company will allow and others in filing claims and waiting large reserve while they are healthy. them to have. The trade of value for for payment. The total of these over­ They are lifelong contracts. Only very equal value, as expressed by the head costs of our insurance system farsighted individuals can see the ben­ simple fee for service system, will need probably exceeds 50% of all expendi­ efit of such a program when they are to find new ways to express itself, un­ tures on health care. young and healthy. Perhaps an even encumbered by the crushing adminis­ The medical savings accounts bigger hindrance is our income tax tration burden of our current system. are a halfhearted attempt to spread the code. We are nowhere near solving Simple fee for service is the only risk vertically, over time, rather than that problem. system under which the patients have a horizontally. They have not been suc­ As the quality of health care un­ right to medical care. There is only one cessful so far. One reason is the in­ der the current system continues to de­ thing that allows a service, any service, flated cost structure due to the large in­ teriorate, the people who are willing to to be yours by right, the cash in your surance overhead. Our contracts re­ pay for them will search for beLter pocket. You have earned it through quire us to bill the insurance companies medical services. Many people pay your own effort and you can exchange no more than what we could charge their taxes to the school districts, but it for the best value that the effort of cash-paying patients. So the patients send their children to private schools others can give you. When someone with medical savings accounts cannot and dig into their pockets to pay the tu­ else pays for your care, it is no longer get a discount for cash payment, even ition. They are disappointed by the yours by right, but yours by permis­ though our services to them do not performance of our public schools and sion. You have to beg for it. That per­ have the same record-keeping, billing are willing to pay whatever it takes so mission can and will be denied, if those and collection overhead. For example, their children can get a better educa­ who grant it think that they can get some colleagues, who see only cash tion. There will be people who pay for away with it. Remember, he who pays paying patients, have been able to cut medical insurance through their em­ the piper calls the tune. ■ their charges by half.

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22 PCM S BULLETIN March, 2000 'W\em Q/ftedical Scady

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POSITIONS AVAILABLE OFFICE SPACE POSITIONS WANTED

Tacoma/Pierce County out­ Lakewood medical space Transcription specialists are patient general medical care at its best. available. Two suites 750 square feet eager to provide prompt, accurate, and Full and part-time positions available in each. One suite 2900 square feet. professional transcription. Free pick-up Tacoma and vicinity. Very flexible Excellent location and visibility. Close and delivery. Daily turnaround. schedule. Well suited for career to many schools and residential areas. Excellent references and exceptional redefinition for G.P., F.P., I.M. Contact 8509 Steilacoom Blvd. Call Dr. Ken background in all specialties. 253-925- Andy Tsoi, M D (253) 752-9669 or Paul Ring at 584-6200 or 582-5856. 3276. Doty (Allen, Nelson, Turner & Assoc.), Clinic Manager (253) 383-4351. New office space available. Up to 5500 sq. ft. or 1000-2200 sq. ft. Will GENERAL Beautiful San Juan Island - finish to suit. 1310 S. Union. Close to Washington State. Full-time salaried hospitals. Convenient parking, ground Medical Records Storage Space position for Board Certified Family level. Call Dr. Michael Lovy at 756- at 2201 S 19th Street. Easy access, Physician. Good benefits including 2182or721-5512. individual locking units. Please call vacation, CME time (with stipend) and Kellis Commercial, Inc. at 475-4363. sabbatical. Full range of practice University Place/Tacoma - including emergency medicine. Must Existing Medical offices available. 990 Must sell surplus at reasonable have strong skills and ability to make to 1500 sq. ft. or will build to suit in new price: 2 birthing beds (motorized). Call independent decisions. Send CV to office building, all located in Sieu or Teresa at (253) 4 7 4 -5 7 15. David M. Gimlett, MD at Professional Office Park. For more [email protected], fax 360-378- information, see our Website at Steilacoom - Great view of the 3655 or call 360-378-2141, ext. 24. WWW.ajbroback.com or call (253) 564- Sound, Olympics and sunsets. In 0444. Cormorant Passage. Light and bright. Vaulted ceilings and Skylights. Expansive hardwood floors. Oak millwork. Brick gas fireplace. Four bedrooms, 2.5 baths, den/office. 2740 sq. ft. Custom Hoover-built one owner home. Owner/agent. Call Bob, 253-279- 7194. Harold Allen Co. $375,000.

TACOMA/PIERCE COUNTY H+H HIGHLINE COMMUNITY HOSPITAL Outpatient General Medical Care. HEALTH CARE NETWORK Full and part-time positions www.hchnet.ora available in Tacoma and vicinity. SEATTLE, WA: Excellent opportunities for BE/BC Family Practice, Internal Medicine, and Very flexible schedule. Well suited Occupational Medicine. Enjoy practicing in a progressive hospital setting with an extensive network of health care providers and specialists throughout SW King County. Minutes from lor career redefinition for downtown Seattle, the shores of Puget Sound and the Cascade Mountains. W e offer state- GP, FP, IM. of-the-art resources, equipment and expertise to provide outstanding care for your patients. Competitive package. For details, call or write us: Gail Mumma, Highline Contact Andy Tsoi, MD (253) 752-9669 Community Hospital Health Care Network, 137 SW 154'" Street, Seattle, W A 98166. or Paul Doty (Allen, Nelson, Turner cc Phone (206) 619-9069 • Fax (206) 431 -3939 Assoc.), Clinic M anager (253) 383-4351 ______e-mail: [email protected]

March, 2000 PC Mb BULLETIN 2 3 B u l l e t in

Policyholder Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether it's a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders, kqually as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and in the luture. is to help physicians, clinics, and hospitals remain successful. JF Physicians ■" Insurance W estern W ashington I -S00-962-1 399 A Mutual Company Eastern Washington 1 -800-962-1398 Oregon 1-800-565-1892 Seattle, WA CO Physicians Insurance 1999

Pierce County Medical Society PRESORTED 223 Tacoma Avenue South STANDARD Tacoma,WA 98402 US POSTAGE PAID TACOMA, WA PERMIT NO 605 Return service requested

24 PCM S BULLETIN March. 2000 13 R eg en ce lead ers m ee t w ith B oard o f T rustees to discuss m any issues any m discuss to rustees T f o oard B ith w t ee m ers lead ce en eg R 13 CO -4 ccess” A are C ealth 05“H t’sPage: en CTC resid P 3 WhtdeTxhv odowihAse lcto? yDai Rokp, A CFP C BA, M D M oskoph, R Statson, avid D ndrew A by by eon ch n llocation?” lu ringing,” A W pril A sset at A and H ith w o and d ventures” d to A riting have frican andw “A “H ce doesTax hat Hand: erien “W p le ex visib will In he bers T em M etired R Ifyuhv a o e Got a co, yThma ga ,MD M t, agean B as hom T by supply octor,” lood D b eal R a area to es o G , rovid p lem rob P eal Services R a lood B have al you f “I egion R ascade C NSDE: E SID IN

B u l l e t in

PCM S Officers/T rusfees: Charles M. Weatherby, M O .....President Patrice N. Stevenson, M D ...... President Elect Susan J. S alo.M D ...... Vice-President J. James Rooks. M l)...... Secretaiy/TreasLirer Lawrence A. Larson, DO ...... PastPresidenl Sabrina A. Benjamin. M D Drew 1-1. Deutsch. M D K evinK. Gandhi, M D Michael J. Kelly.M D A pril 2000 Doris A. Page, [VID Ldward 1. Walk ley, M D Yolanda Bruce, PCMS A President

WSMA Representatives: Speaker of the House: Richard Hawkins,MD Trustee: David Law. MD AM A Delegate: Leonard Alenick. IVID W AMPAC Chair 6th District: MarkGildenhar, MD W AM PAC9th District: Don Russell, DO

Executive Director: Douglas Jackman

Committee Chairs: A gin g. Richard Waltman: A ID S. James DeMaio: B ylaw s, Richard Hawkins: Budget/Finance, James Rooks: College of Medical Education, W. Dale Overfield: Credentials, Susan Salo: E m ergen cy Medical Standards, Ted Walkley; E thics/ Table of Contents Standards Of Practice. David Lukcns: G rievan ce, Lawrence A. Larson; L abor & Industries, William Ritchie; Legislative, William Marsh; Medical-Legal, 3 President's Page: "Health Care Access" Pal Donley: Membership Benefits, Inc.. Drew Deutsch; Personal Problems Of Physicians, Robert Sands: Public Health/School Health, 4 Cascade Regional Blood Bank provides area blood supply Sumner Schoenike: Sports Medicine, John Jiganti. 5 'It You Have a Real Problem ” by Thomas Bageanl.MD The Bulletin is published monthly bv PC MS Membership Benefits, Inc. for members of the Pierce County' Medical Society. Deadlines for submitting 6 Alrican Adventures,' April Retired Physician Luncheon articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. 7 The Invisible Hand: “Handwriting and Hand Wringing” October 15 for the November issue).

The Bulletin is dedicated to the art. science and 8 "Nostalgia of WW II," by John Stutterheim, MD delivery of medicine and the betterment of the health and medical welfare of the community. The opinions herein arc those of the individual contributors and do 9 Tax and Asset Allocation, by David Roskoph, MBA. CFP not necessarily rellcct the official position of the Medical Society. Acceptance of advertising in no 1 1 TPCHD. Prevention priorities determine department direction wav constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin and Pierce County Medical Society reserve the right 1 3 Regence leaders meet with PCMS Board of Trustees to rejecl any advertising. Patnce Stevenson. MD chairs WSMA Women’s Committee

E d ito rs: MBI Board of Directors COME. Suigical Update, Allergy, and GI courses upcoming M a n a g in g Editor: Douglas Jackman Editorial Committee: MB! BoardofD hectors I 6 Doctors' notes on patients' charts Advertising Representative: Tanya McClain Subscriptions: $50 per year, S5 per issue The Pulse. PCMS Alliance thanked for charitable gifts M ake all checks payable to: MJF5T 223 Tacoma Avenue South. TacomaWA9S402 19 Classified Advertising 253-572-3666, FAX 253-572-2470

E-mail address: pcmswatoJpcmswa.org Home Page: http://www.pcmswa.org______

2 PCMS BULLETIN April, 2000 'j/u'K-e frcMihlii o ttcd tm l ddcaehf

President’s Page by Charles Weatherby, M.D.

Health Care Access

It is estimated that there are almost 44 million uninsured Americans. Approximately 700.000 of the residents of Washington State are uninsured. In 35 of 39 counties, it is virtu­ ally impossible to obtain health insurance for individuals. This CluirUw W'callirrh'i. MD will probably decrease access for more people. Legislation is PCMS Prc.nUiu currently being debated to “encourage” insurers to provide coverage to individuals. It appears that Governor Locke is prepared to sign such legislation into law. Health care access remains at the top of the WSMA’s priority list. What are we doing as practicing physicians to improve the access of our citizens? We are fortunate in Pierce County to have a system of community clinics as well as a nationally renow'ned Family Practice Residency Program. However, these programs can only do so much. We must continue to dialogue among ourselves and other organiza­ tions to do more. Are changes needed in our current system? One recent national survey of the public, employers, physicians, and health plans discovered that 83% of practicing physicians believe that fundamental changes are needed or that the system needs to be completely overhauled. This compares to 51% in 1984 and 67 % in 1997. This same survey found differences in the perception of the aforementioned groups regarding certain aspects of health care. For instance, managed care was supposed to save cost and improve the quality of care. While a large majority of the health plans and em­ ployers believe that managed care has improved the quality of care and has contained casts, the large majority of physicians and the public do not. The American public and physicians are now thinking similarly with regards to the needs of our health care system. Somehow, we are going to have to get the employers and health plans to think more clearly like “the rest of us.” However, we can’t just sit around and wait for someone else to “fix the system” for us. The American public is becoming quite angry and impatient. They've grown tired of the rhetoric of our legislators, our Congressmen, and even our state and national medical organizations. The public is resorting to the initiative process for more and more of their issues. We recently experienced how public sentiment enacted Initiative 695 despite its long range negative impact on some important programs. An initiative drive is now in place to establish a single payor system. It is very important that we become actively involved with this process - individually and collectively. Just like 1-695 limited license fees to $30, we can’t afford to let others put limitations on our abilities to practice medi­ cine. The single payor system may be or not be the best alternative, but physicians need to be involved in the decision making.!

April, 2000 PCMS BULLETIN 3 Cascade Regional Blood Services provides area blood supply for doctors and hospitals

Since 1946. when it was founded local surgeons have not had to cancel the national scale for the cost of a unit by a group of Pierce County physi­ surgeries or inconvenience patients," o f blood. cians and local labor leaders. Cascade Drummond continued. “In fact, be­ “We are doing everything we can Regional Blood Services (formerly cause of our close proximity to area to cut costs and increase our blood known as the Tacoma-Pierce County hospitals and because of our collection drawing capacity," Drummond said. Blood Bank) has been providing a safe efforts throughout the county, we are "That’s why we are in the middle of a and constant supply of blood and blood proud that we can supply the blood fund-raising campaign to add another products for thousands of area patients. products anil services when and where mobile unit to our fleet of on-site col­ "We are proud of our record of they are needed." lection vehicles and services. We ex­ service and look forward to working Cascade Regional Blood Services pect to finish raising more than $150,000 with local doctors and hospitals for has been in the news lately as contract for that five-bed bloodmobile within the many years to come.'' said Charles H. negotiations continue with local hos­ next few months.” Drummond, executive vice-president pitals. The blood bank is requesting an "We are a financially mature and of the blood bank. increase for a unit of blood, up to $79. stable organization, but we are also re­ "And. because we've always been This is the first increase they've re­ alistic in knowing that as we move responsive to our local doctors and quested in more than five years and ahead into the future we must be cost- their patient needs for blood supplies. puts the blood bank at the low end of competitive in providing quality, local sendee for area doctors and hospitals." Drummond said. "Our biggest strength is also our biggest weakness. Because it seems we've done our job so effort­ lessly. most people don't even know we are here." "But we are here...and we intend to stay." D rum m ond said. "A nd if our local doctors and more than 19.000 current volunteers and thousands of area busi­ nesses continue to support our efforts as they have in the past, we'll continue providing the blood and services needed by patients who now rely on us for the gift of life.”*

tZTSpine & Femur

DEXA TACOMA/PIERCE COUNTY Detect osteoporosis O utpatient G eneral M edical Care. Assess fracture risk Full and part-tim e positions Quantitate bone mineral density changes available in Tacom a and vicinity. Monitor therapeutic response , 1 www. tacomarad. com Very flexible .schedule. W ell suited for career redefinition for Allenmore Medical Center Lakewood Office G P , F P .L M . (253) 383-2038 (253) 588-6083 Contact Anclv Tsoi, MD (253) 752-9669 or Paul Doty (Allen, Nelson. Tin ner k Assoc.), ( :linie Manager (253) 383-4351

4 PCMS BULLETIN April, 2000 In My Opinion.. by Thomas Bageant, MD

“If You Have a Real Problem, Go to a Real Doctor7’

The innovative approach, quality, their insurance companies, HMOs, efficiency, and availability of American Medicare, or welfare to pay for any Thonttis Bdijcani. MD Medicine is in decline. Several groups paramedical modality that has not been must change their expectations, de­ subjected to blinded studies or statisti­ main unproved. Medical care should mands, intrusions, and approaches if cal analysis. include conventional care, from obstet­ this decline is to be reversed. Over the Third party payers should put rics to psychiatric care. It should also last one hundred years in the United forth plans that meet patient specific include eye care, dental care, ex­ States, conventional medical care has needs. These plans should be concise tended care, and medications. It should extended the average life span of our and easily understood: clearly stating not cover those modalities mentioned citizens by approximately thirty years. what is and isn't covered. Administra­ before as paramedical groups. No other paramedical discipline, like tive “speed bumps" that delay, divert, Government should limit the liabil­ chiropractics, massage therapy, acu­ inhibit, or deny proper care should be ity of drug companies that have prop­ puncture, naturopathy, aroma therapy, abolished. Examples: Mandatory “gate erly tested, reported, and won FDA ap­ nutritional supplements, music therapy, keepers” delay care and cause a con­ proval for their products. Sole rights to or herbal therapy can make such flict of interest for physicians; mandated drug company products should be lim­ claims. Our medical system should pro­ “second opinions” delay care and do ited, such that developmental ex­ vide efficient, quality, medical care that not save money. penses, testing expenses, and a rea­ meets the individual needs of each pa­ Health care workers and medical sonable profit can be made. tient. All medical approaches should be facilities should be paid quickly for ser­ Tort reform that limits punitive put to blinded studies and statistical vices provided. Denied claims should damages, restricts layers’ compensa­ analysis prior to acceptance by patients be subject to rapid, efficient, arbitration tion, holds third parties liable, and or mandated coverage by medical in­ policies. Physician contracts that restrict shortens statutes of limitation will de­ surance. access to specialists withhold compen­ crease the costs of medical care. The Patients must understand that medi­ sation when specialists are used, re­ contingency system for lawyers com­ cal care is expensive and, as medical strict physicians from discussing options pensation should not be allowed for advances are made, that cost will in­ with patients, or deny carc based only malpractice claims. crease at rates that are higher than the on cost should be abolished. All third Government should not mandate increase in cost of living. Patients must parties should be held liable when their that insurance plans cover anything but take more responsibility for their care policies have delayed or denied conventional medical care. Nor should costs and the health care policies that proper health care. Administrative these plans be forced to fully cover re­ are purchased for them. Patients costs must be lowered. Too little of the cently found preexisting conditions should expect available, efficient, qual­ health care premium actually goes to­ like pregnancy or recently diagnosed ity, conventional medical care. They ward the payment of health care ser­ cancers. should demand that their third party vices. Huge bonuses, given to adminis­ Government should provide tax payers cover their needs as deemed trators who have collected funds and incentives for health care premiums, necessary by their physicians. Patients’ found ways not to pay for services, health care expenses, and extended insurance premiums should cover only should go toward lower patient premi­ care expenses. the needs of the individual being cov­ ums. State Insurance Commissioners ered. Examples: Only fertile women Government should define "medi­ should be held accountable when their need obstetric coverage; childless cal care." They should not yield to spe­ policies force companies to stop writing people do not need pediatric coverage, cial interest paramedical groups that health care policies, or when afford- etc. Patients should not expect demand funding for modalities that re- See "Problem” page 1 2

April, 2000 PCMS BULLETIN 5 invites you and your spouse/guest to the

Retired Physician Luncheon

C. I. SHENANIGANS Friday, April 7, 2

3017 Ruston Way, Tacoma 12:00 (noon)

AFRICAN ADVENTURES

featuring:

JOE WEARN, MD and PAT WEARN, RN

(Please clip and mail in the enclosed envelope to PCMS or call 572-3667, no later than Monday, April 3rd)

YES, I (we) have reserved Friday, April 7th to join retired members, (including spouses auests and wiriowsl of the Medical Society for lunch. Name (please print) ’ ’ widows) of

Please reserve lunch(es) for me at $16.00 per person (includes tax and tip). My check is attached.

I will be bringing my spouse or a guest. Name for name tag :_____

Thank you!

6 PCMS BULLETIN April, 2000 The Invisible Hand... by Andrew Statson, MD

a Handwriting and Hand Wringing

“The greatest blunders, like the thickest ropes, are often compounded of a multitude of strands. Take the rope apart, separate it into the small threads that compose it, and you can break them one by one. You think, ‘That is all there was!’ But Antli'cw Shi:\'i'ii, MD twist them all together and you have something tremendous.” Victor Hugo ( 1862)

At a m edical m eeting a few years was easy to call the doctor and verify it. cult to pronounce and even more diffi­ ago, the moderator was reading ques­ Now many prescriptions are filled by cult to remember. tions from the audience addressed to mail order, by people who don't know The pharmacists are another safe­ the panel. He looked at one of the slips the patients at all, and who, perhaps, guard. If the prescription is difficult to of paper and said, “I can’t read this are not even pharmacists, but are phar­ read and could be confused, if the in­ handwriting. Is there a pharmacist in macy technicians, with little knowledge structions don’t make sense, the best the house?” Physicians are notorious ofthe medications and the proper way thing to do is to call the doctor and for their bad handwriting. The pharma­ to take them. verify. We can get huffy sometimes cists are famous for their ability to read Illegible handwriting is not a prob­ when our orders are questioned it. Our handwriting today is not worse lem and never has been. If the hand­ (“Why. any idiot, including myself, can than it has always been. Why, then, the writing is not legible, it does not con­ read this prescription!”), but we need to recent noise about it? vey any information, right or wrong, remember that we are human. We Reading is a form of pattern recog­ and cannot be acted upon. The prob­ make mistakes and the pharmacists are nition. Recognition requires cognition. lem is the misinterpretation of legible the people best placed to detect them Without knowledge of the patterns and handwriting. There are several safe­ and to help us correct them. I have what they may mean, one cannot hope guards to prevent mistakes of this type, seen some very legible prescriptions, to recognize them. To read a Greek and they have lost some of their effec­ filled on military bases by pharmacy text, you have to know the Greek al­ tiveness in recent years. technicians, who did not know enough phabet. You also have to know the The most important safeguard, about the medications to pick up a mis­ Greek language. I suspect the main probably, are the patients themselves. take by the prescribing doctor. reason for the concern now has to do They usually know what medications Another safeguard arc the physi­ with prescriptions and the possibility of they are taking, how to take them, what cians themselves. I have caught myself medication errors. During the last few works for them, what has caused unto­ writing a prescription for an antibiotic years this risk has increased. Several ward reactions in the past. The prob­ and putting down one every three new developments have contributed to lem they have in recognizing their hours as needed, when I intended that this change. medications is the generic substitution. instruction for the prescription for co­ Patients used to get their prescrip­ They start on one type of pills, change deine, which I was going to write next. tions filled at their local drugstore. The to another, then to another. They are The problem here is not illegible hand­ pharmacist there knew the local doc­ told the pills are the same, but look dif­ writing. It is the problem of being tors and their prescribing patterns, as ferent because they are from another rushed or distracted by something else well as the patients and their medication manufacturer. They cannot know for that leads us to make mistakes. history and needs. With this knowl­ sure that they are taking what they took What makes our job and that of the edge, it was easy to interpret a pre­ before. The name of the medication on scription and, if there was a question, it the label also is different, usually diffi­ See ‘‘Writing" page ] 8

April, 2000 PCMS BULLETIN 7 In My Opinion. by John K. Stutterheim, MD

Nostalgia of WWII”

During January 1942 we were time of surrender and raised and living in Malang, Java. My Father restored by the Japanese. After Japan worked under Governor Van Der Plas surrendered the U.S. navy brought in Surabaja, the naval harbor. Dad her to (he west coast and sank her while target practicing. Another U.S. became in charge of finances, when Jntiii Stutterheim. MD Van Der Plas fled for Australia. Mother war ship, a submarine, lowered herself decided in February '42 to join Dad to the bottom of the harbor when under and we stayed with my aunt Loes in attack. examining while he was lying on his Embong Kenongo. At the time Surabaja During I960, when I was working back, suddenly said, ‘Tell me more, was bombed daily by Japanese planes. as an intern in the E.R. of Tacoma what a story - 1 would not have missed At a height not reachable for our anti­ General Hospital, I was confronted by this for the world.” That pulled me back aircraft, they usually showed off about Dr. Hoskins who recognized my Dutch to the present reality and we apolo­ seventeen silvery birds. They accent. He had been aboard that gized to the man, who waved his hand dropped their bombs at will. The submarine at that particular time. We as a signal that this was quite all right. harbor Tandjung Perak was a major were silent for a brief moment of time, My grandson of fourteen read this target for these Japanese bombers. recalling both our memories of that story and snickered. He asked, “Opa,is One U.S. WWI forestacker was hit and period, finally to discuss the circum­ this story going to be in your book?’* placed in drydoek in Surabaja, in 1942 stances evidenced by emotions. - it was ineffectively destroyed at the Adjacent to us, the patient I was Dr. Stutterheim is a retired family physician

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8 PCMS BULLETIN April, 2000 In My Opinion.. by David Roskoph, MBA, CFP

What Does Tax Have to do with Asset Allocation?

What do you think of when you bracket and you make $ 10,000 of short­ hear the phrase Asset Allocation? You term profits; that’s equivalent to $6,100 probably think about the relative per­ of after-tax gains. If, however, you let centages of Large Growth vs. Small the $10,000 profit ride through one Value or Domestic vs. International or year you could net $8,000 of after-tax possibly equities vs. debt (stock vs. gains! To exemplify the disparity be­ bonds). Few independent investors tween the two stated tax rates, you appreciate the virtue of creating a tax would have to make $13,115 profit at allocation of their assets. Since the the highest short-term rate of 39% just Lhh'it! lutsLt‘i>h. MBA, CFP 1997 Tax Reform Act, the disparity be­ to break even with the $10,000 profit tween capital gains and ordinary in­ from long-term capital gains rate of come tax is potentially double or net 20%. The moral of the story1; The ramifications in each of your invest­ 20%. If your income tax bracket is higher your marginal rate, the ment accounts. Each separate account 39%, so too are your short-term capital more careful your short-term in­ probably has several investment alloca­ gains. However, assets held for more vestment decisions. tion options. For instance, your 401K than one year qualify for long-term Your assets are your assets; even or other qualified plan is likely to offer capital gains and are unrelated to your if they are scattered over 8 or 10 sepa­ you several investment alternatives. As income tax bracket. Long-term capital rate accounts. Your appetite for risk well, your variable annuity and vari­ gains are presently 20%*. Forex- does not have to be replicated in each able life insurance plans probably offer ample, if you are furiously day trading separate account as long as the com­ similar alternatives. On the non-quali- stocks you might well consider a realis­ posite picture and timelines make fied side, virtually every investment is tic profit potential in light of the tax sense. Take a minute to consider the bite**. Assuming you are in the 39% investment allocation versus the tax See “Tax" page 10

Original Asset Allocation

Non-Qual Account

[ | Investments intended for long-term hold Investments subject to short-term trading

See page 10 for Tax-Smart Asset Allocution graph

April, 2000 PCMS BULLETIN 9 B u l l e t in

tax consequences of short or long-term As your marginal tax bracket rises, l c l \ from page 9 transactions are irrelevant; the funds it becomes a progressively better deal available. Let’s look at the big picture come out to him as ordinary income to pay long-term capital gains over or­ of a hypothetical investor who has 1/3 when withdrawn. For that portion of dinary income tax. Do the math. The invested in index funds, which he in­ his investments more or less committed difference can be dramatic and well tends to let compound until he draws to a long-term horizon (in this case in­ worth the energy it takes to make a them down in retirement. Our investor dex funds), he should consider shifting composite picture of your portfolio and likes to play the market with the re­ them out of his qualified vehicles. By reallocate among tax-qualified and maining 2/3 taking advantage of oppor­ separating the assets into those likely- non-tax-qualified accounts. You might tunities regardless of their tax conse­ to-be-traded-within-one-year and those do well to consider a financial planner quences. This investor might consider not-likely-to-be-traded-within-one- who can collect the pieces of your scat­ some tax-smart allocation by placing as year, the investor maximizes his after­ tered investments and create a homog­ much of his trading portfolio into his tax gain by minimizing short-term enized, consistent and tax-efficient qualified plan and or variable insur­ gains (ordinary income) without com­ portfolio w hich m akes sense from a tax ance products as possible. There the promising his desired asset allocation. and asset allocation perspective."

Tax-Smart Asset Allocation

| | Investments intended for long-term hold Investments subject to short-term trading

* For taxable years ending after 2000, property held for 5 years qualifies for an even lower 18 %, 8%for brackets below 28%. ** According to the NASAA (North American Securities Administration Association), Independent analysis finds that at least 70% o f day traders lose money and only 1! .5% showed profitable short-term trading.

David J. Roskoph, MBA, CFP is president of Total Asset Management, Inc. in Gig Harbor. 858-2745

Securities offered through Pacific West Securities, inc. Member NASD/SLPC

10 PCMS BULLETIN April, 2000 v _ 'ipo/o/ftf- Q ‘fledtew I (ifoetety

The Health Status of Pierce County

Prevention priorities determine department direction TACOM A-PIERCE COUNTY HEALTH DEPARTMENT

The Tacoma Pierce County Board of Health established three prevention “Tobacco use is the major preventable cause of priorities - behaviors which, if changed, would drop mortality and illness and death in the United States. It causes morbidity statistics. The three areas the diseases at a rate four times greater than department is focusing social marketing campaigns on, to change unhealthy alcohol use and fifty times greater than street behaviors are: tobacco use. alcohol abuse, and violence. Physicians play drugs. Tobacco use or exposure kills more than a key role in these areas. By asking questions and referring 1300 people each clay in the U. S. alone. ” patients to community resources, you too can help lower the incidence of illness and death also add indicators in computer files to Then you or your medical assistant can from these causes. Over the next show who uses tobacco and who does connect the patient to intensive several months, the health department’s not. smoking cessation programs. One column will include practical ways Advise tobacco users to quit: resource is the Health Department’s physicians across the county can help It is valuable for a patient to hear from cessation line at 253-798-4743. to change individual’s behaviors. her/his physician that tobacco use is a Finally, make a follow-up One system that has proven to be health problem. In a clear, strong and appointment. Congratulate the effective - and not time consum ing - is personalized manner, urge every patients on successes and help her/his the 4-A Model of Tobacco Cessation. tobacco user to quit and add that you recommitment after a lapse. Review the During an office visit, the physician: will help. If it is appropriate, add a benefits quitting gives to the patient- personal note, such as ‘'You’ve had especially health-related. Inquire about one heart attack already," or, “Your specific problems and help her/him I Asks about tobacco use child has asthma and environmental problem solve, getting to another I Advises tobacco users to quit smoke only adds to her condition.” commitment to abstain from tobacco ♦ Assists the patient with a quit Assist the patient with a quit use. plan plan: Advise the patient to set a quit Tobacco use is the major prevent­ * Arranges quit programs/ date within two weeks of your conver­ able cause of illness and death in the therapies or connects to other sation. Then suggest that she/he United States. It causes diseases at a resources inform friends, family and coworkers rate four times greater than alcohol use of his/her plans to stop and ask for and fifty times greater than street Here are some ideas for imple­ their support. Recommend that she/he drugs. Tobacco use or exposure kills menting this model. remove tobacco from his/her home, more than 1300 people each day in the Ask about tobacco use: Set up car and workplace. Finally, talk with U.S. alone. Asking questions, advising an office-wide system that asks about the patient about previous attempts to a patient to quit and then helping her/ tobacco-use status and records that stop tobacco use, identifying what him with a plan and a program to slop information in the patient’s record. One worked and what led to a relapse. using tobacco will make a difference in way to do this is to include tobacco use Arrange for a support the lives of your patients and the in the vital signs data collected. program. Consider using nicotine overall health of the community. Another is to put tobacco-use status replacement therapy, prescribing gum Thanks for working with us in helping stickers on patient’s charts. You can or the more effective patch system. people to quit.i

April, 2000 PCMS BULLETIN 11 B ulli-t i n

This could lead to great savings. Sev­ have the luxury of medical students, in­ Problem from page 5 eral examples exist where very expen­ terns, residents, fellows, or nursing stu­ dents. Clinical physicians must often able coverage becomes unavailable. sive pieces of equipment have been stand-alone, render proper care, and Commissioners should not be allowed purchased that now sit idle or fail to run a business. Our teaching center to mandate coverage for special inter­ meet the needs of physicians. Consulta­ must teach more than academic medi­ est paramedical groups. tion with a broader spectrum of medical cine. The Federal Government’s intru­ staff members could have vastly im­ Physicians must avoid contracts sion into American Medicine must be proved efficiency, increased utilization, that produce conflicts of interest or questioned. Both the VA medical sys­ and saved money. How can a hos­ burden them with unnecessary liability. tem and military medicine represent pital system justify this waste and then Their first responsibility is to their pa­ single payer socialized government buy cheap soap, cheap scrub suits, tients, not their employer, not their hos­ sponsored programs. Neither system is cheap toilet paper, cheap paper towels, pital, and not some contract. Physicians known for efficient care or cost con­ etc.? must be willing to speak out when they tainment. Many veterans and military Hospitals should improve materials witness poor care by peers, unethical dependents have difficulty finding management, stenography, computer conduct, impaired physicians, or im­ physicians and facilities for care. So­ hardware and software, and communi­ proper care. Physicians must set reason­ cialized medicine would not improve cation. able fees and demand just compensa­ medical care in this country. Hospitals and States can reduce tion for services rendered. Medicare's original mandate was to pay costs in other ways. The following are All parties concerned need much 80%' of reasonable physician and hos­ three examples of policies that have better communication. We must define pital fees. This chronically under horrible cost benefit ratios and should the needs of citizens and limit care to funded program has never lived up to be abolished. those modalities that have the best expectations. 1) Hospitals should stop seeking Drug companies should continue JCAHO review. The benefits in no chance of helping our patients. Mod­ to research, develop, test, and market way justify the expense. This commis­ ern m edicine is very expensive and all new drugs. They should be liable for sion has become a bureaucratic disas­ citizens must pay if this care is going to any withheld negative test results or ter and does not improve patient care. be available in the future. Patients de­ any fraudulent tests. For FDA ap­ 2) State mandated CMEs seem po­ serve good medical care and physician proved dings they should relinquish litically correct and sound good but and health care facilities deserve ad­ their sole rights when expenses and they have not been proven effective. equate compensation. All of us deserve reasonable profits have been CMEs are effective tools for physicians a better effort from our politicians, ju­ achieved. Generic drugs must be as ef­ but state mandated programs waste dicial system, and legal system. A great fective and safe as brand name drugs. money. deal of work must be done. ■ [f not, the manufacturer should be li­ 3) Certificate of Need require­ able. ments have never been shown to re­ Lawyers should be liable for all duce the cost of care. This requirement expenses and fees when their claims should be abolished. arc frivolous or unfounded. The con­ Academic Medicine must reassess tingency system for compensation its effect on our medical system. These centers are geared up to educated should not be allowed for malpractice AMERICAN LUNG ASSOCIATION, claims. All malpractice claims should be people, but with the decreasing num­ ofW3sh/ngton subjected to an arbitration hearing and ber of physician candidates, these cen­ t the findings of the hearing should be ters are training physician assistants, allowed in court. nurse practitioners, podiatrists, and 1-800-LUNG-USA Hospitals should reaffirm their pri­ nurse anesthetists. All of these people have a place in our medical system but mary mission of efficient, quality patient Lung Information care. Hospitals should trim their admin­ cannot, and should not, replace experi­ istrative staffs. They should stop writing enced clinical physicians. Patients Service Line long, poorly written, overlapping, im­ should not be led to believe that these people are the equal of physicians. possible policies. Pro viding patient Hospitals should, once again, use Academic Centers must recognize their medical staffs as a resource rather and teach efficient clinical medicine. education materials than treat them as a necessary evil. Physicians in clinical practice do not

12 PCMS BULLETIN April, 2000 Regence leaders discuss issues of Patrice Stevenson, MD concern with Board ofTrustees chairs w sm a Women in Medicine Committee John Holtermann, VP, Provider reduce payment by 30%. They have Relations and Jeff Robertson, MD, received intense feedback from Medical Director for Regence, met surgeons and they believe they really Patrice Stevenson, M D , PCM S with the PCMS Board of Trustees at insulted their professional integrity and President-Elect, is chair o f the W SM A ’s their March 7th meeting. They were are sorry for this, but the rates will Women in Medicine Committee. The invited to discuss issues of concern, not be changed. They had 140 com m ittee’s focus is issues confronting particularly contract terminations, surgeons terminate, but feel they still women physicians, particularly network adequacy, reimbursements, maintain an adequate network as they balancing professional and personal etc. meet their standards for adequacy. responsibilities and women's health John Holtermann explained that But, they have many very upset issues. Another goal, according to Dr. they had been meeting with physicians’ specialists. They are in the process of Stevenson, is mentoring women in groups since last fall and they have starting a professional fee advisory leadership roles. been getting feedback that has been committee, which will be multi-specialty The Committee is sponsoring an helpful. He explained that Regence and all members will be physicians. educational program in conjunction needed to return to a profit mode as They are already thinking about with W SM A Annua] M eeting in they have experienced significant January 1, 2001, (new contracts) and September which will focus on cardio­ underwriting losses in the last few are working on options. They are vascular disease and breast cancer. years. Their investment gains are thinking about a CPI adjustment every If you would like more information market driven and are not dependable year, or an inflation factor built in each about Women in Medicine activities, for future planning. However, the year, or a new policy or a split conver­ please call Dr. Stevenson at 841-5849." gains have been considerable re­ sion factor, one for cognitive, one for cently. Regence has set a goal of one- procedural. They did note that their half percent underwriting gain, which policy to not negotiate on fees has they have not yet achieved. They caused grief for them and that as they found claims have been going up 15- have negotiated on other things Personal Problems 17% each year, due to, in part, their perhaps they need to reconsider of Physicians requirement to cover alternative this policy and negotiate on fees practitioners. Outpatient costs have as well. skyrocketed, increasing 12-15% per They noted that they are really Medical problems, drugs, year, and pharmacy costs have become trying to reduce administrative hassles, alcohol, retirement, emotional, astronomical. They said they are just particularly prior authorizations. They or other such difficulties? trying to plug the dikes. Five years are trying to eliminate referral systems ago they spent $5 per every $ 100 on but they noted that the purchasers are pharmacy costs, now they spend $25, a not agreeable. They will be putting '< m cdleasues 20% increase, which they expect will together focus groups to study this >vant tc help continue to increase. They are issue. They did note that authori­ working on many angles for reduc­ zations can be done electroni­ tions, including their administrative cally and suggested that offices costs. They feel they are very efficient do this and to call Regence if *Robert Sands, MD, Chair 752-6056 as a health payer. They reported a $15 they are interested. Bill Dean, MD 272-4013 million increase in physician payment, For the year-, 2000-2001 they will Tom Herron, MD 853-3888 which included significant devaluation be working on a new pharmacy system Bill Roes, MD 884-9221 of surgical procedures. They ex­ that will be three tiered. The system F. Dennis Waldron, MD 265-2584 plained that if you calculate the new will put the cost of highly advertised rate, over time, with weights, it does drugs on to the consumer. ■ Confidentiality Assured

April, 2000 PCMS BULLETIN 13 W hat riches do you have in YOUR basement?

Do you have old medical r a v e l e y ' 5 equipment you no longer use? L Do you have textbooks from the Health Service past ten years you haven’t touched? A service of Especially Dermatology, Peds, Northwest Medical specialties, PLLC Infectious Diseases, Surgery, Ophthalmology, Orthopedics. INTERNATIONAL TRAVEL CAN BE Would you be willing to donate HAZARDOUS TO YOUR HEALTH them to a third world country? Dr. Teresa Clabots, a • PRE-TRAVEL CARE • POST-TRAVEL CARE refugee from Cuba has relatives that HOURS CALL EARLY WHEN PLANNING are taking medical supplies, equip­ MON-FRI 9-5 ment and books back to Cuba this 253-428-8754 summer after a 40 year embargo. If or 253-627-4123 you have anything that you think A SERVICE OF might help, please don’t hesitate to INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph's Hospital) call Dr. Teresa Clabots, 588-6574 or 582-043CK evenings).

N o w

O p e n

S a t u r d a y s

14 PCMS BULLETIN April, 2000 PAfVtV» -'■'((cditn/tfoaW//

COLLEGE Continuing Medical Education OF Allergy, Asthma, Pulmonology MEDICAL CME scheduled May 5

GVMAIIOK The College's CME program fea­ This year's program will feature turing subjects on allergy, asthma and presentations on: pulmonology is set for Friday, May 5. The course is under the direction of t Asthm a Alex Mihali, MD. ► Sinusilus This is a one-day update designed ► Allergic Rhinitis Surgical Update- I Pneumonia and COPD for the primary care provider. It will ► Lung Cancer Screening & focus 0 11 diagnosis and management of M anagem ent dissections, CM E common allergy, pulmonology and ► Atopic and Contact Dermatitis asthma problems. set April 28 & 29 This program is complimentary to For registration information call the all area physicians. An annual confer­ College at 627-7137. Although no regis­ Dr. Virginia Stowell, Tacoma ence, it has been developed with sup­ tration fee is required, physicians wish­ genera] surgeon, is directing the 69th port from local pharmaceutical compa­ ing to attend must complete and return a Annual Surgical Club meeting which nies. registration form. The conference is will be held The program will be held at the anticipated to fill, so early registration is Friday and new Lagerquisl Center in St. Joseph encouraged. Saturday, H ospital. April 28 and 29,2000. The very popular Gastrointestinal Disease CME - June 2 dissections, demonstra­ A GI Update CME program offered physicians from Seattle to Olympia, tions and bi-ennially is set for Friday, June 2, botli in academic and private practice. lectures 2000. The program, directed by Drs. Recognized experts from outside our presented annually by the Tacoma Gary Taubman and Rick Tobin, is a region will also be featured. Surgical Club will be held at Tacoma one-day course for primary care The course will reflect the multi­ Community College in the Lecture physicians. It will feature faculty from disciplinary approach used commonly Hall, Building 16. the Tacoma Gut Club whose members in managing patients with gastrointesti­ On Friday afternoon, April 28, represent a diverse group of expert nal illness. dissections and demonstrations on cadavers will be performed for health care providers and interested students. Dates Program Director^} Beginning Saturday morning, several Monday - Friday short lectures featuring the latest CMH @ Hawaii 1 Mark Craddock, MD April 10-14 developments in surgery will be presented by local physicians and Saturday, April 29 Surgery Update 2000 I Virginia Stowell, MD Army Medical Corps doctors. Asthma. Allergy & I The Surgical Club Annual Dinner, open to Surgical Club members and Friday, May 5 Pulmonology for Alex Mihali, MD invited guests will be held Saturday Primary Care evening, April 29 beginning at 6:30 p.m. Nuts, Bolts & I at Tacoma Country and G olf Club in Innovation: Gary Taubman, MD Lakewood. Friday, June 2 Gastrointestinal 1 Richard Tobin, MD Call the College, 627-7137 for registration information. Disease V I

April, 2000 PCMS BULLETIN 15 B u l l e t in

Doctors’ notes on patients’ charts - Unedited!

Patient has chest pain if she lies on her left side for over a year. On the 2nd day the knee was better and on the 3rd day it disappeared completely. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night. The patient has been depressed ever since she began seeing me in 1993. The patient is tearful and crying constantly. She also appears to be depressed. Discharge status: Alive but without permission. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful. The patient refused an autopsy. The patient has no past history of suicides. Patient has left his white blood cells at another hospital. Patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days. Patient had waffles for breakfast anorexia for lunch. Between you and me we ought to be able to get this lady pregnant. Since she can't get pregnant with her husband, I thought you might like to work her up. While in the ER, she was examined. X-rated and sent home. The skin was moist and dry. Patient was alert and unresponsive. She stated that she had been constipated for most of her adult life, until she got a divorce. The patient was to have a bowel resection. However, he took a job as a stockbroker instead. The pelvic examination will be done later on the floor. Patient has two teenage children, but no other abnormalities. The lab test indicated abnormal lover function. ■

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16 PCMS BULLETIN April, 2000 The Pulse PCMS Alliance

Agencies thank PCMS A for philanthropic gifts

Dear Ms. Thomas: Thank you for the generous donation for Asthma Camp at Camp Left: Mrs. Fran Sealth from the Pierce County Medical Thomas, (left) wife of Society Alliance. As you know, the pediatrician William group’s donation will be used to send a Thomas. MD, with needy child from the Pierce County area students posing as to Asthma Camp. parents o f the Each Fall, we send out an Asthma infamous "Baby Camp newsletter to all campers, Think It Over" doll sponsors, volunteers and donors. The Pierce County Medical Society Alliance will be featured as a donor in the 2000 newsletter. I will send you a copy when it is printed, along with the most recent edition o f our annual report. On behalf of the American Lung Dear Fran: Association of Washington and our You were ccrtainly a bright spot in my day. In my thirty years of teaching I’ve asthma campers, thanks once again. never had someone call and ask for my wish list. Thank you so much for your part in Penny Grellier helping us get the four new realistic babies, gear, and The Gamble Learning Model. Asthma Camp Coordinator Monday after Monday I see students drag in to class saying, “Take this baby, now!” We appreciate your support for our program. We are all working together to reduce teen pregnancy. Thank you so much. Dorothy Hudson Family/Consumer Science Teacher Ms. Thomas & PCMS A Members: Woodrow Wilson High School Thank you so much for the financial support for the YWCA Dear Ms. Thomas: Women’s Health Program, as well as for the vote o f confidence. On behalf of the Board of Directors, staff, volunteers and clients of the Pierce You may expect quarterly reports County AIDS Foundation let me offer my warm thanks for the contribution ofS500 on program performance, and we look made by the Pierce County Medical Society Alliance. This generous commitment forward to recognizing your contribu­ has made it possible to help support critical care sendees for clients: emergency tion in our newsletter. Thank you! grants, home delivered food bags, products for the essential needs bank, and other Tacoma YWCA products which help our clients address the exacerbating affects of poverty on an immune system already comprom ised by HIV. Last year, the Pierce County AIDS Foundation served its 1,804th client, and, in 1999 we served a total of 94 new clients. Increasingly, our clientele has been Dear Ms. Thomas: distinguished from the state as a whole by a clientele which is poorer, has a lower Thank you for your generous gift average educational level and contains a higher percentage of women, people of to Trinity Clinic. Our prescription color, youth, and individuals who are double or triply diagnosed with HIV/AIDS as costs have risen and it is very much well as mental illness and chemical dependency. This is a constituency which has appreciated. We stamp each free even more need for the essential sen/ices provided by PCAF, and of the generous prescription, acknowledging your support that our donors provide contribution. Thank you again. Nancy Ryan Jeanne McGoldrick Deputy Director

April, 2000 PCMS BULLETIN 17 Writing from page 7 all notes and prescriptions should be drops the ball and no-one picks it up typed. They will be neat, easy to read, that patients can get hurt. During the past several years we pharmacists even harder is the flood ot definitely legible. Would that eliminate have been asked to work more for less new preparations on the market about errors? Unfortunately, no. You know pay, the hospitals have cut down on which we are not properly informed, the errors your dictated hospital notes their personnel and services, we all are but which the patients clamor to get can have. It's like playing Pass-it-on. rushed, trying to take care of more pa­ because they have seen the ads on tele­ We all have seen those lists of hilarious tients and to do more chart documenta­ vision or on the Internet. In the past, I transcription errors. Here is one not tion. In sum, we have had to run much used to see five to ten drug representa­ funny at all. The dictation was “The pa­ faster just to stay in the same place. tives per week, telling me about new tient was propped and draped." The Now we are asked to provide all those products and giving me literature to re­ transcription was “....and raped." There services not only in less time and at a view, so I could learn about them. Now it was, neatly typed, perfectly legible. It lower cost, but also without errors. Un­ I don’t even see one drug representa­ is amazing what those gremlins called fortunately, one cannot get Mercedes tive per week. New drugs and new typographical errors can do. We also quality at Yugo prices. The only way to dosages appear on the market with could misspell the name of the drug. very little notice to us. How are we go­ Usually, alert pharmacists can catch reduce medical errors is by constant ing to prescribe them, if we don’t know most errors, but can they always? The vigilance on the part of the entire medi­ they exist, let alone their possible side- opportunities for human error are al­ cal care team, preferably with the par­ effects. cross-reactions or complica­ ways present. Fortunately, most ofthe ticipation of the patients. To achieve tions? All of these are important items time they are minor and easily cor­ that, we need to have knowledgeable to know' in order to prescribe prop­ rected. Sometimes they are serious and and alert medical team members. We erly. potentially deadly. need to pay them what they are worth, Another aspect of legible hand­ The extensive experience with so they don't have to work overtime, or writing concerns our chart notes. The our residents has proven that when moonlight on another job, just to make insurance companies want documenta­ they are overworked, tired and sleep- ends meet. We need to relieve them of tion of services so they can pay. If our deprived, they are more likely to make what is gradually becoming an impos­ chart notes are not legible, we don’t mistakes, and their mistakes are more sible paperwork burden. have the documentation. Of course, likely to be serious. These findings led Knowledge and alertness are the we can read our own handwriting (we to significant changes in their work best tools to reduce medical errors. can, can't we?) and interpret it for load and call scheduling. They conic at a price and if our goal is them. But that may or may not be ac­ In practice we work as part of a fewer mistakes, we should be willing to ceptable. team, with office medical assistants, pay it. But we cannot expect to elimi­ I usually can read what I have pharmacists and nurses. When some­ nate mistakes altogether. That is not written on the chart, but I admit I have one makes a mistake, another member possible. We are human. Let the legis­ a hard time reading someone else's of the team will usually pick it up and lator who has never w'ritten a law with a handwriting. 1 can make out the words help correct it. it is when someone loophole cast the first stone.■ most of the time, but I get lost in the ab­ breviations. We all use abbreviations. We have to. The problem is that every school and every specialty has its own that they understand. Those who did UNION AVENUE PHARMACY not go to that school or are not of that specialty have to guess, sometimes cor­ Professional Compounding Center of Tacoma, WA rectly. sometimes not. We know' AMA means American Medical Association, we can guess when it may mean Vaginal Suppositories Gel, Ointment, and Cream against medical advice, but how many Rectal Suppositories IV Services among us know that it really stands for Urethral Inserts Capsules advanced maternal age? A patient in Sublingual Troche Lip Balms labor may deliver with PCB, which may mean paracervical block, but also, prepared childbirth. 2302 South Union Avenue 752-1705 Let us forget handwriting. Maybe

18 PCMS BULLETIN April, 2000 Classified Advertising

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April, 2000 PCMS BULLETIN 19 B u lletin fierce ^oun/y Q/filedical Society

Policyholder Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether its a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and m the future, is to help physicians, clinics, and hospitals remain successful. I F Physicians @m Insurance W estern W ashington 1-800-962-1399 A Mutual Company

i_r-j.iii'd and sp. -rin ireci bv ihr Eastern Washington 1-800-962-1398 Vw^hciir.on si.iii' Medic.'i! A iio c ijiin n Oregon l-800o65-1892 r 11 W A ■ Physicians Insurance 1999

Pierce County Medical Society PRESORTED 223 Tacoma Avenue South STANDARD Tacoma, WA 98402 US POSTAGE PAID TACOMA, WA PERM IT NO 605 Return service requested

20 PCMS BULLETIN April, 2000 Left, DeM aurice Moses MD, retired Puyallup pediatrician was recently recognized by the Rotary Clubs of Fierce County for Ills service to the community see story, page 9

Right, Joe Wearn, MD was honored by the Franciscans for thirty-three y e a r s o f commitment to m edicine at his recent retirement celebration see story; page 5

INSIDE; 3 EMTALA: A Primer 4 Retired members see Africa in extraordinary pictures taken by Joe and Pat Wearn 6 “Tacoma’s controversial agent of change,” Dr. Federico-Cruz Uribe shakes up the system 7 June General Membership meeting features an evening with Dr. Cruz-Uribe 8 Dystonia Foundation recognizes Dr. Pat Hogan, Tacoma Neurologist 13 TPCHD: Handgun Safety for Pierce County 14 Online Medical Resources B u l l e t in

PCMS Officers/Trustees: _ VPiewe ‘fppttnf// Q,4iedimf Society- — Charles M. Weatherby, M D .....P resident PatriceN. Stevenson, M D ...... President Elect Susan J. Salo, M D ...... Vice-President J. Jam es R ooks, M D ...... Secretary/Treasurer Bulletin. Lawrence A. Larson, DO ...... Past President Sabrina A. Benjamin, MD DrewH. Deutsch,MD K evin K. G andhi, M D M ichael J. K elly, M D M ay 2000 Doris A. Page, MD Edward 1. W alk ley, M D Yolanda Bruce, PCMS A President

WSMA Representatives: Speakerofthe House: Richard Hawkins, MD Trustee: David Law, MD AMA Delegate: Leonard Alenick, MD W AMP AC Chair/6th District: Mark Gildcnhar, M D W A M P A C 9th District: D on R u ssell, D O

Executive Director: Douglas Jackman

Committee Chairs: Table of Contents Aging, Richard Waltman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, W. Dale 3 EMTALA Issue: A Primer Overfield; Credentials, Susan Salo; Emergency Medical Standards, Ted Walkley; Ethics/ 4 Retired members tour Africa with Joe Weam, MD & his wife Pat Standards Of Practice, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, William Ritchie; Legislative, William Marsh; Mcdicai-Legal, 5 Joe Weam, MD honored for retiring after 33 years of service Pat Donley; Membership Benefits, Inc., Drew Deutsch; Personal Problems Of Physicians, Robert 6 Dr. Federico Cruz-Uribe, Tacoma's agent of change Sands;1 Public Health/School Health, Sumner Schoenike; Sports Medicine, John Jiganti. 7 June General Membership Meeting features Dr. Cruz-Uribe The Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce County Medical Society. Deadlines for submitting 8 Dystonia Foundation honors Patrick Hogan, D.O. articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. 9 Rotary Clubs of Pierce County honor DeMaurice Moses, M.D. October 15 for the November issue).

The Bulletin is dedicated to the art, science and 10 Mark your calendar for September 12th General Meeting delivery of medicine and the betterment of the health and medical welfare of the community. The opinions 11 The Invisible Hand: "On Rights and Wrongs" herein are those of the individual contributors and do not necessarily reflect the official position of the Medical Society. Acceptance of advertising in no 12 Go shopping: SupportMAssociation.com way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin 13 TPCHD: Handgun Safety and Pierce County Medical Society reserve the right to reject any advertising. 14 OnlineMedical Resources Editors: MBI Board of Directors Managing Editor: Douglas Jackman 15 COME: Allerg)' and GI courses upcoming; Watchfor May survi Editorial Committee: MBI Board of Directors

Advertising Representative: Tanya McClain 17 "$15 for a Kawasaki," by Teresa Clabots, M.D. Subscriptions: S50peryear, $5 per issue 19 PCMSA: March meeting updates Make all checks payable to: MBI 223 Tacoma Avenue South, Tacoma W A 98402 253-572-3666, FAX253-572-2470 22 A Different Perspective

E-mail address: [email protected] 23 Classified Advertising HomePage: http://www.pcmswa.org

2 PCMS BULLETIN May, 2000 f f l k r c e Q ,'((eclical & c a t t y

cnprin\ FPdtlirP by MaryGiannini, JD opeOltLi rvu,LU/it> Witherspoon, Kelley, Davenport & Toole

EMTALA Issues: A Primer

Editor's Note: In light o f the recent appropriate screening exam, the hospi­ If a patient has an emergency medical < discussions regarding mandated trauma tal must show that it uses a uniform cond i tion, then the hospi tal must pro­ ; call and EMTALA, the following is screening procedure for every pa­ vide treatment to stabilize the emer­ ^ presentedfor clarification o f the act. tient, regardless of die patient's ability gency medical condition or provide for Both Tacoma General/Allenmore and to pay. A number of courts have inter­ an "appropriate transfer" to another St. Joseph/St. Clare medical staffs preted "appropriate medical screening" medical facility. received letters regarding mandated to mean uniform trea t- The definition of "stabi­ trauma call which initiated lots o f ment rather than correct lize" or "stabilization" is key questions and concerns. The PCMS diagnosis, stating that to potential liabili ty for the Board of Trustees also discussed the EMT ALA was not d e- hospital. The EMTALA issue at their most recent board signed to be a federal definition of "stabilize" is meeting and determined that more remedy for misdiagnosis broader than normal physi­ information would be helpful. This or medical malpractice. Ft +l> cian usage: it means " to pro­ article is reprintedfrom the Spokane a court case the burden is EMERGENCY vide medical treatment as County Medical Society Bulletin. on a plaintiff to show the necessary to assure that hospital screening devi­ within reasonable medical The Emergency Medical Treat- ated from the uniform probability no material dete­ Jl£ ment and Active Labor Act screening procedure and that other rioration is likely to result from or occur ("EMTALA") became law in 1986. The patients received a different, more during the transfer." Stabilization does ( law applies to all hospitals that partici­ thorough screening. For example, a not require that a patient's emergency pate in Medicare and provide emer- patient who had been involved in a car medical condition be completely re­ a ' gency services. accident was able to show an EMTALA moved prior to a transfer or discharge. EMTALA protects all persons who violation by presenting evidence that Further, a patient bringing an EMT ALA come to a hospital emergency room, another person involved in the same claim must prove that his or her condi­ regardless of insurance coverage or car accident underwent more diagnos­ tion at d ischarge or transfer would not ll!c ability to pay. The hospital must pro­ tic procedures titan the plaintiff did. have been considered stable for any vide an "appropriate screening exami- (This obviously begs the question other patient. Unfortunately, HCFA en­ !l[i nation" withintheER'scapability (in­ whether the other person's medical forcement officials typically try to hold cluding ancillary services available to condition warranted differait diagnos­ hospitals to tine higher standard of actu­ the ER) to each person who requests tic procedures, but it points out the vital ally removing the emergency medical an exam or emergency treatm ent The importance of a clear hospital policy on condition before transfer or discharge. law specifically applies to pregnant what constitutes a uniform screening It is important to realize that "trans­ women in labor. The hospital may not procedure.) fer" as defined by EMT ALA encom­ delay an examination or stabilizing "Emergency medical condition" is passes "any movement of an individual treatment to ask about a patient's insur­ defined in EMTALA as"amedical outside of the hospital's facilities at the ance or ability to pay, though a recent condition manifesting itself by acute direction of any person employed by (11/99) Health Care Financing Adrrurus- symptoms of sufficient severity (includ­ or affiliated with the hospital." This defi­ tration ("HCFA") Special Advisory Bul­ ing severe pain) such that the absence nition includes discharge to a patient's letin focusing on EMTALA and man­ of immediate medical attention could home, or to a physician's office during aged care authorizes a hospital to seek reasonably be expected to result in : regular office hours. Hospitals have re­ I payment authorization for payment 1) placing the patient in serious cently been cited for EMTALA viola­ from a managed care plan "after pro­ jeopardy; tions for routine discharges where pa­ viding a medical screening examination 2) serious impairment to bodily tients were later discovered to have un­ and once necessary treatment is under­ functions; or detected medical problems or complica­ way." 3) serious dysfunction of any tions. For that reason, hospitals have To meet the requirements of an bodily organ or part." I See "EMTALA” page 20

May, 2000 PCMS BULLETIN 3 B u l l e t in

Retired members tour Africa with Joe and Pat Wearn

Retired members and widows, spouses and guests took a trip to Africa with Dr. Joe Wearn and his wife Pat at the April 7th retired member luncheon at Shenanigan's Restau­ rant inTacoma. Fifty people attended the luncheon which is held three to four times each year. The program was particularly delightful due to the quality and nature of the photographs shown by the Weams. Using top quality photo equipment including an easy clip-on style tripod, Dr. Wearn's slides were extraordinary. Fie captured nature at it's finest Numerous birds, African animals of the wild including giraffes, elephants, monkeys and rhinoscerous and flowers unheard of. Dr. Wearn s presentation was his initiation into tire group as he was just completing his first full week of retirement, (see Speaker Joe Wearn, MD (center) visits with Dr. Bob story page 5) ■ Florence, retired orthopedic surgeon and his wife, Helen

From left, Dr. David Sparling and wife, Barbara, and Dr. Dr. Kiyoaky Hori, reitred anesthesiologist (right) and wife Richard Hoffmeister and wife Juley visit after the meeting Patricia Palms (left) w ith speaker, Pat Wearn

I d'lh, L SrL Widows Rubye Ward (center) and Marilyn Mandeville From left, Julia Mueller, Barbara Sparling, and Patricia Palms (right) visit with Dr. John Colen enjoy African treasures shared by Pat Wearn

4 PCMS BULLETIN May, 2000 Special Feature

HONORED BY PATIENTS, COLLEAGUES AND FAMILY ON

Joe Weam, MD HIS RETIREMENT

Joe Wearn, MD, Tacoma pediatrician, hung up his stethoscope for the last time on March 31,2000. He said goodbye to long time patients and colleagues, having practiced in Pierce County for thirty years. Dr. Weam completed medical school at the University of Pennsylvania, then served in the Army from 1963-1970, completing both an internship and residency. He began his pediatric practice in Tacoma at Western Clinic in 1970. Western Clinic was eventually purchased by the Franciscans. He experienced many changes in medicine during his career but maintained his responsibility to his patients, never lost sight of hi s integrity, and remained devoted to the profes­ sion of medicine. An avid supporter of organized medicine, Dr. Weam was very active in PCMS activities. He was a member of the Public Health/ School Health Committee since 1974, serving as chair in 1998 until his retirement. He has served as a board member of the PCMS for-profi t subsidiary, Membership Benefits, Inc. since 1990, and was president from 1992-1995, leading the way to operation of the temporary services division of the placement service. He was Secretary- Treasurer for PCMS for two terms, in 1990 and 1991, being instrumental in the purchase of the building at 223 Tacoma Avenue South in 1990. Too numerous to mention, he belonged to and supported many other organizations and associations throughout Iris career. The Franciscans honored Dr. Weam at a retirement party on April 9th. Patients, friends and colleagues attended to thank him, honor him and wish him well. The Franciscan leadership ex­ pressed their gratitude for his professional contributions and s teadfast service to their organization. Patients expressed their gratitude as they gave tribute to their doctor and friend. Colleagues and family members couldn't remain silent. "He has made me the doctor I am today," said fellow pediatrician, Dr. Brian Berry. "I owe him a gratitude of debt for all he has done forme, he added. Son Matt, paid his respects and admiration, and wife Pat, was all smiles, "Now I get him all to myself," she beamed! PCMS extends congratulations and best wishes to Dr. Weam and his family. ■ Tacomas controversial agent of change

Health chief Cruz shakes up the system names of people who are in the non-in- fectious stage of that disease. by Jack Hopkins, PI Reporter Tire controversy over AIDS and HIV patients has led the Governor's T ACOM A - Tacoma-Pierce here...well, they seem pretty pale by Advisory Council on AIDS/HIV to ask County Health Department Director comparison," he said. "It made it pretty the state Department of Health to de­ Federico Cruz-Uribe was working easy for me to say: "Well, Federico, clare the Tacoma-Pierce County Health in tire Guatemalan highlands more than what are your values and what are you Department out of compliance with state 20 years ago when government death hying to accomplish?" If it is tine right rules. squads began systematically killing the tiling to do, you should do it. And if But Cruz says it makes no sense to people who were helping him set up a people give you grief, you deal with put a 90-day limit on tire time county program to provide medical care for it...Pressure and threats don't make health departments can keep tack of the tire poor. much of a dentonm e." names of people who have HTV when So, Cruz, 50, head of the Health De­ they pose a threat to the rest of the com­ he is not at partm ent since 1992, lives by those munity for the rest of their lives. all words. "W ith tire new drugs available for troubled One of the first tilings he did after treatment today, they are feeling much by the being named health department direc­ better and., .can fall into their old habits," lawsuits, tor was close ever}' clinic operated by Cruz said. "And the last thing we need is com­ the agency and get the private medical people with the HTV virus behaving as plaints, community to start providing health if they don't have it." threats sendees for poor people. " Cruz-Uribe is completely out of and out­ Changing the agency's focus from control," said Richard Jackman, a rage he providing patient care to disease pre­ spokesm an for Resist the List, a Seattle- Federico Critz-Vrihe. A ID lias vention led to massive staff turnover based organization that has sued the generated and lighted the fuse for controversies Tacoma-Pierce County Health Depart­ tire past few years as he has waged that have swirled around tire depart­ ment to force it to purge the names of war against tine tobacco industry and ment ever since. HI V patients from its records. "Firsthe taken controversial stands on keeping Almost immediately, he targeted breaks tire law to play sex police and lists of everybody who tests positive the powerful tobacco industry. At his now this," Jackman said, referring to the for the AIDS virus or for tuberculosis. urging, the health department board decision to begin collecting names of His problems here are insignifi­ approved a groundbreaking ban on people who hav e non-contagious TB cant in comparison. outdoor advertising of tobacco prod­ infections. Cruz went to Guatemala in 1978 ucts throughout tire county. Cruz, an informed person whose after graduating from medical school in Pierce County w as the first in tire milltownbackground shows inhis dis­ Wisconsin. He quickly got caught up state to enact such a ban. King County in tire civil war raging in that land. taste for neckties - he keeps a supply in and Snohomish County foil owed with his car only for those times he cannot "It was emotionally devastating," similar efforts. Cruz said, tears welling up in Iris eyes avoid wearing one - has plenty of sup­ Then, with the board's consent he porters. and his voice breaking as he recalled began keeping the names of everyone Count Francea McNair, deputy the deaths of co-workers. who tested positive for the AIDS virus county executive and a health board "What was striking was drat tire permanently on file at the health de­ member, among them. people still volunteered - even though partment. He still does that, even "H e is a bright, goal-oriented activ­ they knew they would be killed." though state regulations say the names ist, and you fill find him on the cutting He spent a year inGuatemala be­ must be purged after 90 days. fore the upheaval made it impossible to edge of health issues/' McNair said. "He Next, the health agency began continue. is courageous and not afraid to take compiling a list of the names of every­ "But, it really burned aspace in chances w hen he believes his position one who tests positive for tuberculosis, my brain. And when decisions come is right and will benefit the community." even though no other county health up as I work for heal th systems department in the state tracks the Continued on page 16

6 PCMS BULLETIN May, 2000 June General Membership Meeting

Tuesday, June 13, 2000 Landmark Convention Center Social Hour: 6:00 pm Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm Tacoma

From Vince through Che to Behrhorst: A Journey on the Edge of Public Health

An evening with Federico Cruz-Uribe, MD, MPH Director of Health

(Registration required by June 4. Return this for to: PCMS, 223 Tacoma So, Tacoma 98402; FAX to 572-2470 of call 572-3667)

Please reserve dinner(s) at $20 per person (tax and tip Included)

Enclosed Is my check for $ or credit card # is ______

□VISA □ Master Card Expiration D ate ______S i g n a t u r e ______

I will bring my spouse or a guest. Nam e for nam e ta g :______

Signed_ Thank you! B u l l e t in

Dystonia. Foundation recognizes Doctor of Excellence, Pat Hogan, DO, Tacoma Neurologist

by Ruth Anderson Headache Center, was the only physi­ Following his medical and neuro­ The national Dystonia Medical Re­ cian in Washington State to receive logical training, Dr. Hogan left Madigan search Foundation is proud to an- the honor. Army Medical Center for private prac­ nounee the selection of Dr. Patrick Dystonia is a neurological move­ tice in Tacoma. Throughout his career, J. Hogan, III, Tacoma neurologist, ment disorder characterized by invol­ he has retained a great interest in com­ as a untary muscle contractions and pos­ munity health. He currently serves on "Doctor tures. Patients with this affliction often several boards and committees: Stroke of Ex­ experience pain, loss of employment Advisory Board and Tobacco Control cel­ Task Force for the Franciscan Health lence" because of an inability to control movements, and acute embarrassment System, the Northwest Parkinson's Ad­ in the from knowing their appearance has visory Board, and the Washington State diagno­ Stroke Medical Advisory Committee. sis and been altered. Dr. H oean is the Northwest's Both the Seattle and Tacoma Dys­ treat­ O leading provider in the administration tonia Medical FoundationSupport ment of Grou ps were delighted to learn of the dysto­ of botulinum toxin injections as the Foundation's intent to single out certain nia. Dr. most safe and effective treatment of doctors who are working to find cures Pan Hogan, dystonia. Patients treated with this and to treat dystonia patients. Support Direc­ medication experience considerable group mem bers had no problem recom­ tor of the Puget Sound Regional lessening of their involuntary muscle mending their advisor, Dr. Hogan, who Movement Disorder Clinic in Tacoma contractions, freeing them to pursue routinely meets with the groups to pro­ and the Puget Sound Neurology more active lives. mo te proper treatment and to help pa­ tients cope with the inherent disabilities H+H they face. Pat Stolp, Tacoma Dystonia HiGHLBNE COMMUNITY HOSPITAL Support Group Leader says: "Dr. HEALTH CARE NETWORK Hogan is our lifeline for coping with wvw.hchnet.org our debilitated health. He offers con­ SEATTLE, WA: Excellent opportunities for BE/BC Family Practice, Internal crete treatment, compassion and hope. Medicine, Occupational Medicine, and Infectious Disease. Enjoy practicing in a We couldn't ask for a more tireless progressive hospital setting with an extensive network of health care providers and mentor." specialists throughout SW King County. Minutes from downtown Seattle, the shores of Puget Sound and the Cascade Mountains. We offer state-of-the-art resources, The dystonia "Doctor of Excel­ equipment and expertise to provide outstanding care for your patients. Competitive lence" aw ard is both an honor for Dr. package. Please call 206-988-5780 for more information. Fax or e-mail CVs to Gail Hogan, and a way of bringing aware­ Mumma at fax 206-431-3939 or e-mail [email protected]. ness of this often misdiagnosed disor­ der to the public's attention. Tacoma is fortunate to have this community- Practice Administrators minded, caring professional among its Do you want to reduce the administrative costs of your practice? medical providers. ■ Do you want to provide better medical care to your patients? Office automation provides both of these benefits. We can help you update your Computer Ruth Anderson is the Northwest Information Technology in order to better serve you and your patients. Regional Coordinator fo r the Dystonia The Whittier Group, Inc. has Microsoft Certified Professionals that can assist you with: Medical Research Foundation. She can • Network Design and Installation • Network Administration be reached at 360-893-4412. • Network Upgrading . Internet Set-Up Patricia Stolp, Tacoma Support Group Our Professionals are certified and familiar with: Leader, Puget Sound Dystonia • Microsoft Windows NT, 98, 95 • Microsoft Exchange Server Awareness & Support Group may be • Microsoft Windows NT Server • Microsoft Proxy Server reached at 847-2368 Give us a call to discuss your needs. Please contact Mike Munoz 1-888-282-0545.

8 PCMS BULLE 1 IN May, 2000 ADVANCED TRAINING IN MANAGEMENT FOR PHYSICIANS AND OTHER CLINICAL PRACTITIONERS

AT THE UNIVERSITY OF WASHINGTON Evening/Weekend Master in Health Services Administration (M.H.A.)

The Department of Health.Services in the UW School of Public Health and Community Medicine (in cooperation with the UW Educational Outreach) invites you to learn more about our evening/weekend Master in Health Services Administration (M.H.A.) program.

This unique two-year evening/weekend program is designed for mid-career physicians and other elinical/medical practitioners who have demonstrated interest in management. It provides advanced in- depth knowledge and skills in planning, organizing and implementing programs that address health needs and improve the cost-effectiveness and quality of patient care. Participants gain mastery of approaches and skills for managing people, getting things done in organizations and leading organizations in adapting to the changing environment of health care.

Program Benefits:

§ The program prepares graduates to move. § To facilitate the sharing of diverse into executive positions and to assume roles experiences and management problems, in health care organizations that include classes are made up of medical substantial management responsibility. professionals from diverse settings. § The program structure enables practicing § Participants proceed through the sequence professionals to continue their careers while of courses together - developing a strong gaining their master’s degree. cohort. § The program provides opportunities for § Team teaching is an important element of networking with professionals in health the program, combining the skills of active services management. practitioners and professionals from the § The integration of professional, local health care community with University organizational and societal perspectives and faculty. values in the management of health care § The MHA Program is fully accredited by the organizations is stressed. Theory, case Accrediting Commission on Evaluation in studies, best practices and the experiences Health Services Administration (ACEHSA). of participants are used to strengthen . practical management skills.

Application Deadline:

The application deadline for autumn 2000 admission has been extended to July 31 — provided space remains available. We will begin reviewing applications after April 30.

For More Information or an Application Packet

Please contact the Program Office ([email protected] or 206-616-2976) or visit our Web site at depts.washington.edu/mhap.

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B u l l e t in

Expedition leader to speak at September membership meeting Do we have Dramatic tale of high adventure resolving 1924 mystery M ark your calendar'for the September General Membership Meeting your e-mail

Reserve Tuesday, September 12, became of them? address? 2000,6:00 p.m. for an evening of high This expedition stunned the adventure as Eric Simonson speaks on, mountaineering community with the "Finding Mallory." discover}' of the remains of Mallory. please send Simonson, owner and active Two major television documentaries partner in International Mountain have focused on the expedition. He it to us at: Guides (one of the oldest mountaineer­ will relate the mysteries, the quest to ing companies in the country) as well as solve them, and what the expedition owner and operator of Mt. Rainier did at the September meeting. Alpine Guides will speak on the Simonson s climbing resume pcmswa@ experiences of the expedition that set includes Mt. McKinley, Aconcagua in pcmswa.org out to solve two of exploration's Argentina, Cho Oyu inTibet, Mt. greatest mysteries: Did George Elbrus in Russia, and Mt. Vinson in Mallory and Sandy Irvine reach the Anarcdca. summit of Mt. Everest in 1924, and what Watch your mail for details. ■

10 PCMS BULLETIN May, 2000 ''P ie r c e ‘io m n /y QM edical ^focietu-

The Invisible Hand... by Andrew Statson, MD

On Rights and Wrongs

"He that would make his own liberty secure mus t guard even his enemy from oppression." Thomas Paine (1795)

"I want an interpreter present at namic living organism. People band to­ Andrew Statson, MD my visit," she said through the Teletype gether for a number of reasons. operator. "It's my right." She was a Through joint effort and specialization deaf-mute who had come to my office a they cam produce more than they can the person receiving it and to the com­ few times before. We had communi­ by themselves. They can concentrate munity at large. One day we may have cated by writing on paper. Now she on doing what they do best and trade to call this loan and we expect drat it will wanted a sign language interpreter. with others to get what they are not as be repaid. Another assumption is tha t When I got paid for the visit, sub­ able to produce. In the process of their the person in distress now will recover tracted the fee of the interpreter and work they make discoveries and ac­ and eventually be able to repay us in figured my overhead, there was noth­ quire knowledge, which they also someway later. ing left. Some colleagues have re­ trade with others. Thus they develop a Of all the peoples in the world ported they had to pay an interpre ter pool of knowledge which becomes the Americans have been the most gener­ even though the patient did not keep basis of civilization. ous in helping others. A major reason is the appointment and they could not Together they can better protect that they have been the most prosper­ charge for a visit. In this country only themselves from enemies who would ous and the most able to do so. After the self-employed can legally work for rob them of their property and of their the devastation of WWII this country less than the minimum wage. life. The mutual benefit of life in soci­ established the Lend-Lease Program to At the dawn of the American re­ ety is expressed by the exchange of help Europe rebuild itself. Those were public, the state assemblies discussed effort for effort, of value for value, it is loans that were repaid, but America the inclusion of the Bill of Rights into expressed by trade. Neither trade nor also set up a very generous foreign aid the constitution. Some people argued society itself can exist without order. program. Wha t we expected for ou r that these amendments were not neces­ The root of order is justice. Justice gifts was not the love, but at least the sary. These rights were so elementary, consists in giving and getting what is respect of the people we helped. In­ so basic, so natural, that there was no earned, the deserved, no more and no stead, our- embassies were vandalized, need to spell them out. Of course less. Justice therefore is the opposite of our people were taken hostage and people should be secure in their charity, which consists in giving and sometimes killed, their only crime be­ homes and in their property. Of course getting the unearned, the undeserved. ing that they were Americans. We there could be no unreasonable sei­ Yet all over the world and throughout gave the undeserved and we received zure of private property, and when a history one custom has been an inte­ the undeserved. That was charily and seizure was reasonable, the owner gral part of social interactions, the cus­ justice operating at the same time. would be compensated justly. Of tom to help people in distress. Tliis The twentieth century saw charity course. type of help frequently is called char ­ become institutionalized. What was a Those opposed to the inclusion of ity, but it does not quite meet the defini­ loan or an investment became a legal the Bill of Rights into the constitution tion right, to be paid by those who produce tamed out to be right, but for the Helping people in distress is based to those who don't, in defiance of jus- wrong reason. The Bill of Rights be­ on some assumptions. One of them is dee. Med ical care as a right means that comes a useless document when Con­ the realization that one day we may be some people will have to work and gress arid die courts twist its meaning to in distress and will welcome help then. earn money, which they will not re­ suit their purposes. In this respect the help we give now, ceive, so that others can get medical Humansociety is a complex dy­ | while we are able to do it, is a loan to See"Right"pagel8

May, 2000 PCMS BULLETIN 11 B u l l e t i n

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PCMS members may now Through a recent affiliation with SupportAfyAssociatioacom, enjoy the benefits of shopping PCMS will benefit by receiving a royalty from every pur­ online with over 200 of the chase made from the numerous merchants. world-wide-web's top mer­ To get started, go to the PCMS homepage, chants, all consolidated into one, www.pcmswa.org and click on the active "SupportA/y easy to use, shopping portal. Association.com" logo. Click on Association Members and find Pierce County M edical Society - M em bership Benefits, Inc. ONLY 24 hours in the Log in your email address and you are on your way. day, WHEN do YOU SHOP7 For more information, call PCMS, 572-3667. ■

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12 PCMS BULLETIN May, 2000 The Health Status of Pierce County m Handgun Safety T A C O M A -P IE R C E C O U N T Y TheTacoma-Pierce County anns are stored loaded and unlocked, HEALTH Board of Health established three pre­ fostering a real risk for injury or death. DEPARTMENT vention priorities-behaviors which, if The American Association of Pedi­ have guns for protection. Give adults dianged, would drop mortality and atrics (AAP) released an updated the following phone number to morbidity statistics. The department is policy on fireanns in April 2000 (for call for more information about focusing social marketing behavior more infonnation, see their website at handgun locking devices - lock change campaigns on: tobacco use, al­ www.aap.orgI The association states boxes and trigger or chamber cohol abuse, and violence. Physicians that" the most effective measure to pre­ locks: 1 877-LOK-IT-UP (1-877- play a key role in these areas. By ask­ vent firearm-related injuries to children 565-4887). This number connects ing questions and refening clients to and adolescents is the absence of guns to individuals who can provide community resources, you too can help from homes and communities." They information and also a coupon for lower the incidence of illness and also suggest that physicians and discounts on locking devices. death from these causes. Over the next other health care professionals For many physicians, it has become several months, the health department's inform patients about the dangers routine to ask risk factor questions dur­ column will include practical ways phy­ posed by guns in the home. AAP ing an annual physical: Do you smoke? sicians across the county can help to suggest an educational approach Howr much do you drink? Do you exer­ change their patient's behaviors. This with families, similar to the fol­ cise regularly? Add questions about month'scolumn spotlights handgun lowing: handgun possession and storage to that safety. ODiscuss with parents the real list. Protect your patients and their fami­ Recent tragedies in Pierce danger keeping a gun in the home lies from preventable harm. ■ Count)', and across the nation, have poses. Suggest the safest thing is not to demonstrated what happens when fire­ have a gun, particularly a handgun, in tantily Support ('enters/ arms fall into the wrong hands. Statistics the house at all. M aternity Support Services to note: ©If, however, an individual de­ ♦Firearm homicide is the second cides to keep a firearm, recommend leading cause of injury or death for 15- strongly that the gunbe kept unloaded Working with families who could use additional supportand resoucres? Public 19 year olds in Pierce County. and locked up. Advise locking and health Nurses and Family support Workers ♦During the five year period from storing bullets in separate locations to are available throughout the county through 1992 to 1996, the homicide rate in which children do not have keys. Ad­ the Family Support Center system. Pierce County was 84% higher than vocate that those who have handguns the rate for the entire state (5.9 deaths use locking devices. Nursing services focus primarily on prenatal per 100,000 people in Pierce County ©Even if parents do not keep to age three, assessingfamilies in their compared to 3.2 deaths per 100,000 in guns, draw their attention to the need homes and creatingan individualized plan Washingtonstate). to teach children about gun safety any­ of care. Social workers, nutritionists and ♦In Pierce County from 1996 to way. Suggest they talk with their chil­ family support workers connect families to 1998,37% of households with children dren about the risks of playing with a com m unity resources and assistance. Together, nurses and other professionals under the age of 18 owned firearms, gun and to steer clear of them. Recom­ provide a seamless system of early exposing approximately 75,000 chil­ mend that they speak with the parents prevention, parenting education and dren to handguns, rifles or shotguns. of their children's friends about keep­ support ♦The 1996-98 survey showed that ing firearms in their homes empty and 57% of firearm owners store their guns locked up. Refer families to theFamily Support Centers unlocked, 22% store them loaded, and The Tacoma-Pierce County' by calling Becci at the Health Department: 14% stored firearms both loaded and Healtli Department has begun a cam­ 253-798-5403orfaxing information to her at unlocked. paign to encourage handgun owners to 253-798-2872. Healthcare providers should be store their firearms with a locking de­ Questions? aware that many of their patients pos­ vice. Lock boxes, for example, keep Ca II Sue Wa len, RN, at 253-798-6517 or sess firearms or live in homes where guns out of the wrong hands and yet Allison Kemmer, RN at253-7984700. guns are stored. Some of these fire- are quickly accessible for those who

May, 2000 PCMS BULLETIN 13 B u l l e t in

Online medical resources

MEDLINE ACCESS PHARMACEUTICALS Direct www.nlrrmih.gov Dragtndex: www.rxlist.com Basic search: wwwjxbi.nlm.nih.gov/PubM ed/ Phys. Desk Reference: www.pdr.net Advanced search: http: / / ncbjilm.nih.gov/ PubM ed/ Medline.html Rx info: rxmed.com Image-based: wwwjilm.nili.gov / research/ visible/ Full text (fee): www.ovid.com CLINICAL TOOLS Delivery: http://tendoanlnxnih.gov/ld/loansome.html Algorithms: www.mddioice.com Prescribing: www.iscribe.com MEDICAL JOURNALS Handheld internet access: www.ephysician.com Peer-reviewed: www.medscape.com NIH Stroke Scale: www.neurotools.net Medical reference works: www.mdconsult.com Transcription online: www.e-docs.net Journal of AMA: http: / / jama.ama-assn.org/ Hist / phy s.chklst www.medinfo.ufl.edu New England J of Med: www.nejm.org Health assessment www.healthmagic.com AmMedical News: www.ama-assaorg Risk assessment www.ahn.com AmFamily Phys: www.aafp.org MISCELLANEOUS OUTCOMES DATA Recruitment www.medconnectcom Medicare database: w-vw.carescience.com Job posting: www.webdoctor.com Stateistics: www.mdnetguide.com Research links: www.forhealthfreedom.org Evidence-based med: www.cochrane.org Med Mtgs: www.physidansguide.com / educhtml Community health www.chita.org IMMUNIZATION/DISEASE OUTBREAK Health trends: www.helix.com Center for Disease Control: www.cdc.gov ALTERNATIVE MEDICINE: PROFESSIONAL “COMMUNITY” www.askcirweil.com Physician's Online: www.po.com www.altemativemedicine.com List servs, newsgroups: www.hon.di © eHealthCoach. com

r a v e lL e r d Health Service A Service of Northwest Medical Specialties, PLLC INTERNATIONAL TRAVEL CAN BE HAZARDOUS TO YOUR HEALTH • PRE-TRAVEL CARE • POST-TRAVEL CARE HOURS CALL EARLY WHEN PLANNING MON-FRI 9-5 p~ i ? 253-428-8754 or 253-627-4123 A SERVICE OF INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph’s Hospital)

14 PCMS BU l LETIN fvUiy. 2000 COLLEGE Continuing Medical Education CP MEDICALGI Disease Course Designed for EDUCATION Primary Care Physicians Regis (ration is openfor the 5 th An­ proach. nual G. I. Course set for June 2, 2000 Specifically called "Nuts, Bolts and at the Washington State History Mu­ Innovation in Gastrointestinal Disease" seum. Co-directors of the course are this course is co-presented by the Col­ COME to survey Drs. Gary Taubman & Richard lege and die Tacoma Gut Club. Tobin. Club members represent a diverse This one-day course is designed group of expert physicians from Seattle for physician for the primary care physician and to Olympia, both in academic and pri­ should also appeal to the specialists and vate medicine. Hie following are a few CME interest ancillary heal th professionals with an of die topics diat will be addressed: interest in abdominal and gastrointesti­ ■ Gastrointestinal trauma The College of Medical Education nal medicine. The course emphasizes a • End stage liver disease will again survey member physicians practical and multi-disciplinary ap- ■ Thinking about PEGS for general and specific topic interest for course offerings. The survey will rate physician interest in macro areas of medicine citing the specialty break­ Allergy, Asthma, Pulmonology down listed in thePCMS Directory. The survey will seek more spe­ CME scheduled May 5 cific topics of interest within the macro specialty areas. The survey will allow The C ollege’s CM E program fea­ presentations on: the College to respond to local physi­ turing subjects on allergy, asthma and ► Asthma cian need in designing and implement­ pulmonology is set for Friday, May 5. ► Sinusitus ing courses. The course is under the direction of ► Allergic Rhinitis The College will also solicitfor Alex Mihali, MD. ► Pneumonia and COPD specific physician interest inside the This is a one-day update designed ► Lung Cancer Screening & many annual courses designed for pri­ for the primary care provider. It will Management mary care. The courses offered annu­ focus on diagnosis and management of ► Atopic and Con tact Dermatitis ally focus on infectious diseases, mental common allergy, pulmonology and health, cardiology, and allergy, asthma, asthma problems and is complimentary For registration information call the and pulmonology. to all area physicians. College at 627-7137. Although no regis­ The survey will also seek feed­ The program will be held at die tration fee is required, physicians wish­ back on possible topics for the annual new Lagerquist Center in St. Joseph ing to attend must complete and return Internal Medicine Review and Sur­ Hospital. a registration form. The conference is gery Update, organized annually by This year's program will feature anticipated to fill, so early registration is theTacoma Academy of Internal Medi­ encouraged. cine and the Tacoma Surgical Clubs re­ spectively. And the survey will seek topicsforthe College's multi-specialty Dates Program Director^) conferences, such as the annual course A slhin a, A llcrgy & held in Whistler. Finally, suggestions Friday, M ay 5 P u lm one logy for Alex Mihali, MD for new courses will be sought. Prim ary C arc

The survey will be conducted in N u ts, D o Its & May, and will aid the College Board in Innovation: G ary Taubm an, M D Friday, June 2 preparingnextyear's CME program G astrointeslinal R ichard Tobin, M D schedule. Disease V

May, 2000 PCMS BULLETIN 15 u z from page 6 department's leadership was being Need office help in a hurry? criticized for threatening to slash Cruz acknowledges he is not likely vital services without even looking to back down from the stands he has at other possible cuts. And there Pierce County Medical Society taken, regardless of what his opponents was a sexual-harassment scandal Medical Placement Service do. brewing. "Hike conflict," said Cruz, who was "They wanted change...and bom and reared in Green Bay, Wis. "I I'm good at making change," Cruz the solution fo r a ll your don't mean I'm looking for fights. But if said. "That's my personality. That's staffing needs 1 am engaged in my job and it upsets my style...I'm not a long-distance Weprovideforyou: people and they get in my face about it, runner. I'm a sprinter." this helps me get focused." Cruz says he promised his ► An available pool of qualified Cruz's critics say he violates pri­ children that tire family would not dinkal&administrativeapplkanls vacy rights. They say people who move again until they were ► Cove-age for vacations, illness, carry HIV or have TB in the inactive through school. His son has gradu­ leaves of absence,peakwork loads, stage will not be tested or seek medical ated, bu t he has a daughter in the pregnancy, etc help if they know their names will be sixth grade. ► Employeeswithoutthehassleof reported to the health department. Future battles? salaiy,benefits,taxesand other such Cruz insists those fears are unwar­ Violence prevention, gun emptoyeeiBqiiremenls ranted. locks, programs to stop alcohol "Tire public doesn't understand the abuse by young people. ^ Ten ; to Pen 11: A unique oppTrtuniiy way we handle that information," he There is much that needs to ii i V'/i'al..vu'l :mtha pjlmtialia'nployiX'ana said. "Everything is under lock and be done, and w e need to be ag­ bill biisiii-ivilJioijtnlilieptioii lohire! key...There are multiple levels of secu­ gressive," Cruz said. ■ rity, and staffers know that if they vio­ For more information: call late the confidentiality of patients, they Reprinted from The Seattle Post- Deborah Pasqua: 572-3709 lose their job and have a chance of go- Intelligencer, April 4, 2000 ingtojail." Sometimes privacy rights just have to take a back seat, Cruz says. " Individ u al rights always come in second to the rights of the community to protectitself," he said. "When you don't have a cure for something, you have to figure out a way to protect the commu­ nity." E R ^ S E Cruz completed his medical resi­ dency in obstetrics and gynecology af­ THAT TATTOO terreturning from Guatemala. And he WORRIED ABOUT WHAT YOUR SPOUSE, held a number of public heal th positions YOUR FRIENDS OR EVEN YOUR BOSS in Georgia and Florida. THINKS ABOUT YOUR TATTOO? By then, he was earning a reputa­ OR ARE YOU JUST TIRED OF tion as a merchant of change. He would LOOKING AT IT? go into an agency, shake it to its core, Today’s newest Alexandrite laser, stay three or four years and move to will remove your tattoo another agency to do the same thing with minimal discomfort & again. less than 1% risk off scarring. The Tacoma-Pierce County ('all lod(tv lor more in/onmitioii Healtli Department was going through troubled times when Cruz packed up PIERCE COUNTY his family and moved here. City and LASER CLINIC county officials were unhappy about a Direelnr IVler K, M:irsh M.l). major budget shortage. The (253)573-0047 In My Opinion.... by Teresa Clabots, MD

$15 for a Kawasaki

I started my solo practice in 1998, tiling that came to my mind was Ebola after being with a group and a multi­ virus. specialty clinic for several years. I referred the infant to the Many of my patients followed me, and I inpatient service at Mary Bridge. They worked diligently to transition them to soon diagnosed Kawasaki's. I called Tcivsa C/ahnt.s. MD my new office. the infectious disease doctors and After4months of working without called the CDC, who faxed me the pay, I asked my biller why this was form to fill out, and I went to see him at so that the inpatient service, MBCH, happening. I presumed it would take lunch. From red conjunctivitis and and the cardiologist could get paid. She three months, but four seemed a little irritability and fever, he had devel­ refused. I called the plan and they much. Patients had my name on their oped a desquamative rash, mucosal suggested thatshe return her $15.00 insurance card and came to me for hemorrhaging, and his echo showed capitation fee, which would allow me to their care, I submitted the claim, but the coronary aneurysms. Surrounded by do the referral once the patient was money continued to go to my former his family members and an IV running reassigned tome. This would also employer. What a fiasco. I learned with Immunoglobulin, he was very, record the hospital statistics under my very quickly what the rules of the very sick. 1 went back to my office and name rather than hers. 1 called her insurance company are - whoever filled out a referral form to the Mary again and asked her to return the "owns the contract" receives the Bridge inpatient team, since I was the $15.00 to the plan for the last month, so money. Although I performed the primary care physician. The plan that I could receive assignment for the work, the insurance company contin­ denied the referral. They said that I patient, and consequently do the ued to mail payment to the doctor that was not the primary care physician. I referrals. She refused. I got angry and theinsuiance company had "reas­ said, "well you are going to pay for the called her boss. He also very politely signed" the patient to. They did not Mary Bridge services, aren't you?" refused. By now I was furious. I could contact the patient or receive their They said, "no, we have to have a valid not believe it. For just $15.00! The permission to do this. referral to do that." I argued, "I have insurance company said, "our hands are One newborn I saw daily, did a been on your plan for 13 years, you tied." newborn check, and a two week, and reassigned him to a doctor without the I called the WSMA, I called the twomonthfollowup. After several parent's authorization, I have been Attorney General's office, I called the attempts at collection, the plan admitted seeing the baby since he was bom, Insurance Commissioner. I wrote a thattlie baby was mine, butinformed and he is now four months old, and letter of complaint to Deborah Senn. me I had to re-apply to the plan. I even though you won't pay me you One month later, thanks to explained thatlhad been with their must pay Mary Bridge." They told me Deborah Senn's office, Mary Bridge company since 1986, and I saw no that I needed to contact the physician was paid in full. It took me almost eight reason 13 years later that I should have that the baby had been assigned to, get hours of the little free time that I have to to re-apply. They told me that they had them to return the $15.00 monthly get this accomplished Our system is been informed I had quit medicine, capitation fee, and then they would broken. (which was not true). I submitted my assign the baby to me, and I coul d then Last month United Healthcare application The mother was told that do the referral to Mary Bridge. decided to stop requiring yes, I could be her provider. The This baby ran up quite a bill, and "preauthorizations." They had spent infant came in with a fever, and I the parents had paid for insurance. It 100 million dollars to "manage" 100 couldn't find the source. I re-examined seemed only right that they should get million dollars of health care. About the infant 24 hours later. He was more full advantage of their paid benefits. time. 1 sure hope other plans will see irritable, he had erythematous conjunc­ I contacted my colleague and the light. ■ tiva, and at the time I was reading the explained the situation. I asked her to book called, "the Hot Zone." The first just make the referral to Mary Bridge

May, 2000 PCMS BULLETIN 17 B u l l e t in

Right from page 11 This does not exclude the need ever, if we want it to last, we will have care they cannot earn, in defiance of for a social safety net. Destitute and to base it on the principle of justice, on justice. A society may exist for some sick people potentially can be a source the trade of value for equal value. time in defiance of justice, but it cer­ of disorder in society and there should Somewhere in there we will find that tainly cannot prosper and eventually it be a way to take care of them. In the helping people has some value, but collapses from internal or external past this was done by hospices, usually they also will have to know that this pressure because it lacks the will to de­ run by the churches and supported by help is not theirs by right and they will fend itself. private contributions. The recipients of have to earn it. Before Medicare and Medicaid such help were fully aware that what Every system is based on some many hospitals had charity wards. The they received was a gift, not theirs by give and take, and these have to be physical facilities were simple, the right, but given to diem through the fairly balanced in order for the system amenities were minimal, privacy was good will of others, to be repaid as best to survive for long. If there is more nonexistent, the care was given by stu­ they could. give and not enough take, the system dents and residents. The patients paid Unfortunately, there is no going will use up its resources and wither some cash for their care, bu t the cost back to the "good old times." W hen away. If there is more take and not was low, and if they couldn't pay they something has been given to the enough give, the system becomes still got care. They paid by allowing the people, it cannot be taken away. In­ bloated and dysfunctional, eventually young physicians to learn medicine by stead, something else happens. Wha t is bursting at the seams and destroying it­ taking care of them. That was their con­ given free gradually exhausts the re­ self. Justice requires a balance. I would tribution to the community. That is how sources allocated to it and loses its like to close w ith two proverbs, an En­ they earned the care they received. value. By the time it becomes almost glish one, "right wrongs no man," and a Payment does not always have to be in worthless, the system falls apart. At German one, "he who refuses to submit cash, but justice requires payment. A some point along this line, before the to justice must not complain of oppres­ right cannot be right if someone is old system breaks down completely, sion" ■ wronged as a result. we will have to build a new one. How­

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18 PCMS BULLETIN May. 2000 ? oMedtccd (^bcicf-y-

the Pulse PCMS Alliance

A general meeting was held on Coalition to take to thrift stores. Discussion was held concerning March14,2000 at the Medical Society Anton’s Law requiring the status of the Alliance and die office in the board room. The meeting booster seats for children out of recommendations from the Board to was called to order at 10:10 a.m. car seats and still under 80 pounds will the membership. Ballots were d istrib- Members attending included be signed into law in this session of the uted and counted. The vote was to Kathy Samms, Mona Baghdadi, Legislature.O disband. No further action will be taken Kris White, Alice Yeh, Helen Comments from guests: Karen until the Pierce County Medical Whitney, Fran Thomas, Nikki Bolin stated thatWSMAA wanted to Society has formed their Foundation Crowley and Ginnie Miller. show support to PCMSA when they and received nonprofit status. The President Yolanda Bruce presided. sent their letter in January. Cindy PCMSAA will maintain their 501 (c) (3) Karen Bolin, WSMAA Membership Berger expressed concern about the status as needed to continue with the Chairwas also in attendance. loss of philanthropic funding if going Holiday Sharing Card and its Philan­ Minutes of the January, 18th inactive or disbanding. Kris White thropy Outreach until that time. meeting were approved as amended. spoke as WSMAA president regarding On Wednesday, May 17,11:30 a.m. Treasurer's reportnoted a balance of the changes occurring at the State; the a luncheon will be held a t Grazies. To $3,200 after dispensing the philan­ change for the WSMAA into a commit­ make reservations, call Nikki Crowley thropic funds. There were no out­ tee of the WSMA. at253-922-7233.1 standing bills. Committee Reports: Philanthropy - Fran Thomas read thank you notes from recipients of funds from the Holiday Sharing Card. TACOMA, RADIOLOGY Health Promotion - Alice Yeh reported information on the April Stop TV Viewing for one week project, suggesting an aim for family time that week. Also mentioned was the Milton MOM March scheduled in WashingtonD.C. on Mother's Day to advocate gun control. Cell phone collection for use in family shelters for emergencies was discussed. Recall list for car seats will be made available through Safe Kids EJ^Spine & Femur DEXA Detect osteoporosis Assess fracture risk 5u.rcj.erij. Quantitate bone mineral density changes think Monitor therapeutic response www.tacomarad.com o f uUA. Union Avenue Pharmacy & Allenmore Medical Center Lakewood Office I Corset Shop j Formerly Smith's Corset Shop (253) 383-2038 (253) 588-6083 " 2302 S. Union Ave 752-1705

May, 2000 PCMS BULLETIN 19 \ B u l l e t in

ample, if the hospital is unable to locate aged care patients. One of OIG's par­ ticular concerns is that patients may EMTALA from page 3 an on-call physician willing to come to the hospital to see the patient because routinely be kept waiting so long for the patient is indigent. Again, this situa­ services that they leave without being become very sensitive to decisions tion causes hospitals to be very con­ seen. Another concern is that hospitals made by on-call phy sicians who may cerned about on-call physicians not will delay performing the required not actually see the patient, bu t who de­ coming to the hospital to see a patient. screening exam of a managed care pa­ termine the patient can be discharged, If the on-call physician, in conjunction tient in order to get audnorization from or can be seen the next day during of­ with theER physician, determines in a managed care company for pay­ fice hours, or can be followed up at a good faith that he or she does not need ment.5 later time. ER physicians are now re­ to see the patient in the ER, then that While hospitals bear tine primary quired to document tine fact that an on- determination must be clearly docu­ responsibility for EMTALA, physicians call physician fails or refuses to come to mented by the ER physician. are affected as well. Emergency room the ER to see a patient (under EMT ALA allows an individual who physicians and other emergency room EMTALA law, because the patient suffers personal harm as the result of a staff must perform the appropriate can't pay, but in HCFA's view, for hospital's violation of EMTALA to screening exams, stabilize, or arrange pretty much any reason) and the on- bring a civil action against the hospital. for stabilization of, patient, and docu­ call physician and the hospital may be Physicians cannot be sued directly for ment the entire process, including the subject to a substantial fine. Not surpris­ EMTALA violations, though hospitals need, if any, for transfer. On-call physi­ ingly, hospitals would like to require who are sued could seek contribution cians are specifically identified in regu­ that an on-call physician come to the from a physician for damages tine hos­ lations as being part of the capability of ER every time he or she is called, be­ pital is required to pay. Hospitals and dne emergency department, and hospi­ cause it minimizes the hospitals' liability. physicians are also subject to civil fines tals are required to maintain a list of on- Clearly this kind of requi rement would of up to $50,000 for each violation. Fi­ call physicians to provide treatment put a huge burden both on physicians nally, both hospitals and physicians may necessary to stabilize patient emer­ and on the health care system gener­ be excluded from the Medicare pro­ gency medical conditions after the ally. gram. screening exam. On-call physicians are An "appropriate transfer" must be included in tine definition of a "respon­ carefully documented. If a transfer Local Issues and Recent Cases sible physician" subject to monetary must be made without stabilizingthe pa­ The Emergency Medical Treat­ fines for EMTALA violations. Of the 11 tient because the hospital does not ment and Active Labor Act Region 10 enforcements in fiscal year have the capability to do so, then writ­ ("EMTALA"-Tine Patient Anti-Dumping 1999, two cases involved on-call physi­ ten certification of the transfer has to Law) is getting increased attentionfrom cians: one a refusal of a physician to ac­ include the medical conclusion that the bo tin government officials and patients cept a transfer; the other a physician medical benefits reasonably expected and their lawyers. A recent survey of who refused to come to the emergency from transfer outweigh the increased "hot" health care issues for the year room at the request of an "on-call" risks to the patient. If the transfer is a 2000 included EMTALA enforcement emergency room physician. (Most of discharge to home or to a physician's as a high government priority. Tine fig­ the other cases, according to Region 10 office for follow-up, then the certifica­ ures bear this out: in fiscal years 1987- HCFA officials, involved charges of in­ tion must include the physician's docu­ 1997, OIG reached a total of 79 settle­ adequate screening exams.) The emer­ mentation that the patient's condition is ments and judgments for EMTALA vio­ gency physicians are expected to re­ stabilized. lations, worth about $1.84 million In fis­ port on-call physicians who refuse to The purpose of EMTALA was to cal year 1998 alone, the agency see a patient without a reasonable ba­ prevent patient'' dumping". Du mping is reached 53 settlements and judgments, sis. defined as "the practice of hospital and in the fiscal year 1999,61 settle­ A case last year from West Vir­ emergency departments, despite being ments and judgments. In OIG's Region ginia points out dne level to which gov­ capable of providing the needed medi­ 10, which includes Washington, there ernment officials may be involved in cal care, transferring patients to other were 11 EMTALA enforcement cases deciding whether physician's actions facilities or turning them away because in fiscal year 1999. w ere appropriate. In that case, five these patients are unable to pay." The Department of Heeil tin and auto accident patients, two widn severe Chomping includes discharging a patient Human Services, Office of the Inspec­ head and abdom inal injuries and bleed­ who is not stabilized, and not providing tor General ("OIG") recently published ing, were brought to a small rural hos­ an appropriate screening exam. "Con­ a special advisory clarifying hospitals' pital widnno trauma center, and a structive dumping" includes long de­ responsibility to provide emergency lays in providing treatment; for ex­ care, particularly widn respect to man­ See "EMTALA" page21

20 PCMS BULLETIN May, 2000 S' / % e m t a l a frompage 20 on-call. EMTALA is an "unfunded mandate"-a huge additional financial burden to hospitals and physicians al­ Organ &Tissue longstanding policy of transferring ready facing declining reimbursement. such patients to larger hospitals. Dr. Yet increasing enforcement efforts, Cherukuri, the surgeon on-call that and the fact thatmany plaintiffs' law­ 3 night, was charged with violating the yers heat EMTALA as an extension of "stabilization" language of EMTALA, medical malpractice law, are unrelent­ because he transferred the two pa­ ing pressures. tients with head injuries to a larger Local hospitals feel (pursuant to trauma center before operating on HCFA interpretive guidelines on their stomach injuries to stop internal EMTALA) they must create an on-call bleeding. The charge was that where list of each specialty practiced in tine Share Your Life. there is internal bleeding, stabilization hospital, but in some specialties the Share Your Decision."" required an abdominal operation by burden then falls on very few physi­ the surgeon before transfer. cians. Specialists may be very hesitant The court ultimately dismissed the to be on a specialty list for an area of For more information on charges against the surgeon, conclud­ practice they haven't spent time wi th organ and tissue donation ing that he had sufficiently stabilized since medical school. It may well be please call the two patients prior to transfer with­ that to do so would constitute a stan­ out performing surgery, and that he dard of care problem, generating mal­ LifeCenter Northwest did not even have anesthesiology practice issues along with EMTALA available so that he could operate. problems. toll free 1-877-275-5269 There was no evidence at all the hos­ Hospitals also have a tendency to pital intended to "dump" the patients, want an absolutely uniform procedure and it was undisputed that the condi­ (requiring on-call physicians to come to tions of the two patients did not dete­ the ER for every call, for example), an riorate during the transfer to the expensive and probably unnecessary trauma center. The case demonstrates, solution. Physicians, on the other hand, though, the extent to which govern­ need to acknowledge that a very few ment officials can " second guess" medi­ of their colleagues may unreasonably cal decision making.2 refuse to respond to calls, and that puts The American College of Emer­ hospitals and other physicians at risk. gency Physicians recently released a Determinations about screening, stabi­ study (available at its website, lizing treatment, and possible transfers "Defending need to be made by emergency physi­ America's Safety Net"), which dis­ cians or other personnel in conjunction cusses on-call coverage in relation to with on-call doctors on a case-by-case EMTALA. Itis already difficultfor basis, reasonably and in good faith be­ hospitals to fulfill their legal duty to ing sure the process is documented. provide on-call coverage. Physicians, What is the solution? The regulat­ dealing with restrictions of managed ing climate makes it imperative tha t hos­ care, heavier work loads, anticipation pitals and physicians collaborate to of retirement, or just the desire for a solve a community wide problem. B saner lifestyle, are less inclined to take trauma call. Hospitals are being forced 164 Federal Register 61353(11-9- to enforce mandatory call coverage 99) requirements as a condition of medical 2 Cherukuri v. Shalala, 175 F.3d staff membership, very unpopular with 446 (6th Circuit, 1999) physicians; or to pay stipends for phy­ sicians, especially specialists, to serve

May, 2000 PCMS BULLETIN 21 B u l l e t in

A Different Perspective

If we could shrink the earth's 6 people w ould possess 59% of the Did You population to a village of precisely entire world's wealth and all 6 100 people, with all the existing would be from the United States. human ratios remaining the same, it 80 would live in substandard Remember? would look something like the housing following. There would be: 70 would be unable to read 50 would suffer from malnutrition 57 Asians 1 would be near death 21 Europeans 1 would be near birth ✓ 14 from the Western Hemi­ 1 (yes only 1) would have a sphere, both north and south college education WAMPAC 8 Africans 1 would own a computer 52 would be female Washington Medical Political 48 would be male When one considers our world Action Committee 70 would be nonwhite from such a compressed perspective, 30 would be white the need for acceptance, understand­ 1800 Cooper Point Road SW 70 would be non-Christian ing, and education becomes glaringly Bldg7, Suite A 30 would be Christian apparent.* Olympia, WA 98502 89 would be heterosexual Phillip M. Harter, MD, FA CEP 800-562-4546 (360)352-4848 11 would be homosexual Stanford Univ School o f Medicine

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CALL 597-6473 OR 597-7982. ^

22 PCMS BULLETIN May, 2000 Wwce % xm if Q/f'ieclical Qfoaety

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May, 2000 PCMS BULLETIN 23 Policyholder Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

Whether it's a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond 10 questions in person, by phone, and by mail. Our goal, now and in the luture. is to help physicians, clinics, and hospitals remain successful. F Physicians mm Insurance Western Washington 1-800-962-1399 A Mutual Company Eastern Washington 1-800-962-1398 i routed ,!Ul1 .spiiTi-•■'n'ud by ilic V, ;<£htrv.:!'Ti S:.ul M edic.il '‘.iic'ct.r. Oregon 1-800-565-1892 >catiic. W'A Physicians Insurance 1999

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INSIDE: President’s Page: The New Physicians Mi mi Pattison, MD and End-of-JLife Care program earn national recognition Area hospital leaders discuss the future of healthcare in Pierce County June General Membership meeting features an evening with Dr. Cruz-Uribe Update your 2000 PCMS Physician Directory with recent changes PCMS Welcomes new members TPCHD: Hepatitis B and D Update PCMS Officers/Trustees: Charles M. W eatherby,M D ...... P re sid e n t PatxiceN. Stevenson, M D ...... PresidentElect S u san J. S alo , M D ...... Vice-President J. Ja m e s R o o k s, M D ...... Secretary/Treasurer Lawrence A. Larson, DO ...... Past President Sabrina A. Benjamin, MD D re w H . D e u ts c h , M D K e v in K . G a n d h i, M D M ic h a e l J. K e lly , M D D o ris A . P a g e , M D E d w a rd I. W a lk ie y ,M D YolandaBruce, PCMSA President

WSMA Representatives: SpeakeroftheHouse: Richard Hawkins,MD Trustee: David Law, MD AMA Delegate: Leonard Alenick, MD W AM PAC Chair/6th District: M arkGildenhar, MD W AM PAC 9thDistrict: Don Russell, DO | une 14 Executive Director: Douglas Jackman Committee Chairs: Table of Contents Aging, Richard Wallman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, W. Dale 3 President's Page: The New Physicians Overfield; Credentials, Susan Salo; Emergency Medical Standards, Ted Walkley; Ethics/ 4 MimiPattison,MD/End-of-Life program honored by AHA Standards Of Practicc, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, William Ritchie; Legislative, William Marsh; Medical-Legal, 5 "DisappearingNurses," by Loma Burt Pat Donley; M embership Benefits, Inc., Drew Letter to the Editor, from Grace Moses Deutsch; Personal Problems Of Physicians, Robert Sands; Public Health/School Health, Sumner Schoenike; Sports Medicine, John Jiganti. 6 May General Membership Meeting well attended

The Bulletin is published monthly by PCMS 7 J une General Membership Meeting to feature Dr. Cruz-Uribe Membership Benefits, Inc. for members of the Pierce County Medical Society. Deadlines for submitting articles and placing advertisements in The Bulletin 8 2000 Physician Directory Changes are the 15th of the month preceding publication (i.e. Important L&I phone num bers October 15 for the November issue).

The Bulletin is dedicated to the art, science and 9 The Invisible Hand: "Reputation vs. Regulation" delivery of medicine and the betterment of the health and medical welfare of the community. The opinions 10 Welcome New Members herein are those of the individual contributors and do not necessarily reflect the offlcial position of the Medical Society. Acceptance of advertising in no 11 TPCHD: Hepatitis B and D Update way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin 12 Applicants for Membership and Pierce County Medical Society reserve the right to reject any advertising. 13 PCMS Bicycle Club members pedal 50 miles in Daffodil Gassic Editors: MBI Board of Directors M anaging Editor: Douglas Jackman 14 "Nostalgia of World War II," by John Stutterhiem, MD Editorial Committee: MBI Board of Directors

Advertising Representative: Tanya McClain 15 "Dr. GENIUS and the RED SNAPPERS/' by Teresa Clabots, MD Subscriptions: $50 per year, $5 per issue 17 College of Medical Education Make all checks payable to: MBI 223 Tacoma Avenue South, Tacoma WA 98402 253-572-3666, FAX253-572-2470 ZL Expedition leader to speak at September General Meeting

E-mail address: [email protected] 23 Classified Advertising Home Page: http://www.pcmswa.org

2 PCMS BIJLLE I IN June, 2000 Presidents Page by Charles Weatherby, M.D.

The New Physicians

Qiiropractors. Naturopaths. market, $24 billion mu st be removed Acupuncturists. Aroma therapists. from another portion. If legislation is Massage Therapists. Complementary passed, we will dnen see less out-of- and Alternative Medicine. Many of us pocket patient expenditure and more "real physicians" laugh and even scoff insurance reimbursement One study at these alternative providers. How estimated that 75% of patients who Charle.'i H'uitliicrh : ML> dare these providers try to use their use CAM providers don't inform unproven and nonsdentific anecdotal their"real physicians." Atthe treatment regimen on the American conference, I was quite surprised that Are we becoming more distant and public. After all, in what "real" journals with a show of hands, over one third of impersonal? Do patients prefer their do we see their research being the physician attendees had received hands-on/ manipula dve approach to published? What does the ID A say about their latest drugs? My question is, who's fooling who? I recently attended the Washing­ “If our patients are flocking to these CAM ton State Medical Association Leader­ providers and are now willing to pay these bills ship Conference. At this conference, I learned that Complementary and out-of-pocket without insurance reimbursement, it Alternative Medicine (CAM) is now becoming a large part of the American is time for us “real physicians” to wake up.” Health Care System. Americans are now spending $24 billion annually on CAM. That number is growing expo­ care from a CAM provider during the our perceived just-take-a-pill ap­ nentially yearly. Almost all of this is out- previous year. What does that tell us proach? Do the CAM providers of-pocket. That's right. Cash money. about our fellow physicians? actually listen to the patient while we They don t have to worry about that Our medical leadership is at least just expect the patient to listen to us? middle man called health insurance. trying to make us aware of the CAM Whatever the reason, it's time that we However, they soon may. These situation. How we respond to the realize that there are non MDs/DOs providers as well as their patients are situation is up to us as individual providing health care and the lobbying nationally for health care physicians as well as us as a medical American public is seeking them out. coverage for these services. There is society. If our patients are flocking to There must be ongoing discussion legislation being introduced in our state these CAM providers and are now and debate about diis issue on a local, every year in support of this. Our own willing to pay these bills out-of-pocket state, and national level. We must state insurance commissioner is on without insurance reimbursement, it is realize that despite how we view record as supporting this legislation. time for us "real physicians" to wake ourselves as the expert in regards to When you are talking about a $24 up. What are these CAM providers health care, the American public is billion market, it is no longer a laughing doing that we are not? Are we making seeking other options. So, in our matter. The health care market is our patients feel too rushed in our discussions regarding the future of definitely a finite market. So, if $24 average eight to ten minute encounters health care, let's not forget to include billion is going to one portion of the while they are spending30-45 minutes? the American public at our roundtable.!

June, 2000 PCMS BULLETIN 3 End-of-life care program and medical director Mimi Pattison, MD earn national AHA recognition

Franciscan Health System's meaningful lives. Of-Life Care, which will be given innovative way of caringfor patients at The program and services are annually to up to three programs. The the end of life recently earned national tightly linked to the patient's physician. awards are funded by the Robert distinction as one of three programs in The coordinator regularly checks with Wood Johnson Foundation, tine nation to win the AmericanHospital physicians in the clinic to find out "if Princeton, N.J. (RWJF), initiated by Association's Circle of Life Award. they would be surprised if any of the the AHA, and co-sponsored by the ‘ Em m y patients with certain conditions died'in American Medical Association, the Award- the next year." If the answer for a National Hospice and Palliative Care winning particular patient is, "no," the patient is a Organization, and the American television candidate for this innovative program Association of Homes and Services for journalist Bill that will connect diem to people and the Aging. The sponsors collectively Moyers community programs. The program represent the majority of hospitals, presented the also educates patients and their families physicians, hospices, nonprofit award to about dieir hospice benefits, resulting nursing homes, and elder services in Franciscan's in earlier hospice referrals. the nation. Mian l'v. M f' Improving "It's an honor to be recognized Franciscan Health System Care Through nationally for something we started as a includes St. Clare Hospital in Lake­ the End of Life program at the annual very simple approach of reaching out wood, St. Francis Hospital inFederal meeting of die American Hospital to patients and families," said program Way, St. Joseph Medical Center in Association's (AHA) subsidiary, Health directorGeorganneTrandum, RN. Tacoma, Franciscan Medical Group (a Forum, held in Orlando, Horida in " Chronically ill patients need support multi-specialty provider network), and early May. and easy access to their doctor's care. the Franciscan Care Center at "It has been my privilege to work Improving Care through End of Life Tacoma, a continuing care facility. with a team of caring professionals and fills a gap and builds a bridge until the Franciscan Health System is a part of volunteers who have developed this time is right for Hospice." Catholic Health Initiatives, one of the program and provide a unique The three programs were the first largest not-for-profit health care approach to care at the end of life," said recipients of the new Circle o f Life systems in the country. the program medical director Dr. Award: Celebrating Innovation in End- Congratulations, Dr. Pattison. ■ Mimi Pattison, a prim ary care physician at Franciscan Medical G roup's Gig Harbor Clinic. The main goa 1 of Fran- . ciscan's medical clinic program ’ is to help patients choose how they want to live the rest of their r a u e l e r 5 lives, not just how they want to die. L Their program also lends supports to H ealth Service family members. The program is not A Service of hospital-based, but is developed for Northwest Medical Specialties, PLLC clinics, three of which are already operating through Franciscan Medical INTERNATIONAL TRAVEL CAN BE Group. The program relies on a nurse HAZARDOUS TO YOUR HEALTH coordina tor, chaplain, physician, and a corps of volunteers to marshal the • PRE-TRAVEL CARE • POST-TRAVEL CARE resources in the community, clinic, and HOURS CALL EARLY WHEN PLANNING hospital to ensure that dying patients MON-FRI 9-5 have the support they need and want 253-428-8754 so they can live full and more or 253-627-4123 A SERVICE OF INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph’s Hospital)

4 PCMS BULLETIN June, 2000 y fyenw'(I'omity Qiieclical V __ /

In My Opinion....

Disappearing Nurses Letter to the

by Loma Burt Editor

Dr. Nichol Iverson’s article in up and are not being recognized; con­ To the Editors: Hie March, 2000 PCMS Bulletin, "Hey sequently more deaths are occurring Re: "H ey N urse" by Nichol as a result. Nurse" prompted me to look up the Iverson, MD (Bulletin March, 2000) notes I took on a program that Barbara Dr. Snyderman declared that I found the first paragraph of your Walters presented November 26,1999 nurses are being discriminated against article so offensive that it certainly on20/20 "Your Life Is In by the hospitals and are invalidated the content of your article. Their Hands." Barbara dismissed if they make any I am offended that you assume that everyone would "get it as a joke" interviewed Dr. Nancy complaints. One nurse, when you use "Black slang" to denote when agitated for in­ Snyderman, a staff mem­ poorly trained hospital employees who ber of ABC TV, about creased staff, was fired. lack compassionfor patients. "Disappearing Nurses." How do the hospitals You are using Black stereotypes Dr. Snyderman's answers in Pierce County mea­ to call attention to what you are saying were chilling! It seems sure up? Hopefully, bet­ and you are insulting Black people in the process. that to save money, hospi­ ter than other parts of the Some attempts at humor are not tals in some areas are re­ country. Perhaps some clever or funny, just unpleasant. placing nurses with RNs in our area will an­ Aggrieved, annoyed, and people who have had less swer this question for us outspoken. than a month of training. anonymously, of course! Grace Moses Some go from mopping up From the personal Grace Moses is the wife o f Dr. Buck to bedside care in as little as three experience of a family member, I can Moses, retired Puyallup pediatrician. weeks. In one instance, a hospital was say that Allenmore Hospital has excel­ using people from a penal institution. lent personnel. The nurses and techni­ (Editor's Note: PCMS apologizes for They cost about a third as much as cians in the ICU were excellent, as any m isunderstanding.) trained nurses. These employees are well as the personnel on the surgical calledPCAs (Patient Care Aides). floor. Also, a gold star goes to the St. They are unlicensed and learn on the Joseph Rehab Department for the fol­ job how to take a pulse and blood pres­ low-up. sure, change IV lines, draw blood, and In the conclusion of the Barbara TACOMA/PIERCE COUNTY give medications. Waltei7 s interview, Dr. Nancy Outpatient General Medical Care. They are not able to recognize a Snyderman sugges ted that if y ou are a Full and part-time positions serious problem and take vital signs; patient, ask, "Who is my nurse?" and available in Tacoma and vicinity. therefore they may neglect to see that then ask for assurance that any aides Very flexible schedule. Well suited a patient gets prompt attention from the entering your room are licensed, in for career redefinition lor nurse on duty. The patient's life de­ addition, have a family member and GP, FP, IM. pends on the nurse's quick action to your doctor back you up. ■ Contact Andy Tsoi, MD (253) 752-9669 take care of the problem and notify the or Paul Doty (Allen, Nelson, Turner 6c doctor. Assoc.), Clinic Manager (253) 383-4351 Loma Burt is the wife o f retired Many more infections are showing general surgeon, Robert Burt, MD

June. 2000 PCMS BULLETIN 5 Local hospital leaders Federico Cruz-Uribe, draw large crowd at May agent-of-change Health Membership Meeting Director, will tell his story Editor's Note: For a complete reporting on this program, at June General Meeting please see the PCMS Bulletin, Februaiy, 2000, page 5.

Leaders from Franciscan Health System, Good Samaritan Federico Cruz-Uribe, MD, MPH, Tacoma-Pierce Hospital, Puget Sound Hospital and Multi Care Medical Cen­ County Health Department Director will speak at the June ter each gave their perspective on the fu ture of heal th care a t General Membership Meeting. The meeting will be held on the May General Membership Meeting. Speaking were Jo­ Tuesday, June 13 a t the Land­ seph Wilczek, President & CEO for Franciscan Health Sys­ mark Convention Center in tem; Ed Miller, CEO, Good Samaritan Hospital; Mark Tacoma (see facing page, for de­ Gregson, CEO, Puget Sound Hospital; and George Brown, tails.) MD, VP Acute Care, MultiCare Medical Center. Over 125 Dr. Cruz will share his per­ people attended the sonal public health story and re­ meeting. late his own life-changing experi­ All speakers ences, particularly liis year in the agreed that changes in Guatemalan highlands before the hospital/physician rela­ upheaval that made itimpossible tionships and competi­ for him to remain there. tion for dollars will con­ His accounts will bring him to tederico Cruz-Uribe, MD tinue. Pierce County and encompass the Competition and philosophy and determination he uses everyday in battling challenge were words traditional public health beliefs and other behemoth issues, used often by all such as tobacco advertising. presenters. Challenges Since beginning his job as H ealth Director in 1992, he has included issues such as implemented sweeping changes in the administration of the reimbursements, medi­ department, including a total shift in the philosophy of how cal mistakes, pain man- n „ „ , D^, „ Dr. Susan Salo, PCMS Vice Presi- public health is planned and administered in Pierce County. agement, Wall Street, . . . . , , , ° . , dent introduced the speakers and His first major change was to focus on disease prevention, staffing and, of course, , , , ° , moderated the panel discussion leaving direct patient care to community health care provid­ government regula­ ers. tions. ■ FAX your registration (facing page) to 572-2470.1

From left, Drs. Steven Litsky, Carlos Moravek and Richard L to R: Drs. John McGowen, Col. Howard Cushner, Gerry Dehlinger listen intently as hospital representatives share McGowen and Leonard Alenick. Col. Howard Cushner, MC their thoughts about the future o f health care is Chief of Medicine at Madigan Army Medical Center

6 PCMS BULLETIN June, 2000

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“PAID ADVERTISEMENT” June General Membership Meeting

Tuesday, June 13, 2000 Landmark Convention Center Social Hour: 6:00 pm Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm Tacoma

From Vince through Che to Behrhorst: A Journey on the Edge of Public Health

An evening with Federico Cruz-llribe, MD, MPH Director of Health

(Registration required by June 4. Return this for to: PCMS, 223 Tacoma So, Tacoma 98402: FAX to 572-2470 of call 572-3667)

Please reserve dlnner(s) at $20 per person (tax and tip included)

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2000 PCMS Directory changes Important L&I

Please make note o f the following changes to your 2000 PCMS Physician Directory. phone numbers Updates will he made each month in the Bulletin.

Archer, Bryan, MD (Retired) Roller, Gilbert, MD (Retired) Nurse Consultant Change address to: 3230 W 51s' Vista Change address to: 805 61s1 St. Ct. W. Lindsay Shuster 360-902-9105 Femdale, VVA 98248 University Place, WA 98467 Nurse Consultant Supervisor: Phone: 360-312-9460 Pat Patnode 360-902-5030 Schmitz, Bradley, MD Becker, Herbert, MD Change 552 phone prefixes to 403 Claims Unit Add pediatric ophth to specialty 360-902-9105 Stringfellow, Steven, MD 360-902-6666 Brachvogel, Max, MD Physician only phone # 403-6059 Claims Unit Supervisor: Retired4/28/2000 360-902-4742 Wilson, James M., Jr., MD Stephen Duncan, MD Change 552 phone prefixes to 403 ■ Billing Questions: Change address to: Group Health 611 1-800-848-0811 ■ 31st Ave SW Puyallup, WA 98373-3723

Ginsberg, Daniel, MD Change 552 phone prefixes to 403

Gustafson, Julie, MD Change address to: 104 27lh Ave SE Puyallup, W A 98374 TACOMA RADIOLOGY

Hamill, Lisa, MD Physician only phone # 403-6059

Huang, Dur, MD Change address to: 2223 S Meridian #A Puyallup, WA 98371-7503

Klatt, Gordon, MD Change address to: 1307 South 11th Street, Tacoma, WA 98405 Phone:274-9732 Physician only phone: 274-9737 FAX: 274-9736 H^Spine & Femur

Mihali, Alex, MD DEXA Change 552 phone prefixes to 403 Detect osteoporosis Pratt, David, MD Assess fracture risk Change specialty to Orbital and Facial Quantitate bone mineral density changes Plastic Surgery M onitor therapeutic response , www.tacomaraa.com Realica, Ross, MD Change middle initial to M. Allenmore Medical Center Lakewood Office (253) 383-2038 (253) 588-6083

8 PCMS BULLETIN June, 2000 In My Opinion.... The Invisible Hand by Andrew Statson, MD

Reputation versus Regulation

Escaping with your reputation is better than escaping with your property. African Proverb

hidym- Stair,on. MU

In 1976, the Bellevue-Stratford ho­ that such growth can be prevented by world. It achieved this stature not on tel in Philadelphia entered the name of regular and thorough cleaning of the the basis of certifications, inspections, the American Legion into the annals of water collecting trays, the filters and licenses, credentials, evaluations or medicine and into the textbooks of in­ tile ducts. Removing the moisture and any other actions of any medical or po­ ternal medicine and microbiology. The the dust would have done it They did litical organization or authority; but on outbreak of what became known as Le­ not live up to the quality of service the the basis of a very simple factor, its gionnaires disease was traced to the air market expected of them and they suf­ reputation for good work. conditioning system of the hotel. I re­ fered the consequences. More from "Doctors of the Old member the rumor that the hotel had In the early days of the Old West West": "Whereverseveral medical been inspected by the local health de­ there were no regulations, no inspec­ doctors of serious intent congregated, partment a few months earlier. This is tions. People made it or failed on the they soon were meeting to discuss the notunusual, since all establishments of­ basis of their reputation. In his book formation of an association, to advance fering food and lodging to the public "Doctors of the Old West" Robert the causes and the knowledge of their are inspected periodically. Of course Karolevitz writes, "No-one will ever profession, to eliminate the unworthy the health inspectors could not have know how many men called 'Doc' prac­ and to banish the quack. Education and been expected to detect or, if detected, ticed their own version of medicine licensing were heated topics. In the to realize the significance of a little with neither degree nor formal educa­ Old West, until territories and states known germ, which, until than, had not tion. At the time, they filled a gigantic were created, legal restrictions were been implicated as a human pathogen. void and, to their great credit, many of virtually nonexistent, and, in many The hotel cleaned up its air condi­ them achieved a professional level places, a doctor was a doctor simply if tioning system, was re-inspected and whichfew 'diploma doctors' could he said he was.... Out of this medical certified fit for occupancy by the health boast. But, at best, it was on-the-job melange, however, evolved a profes­ department. The market, however, had learning process with success or failure sional unity which rose above the char­ a different idea. After two years of fi­ measured interm sof life or death. In latans and the montebanks. But people nancial losses the hotel had to close its retrospect, it is obvious now that even being gullible as they are, quackery door. You may argue that the action of the school-trained physicians were never did disappear; it merely changed the market was too harsh. The hotel more ignorant of the science they pur­ itsform." perhaps did not deserve that punish­ sued than they could possibly have With minimal knowledge and train­ ment. After all, the management could imagined" ing, the doctors of the Old West had to not have known about the contamina­ Texas was the first state in the learn their limitations and do the best tion with legionnella, so how could it West to establish a board of medical they could to treat frontier people un­ have prevented it? examiners in 1873. Three years later, der frontier conditions. Those who did That is true. The management California passed the first medical prac­ earned the respect of the people they could not have known of the contami­ tice law. When William Worrall Mayo served. Those who didn't were run out nation with this specific germ How­ opened his office for the practice of of town. Granted, they could go some­ ever, it should have known that air medicine in Rochester, all he had to do place else and start all over, but unless conditioning systems gather moisture is put up his shingle. His two sons es­ they mended their ways, they were and dust, and these two together repre­ tablished the Mayo Clinic, which was bound to get into trouble again. At sent a favorable environment in which destined to become one of the most least, they had another chance and an germs can grow. It should have known prestigious medical institutions in the See "Reputation" page 20

June, 2000 PCMS BULLETIN 9 New Members

Druet, Jack j., MD LeBoux, Edward J., MD Sandler, Andrew S., MD Pain Management Pulmonary Disease/Critical Care Internal Medicine Practices at Allenmore Anesthesia Practices at Pulmonary Consultants Practices at Northwest Medical Associates, 1901S Union St., Tacoma, PLLC, 316 MLKJr Way #401, Tacoma, Specialties PLLC, 1624 SI Street, #405, 98411; Phone:596-5131 98405; Phone: 572-5140 Medical Tacoma, 98405; Phone: 383-3366 Medical School: UCSF School: Oregon Health Sciences Medical School: Mount Sinai School of Internship: USCF University Medicine Residency: USC Internship: Oregon Health Sciences Internship: Mount Sinai Med Center Fellowship: Stanford University Residency: Mount Sinai Med Center Residency: Oregon Heal th Sciences Fellowship: UCSF Haberlin, Polly R., MD University Internal Medicine Fellowship: Oregon Health Sciences Wilson, Alexandra K., MD Practices at MultiCare Internal University P e d ia tric s Medicine, 521 MLKJr Way, Tacoma, Practices at Pediatrics NW Specialty 98405; Phone:403-1590 Malhotra, Vinay, MD Core PS, 316 MLK Jr W ay #305, Medical School: Univ of Washington, C ard io lo g y Tacoma, 98405; Phone: 552-1434 School of Medicine Practices at Cardiac Study Center, hie., Medical School: Stanford University Internship: Veterans Administration PS, 1901S Cedar #301, Tacoma, 98405; Internship: Childrens Hospital Oakland Medical Center Phone:572-7320 Residency: Childrens Hospital Residency: Internal Medicine Spokane Medical School: Armed Forces Medical Oakland College, Pune India Fellowship: University of California Hills, Sandra L., PA-C Internship: University of Illinois Family Practice Hospital Residency: University' of Yuan, Jessie S., MD Practices at Lakes Medical Center, Illinois Family Practice 19820 Hwy 410, #101, Bonney Lake, Hospital Fellowship: University' of Practices at CHC at Lakewood, 9112 98390; Phone:862-9969 Illinois Lakewood Dr. S #203, Lakewood, Medical School: Univ of Washington 98499; Phone: 589-7030 Marsh, Gregory B., MD Medical School: Brown University Kahlstrom, Richard A., MD Anesthesiology School of Medicine Pulmonary Disease Practices at Pacific Anesthesia, PO Box Residency: Community Hospital, Santa Practices at Pulmonary Consultants 2197, Tacoma, 98401; Phone: 779-6313 Rosa California ■ PLLC, 316 MLKJr Way #401, Tacoma, Medical School: Univ of Washington 98405; Phone: 572-5140 Residency': Stanford University' Hosp. Medical School: Univ of Washington Residency: Univ of Washington Mohr, K. Scott, PA-C Fellowship: Univ of British Columbia Orthopaedic Surgery Practices at The Orthopaedic Center AMERICAN LUNG ASSOCIATION* Kuehler, Bianca M., MD PLLC, 1112 6lh Ave #300, Tacoma, ofV\fcsJiington Anesthesiology 98405; Phone: 272-2224 t Practices at Advanced Pain Medicine Medical School: Interservice Physician Physicians, 1628 S Mildred St. #105, AssistantProgram, Houston Texas 1 -8 0 0 -LUNG-USA Tacoma, 98465; Phone: 564-2009 Medical School: Justus Liebig Universitat, Giessen, Germany Lung Information Internship: WinterbergHospital, Service Line Jaarbrucken, Germany Residency: Oregon Health Sciences University Providing patient educatioii 1>laterials The Health Status of Pierce County w

Hepatitis B and D Update TACOMA-PIERCE; COUNTY HEALTH DEPARTMENT

Communicable Disease Control chronic hepatitis B - so an individual County. Each person screened will staff at the Tacoma-Pierce County has chronic hepatitis B and then can be also be vaccinated against hepatitis B Health Department are continuing to infected with D because of the pres­ Because of the connection between screen intravenous drug users for ence of B. tile B and D viral infections, immuniz- hepatitis B and D. As of May 15,2000, fourteen cases of the disease have been detected; three of those infected have died. In 1999, only seven cases of "As of May 15, fourteen cases of the disease have hepatitis B were reported and no one been detected, three of those infected have died. In died of the disease. The sudden in­ 1999, only seven cases of hepatitis B were reported crease in numbers activated the Health Department's disease outreach re­ and no one died of the disease." sponse and prompted the Centers for Disease Control in Atlanta to send in­ vestigators to help set up a screening process and analyze results. Like hepatitis B, die spectrum of ing against hepatitis B prevents hepati­ Hepatitis B is more common in de­ clinical disease in acute D co-infection tis D. veloping countries - an epidemiol ogi- or super-infection varies fromno symp­ The screening process includes a cal map of the world shows more cases toms to the fulminant-type of hepatitis. series of questions, answers to which in Africa, South America, and South­ Chronic infection can also be asymp­ are voluntary, to get a picture of how east Asia. In most developed countries, tomatic or quickly progress to cirrhosis the disease is spread within Pierce including the USA, the incidence of of the liver and dea tli due to liver fail­ Cou nty. The questions take about ten Hepatitis B is considered low. Most in­ ure. minutes. The individuals will have fections occur among certain adults Who gets the disease parallels who blood drawn, to be tested. They will high-risk populations that gets hepatitis B: higher in developing then be given the first of three injec­ include intravenous drug countries, lower in de­ tions to immunize them. Based on CDC users, people with mul­ veloped countries. The recommendations, the immunizations tiple homosexual or het­ risk groups are similar: will be given on an expedited basis: erosexual partners, ^ injection drug users es­ one month and four months after the household or sexual con­ pecially. The prevalence first injection (instead of the typical one tacts of people with of hepatitis D infection is month and six month regimen). All chronic hepatitis B infec­ lower among homo­ three are needed to prevent the dis­ tion, people on hemodi­ sexual men, persons with ease, so people being screened can alysis, people receiving multiple heterosexual expect to be encouraged to return for frequent blood transfu­ partners, and household the rest of the series. sions, and people with oc­ contacts of people with There is no charge for the cupational exposure to blood or body chronic hepatitis B infections. Hepatitis screening or for the immunization. fluids. D infection in the USA is found in Screening occurs at a special An acute Hepatitis D infection about five percent of cases of acute clinic held every weekday from 1:00 - does not occur alone, it needs the B vi­ hepatitis B. 4:00 PM, at the 3629 South D Street, rus in order to replicate. Infection with Since there is no treatment for Tacoma. Please refer patients who are hepatitis D generally occurs in one of hepatitis, only prevention through im­ atriskfor hepatitis B and/or hepatitis two ways: 1) an acute co-infection with munization, Heal tli Department staff D, especially injecting drug users or hepatitis B - meaning someone is in­ are planning to screen all intravenous their partners, to the Health fected with both viruses at the same; 2) drug users and their sexual and Department's clinic. For more informa­ a super-infection of a person who has needle-sharing partners in Pierce tion, you or anyone can call 798-2987.*

June, 2000 PCMS BULLETIN 11 B u l l e t i n

Applicants for Membership Volunteer at Editor's Note: The following physicians have made application to PCMS for asthma camp membership Calling all licensed medical Colombini, Rose-Marie J., DO Loomer, Jeffrey B., MS, MD professionals! A unique opportu­ Family Medicine Rheumatology nity exists to help children with Practices at Lakes Medical Center, Practices at Tacoma South Medical asthma learn how to manage their 19820 Hw y 410, #101, Bonnev Lake Clinic, 2111S 90“’ St, Tacoma 98444; conditions. The American Lung 98390; Phone: 862-9969 Phone:539-9700 Association of Washingtonis Medical School: Western University of Medical School: St. George's looking for volunteers to help staff Health Sciences, College of University School of Medicine Asthma Camp at Camp Sealth on Osteopathic Medicine of the Pacific Internship: Greater Baltimore Medical Vashon Island, June 26 to July 1, Internship: Sail Bernardino Cournty Center Medical Center Residency: New Britain General 2000. Volunteers provide medical Residency: San Bernardino County Hospital supervision to children ages 6 to Medical Center, Arrowhead Regional Fellowship: Dartmouth-Hitchcock 14 with moderate to severe Medical Center Medical Center asthma. These children participate in a w ide range of camp activities Jenmer, Carrie L., MD Louie, Douglas H., MD, PhD along with receiving education on Pediatrics Family Practice/Geriatrics asthma management, proper use Practices at Franciscan Medical Group, Practices at Franciscan Medical Group of medication and identifying St. Joseph Clinic, 1708 S Yakima Ave, at St. Joseph, 1708 S Yakima Ave, triggers. Tacoma, 98405; Phone: 593-8407 Tacoma 98405; W e need volunteers to Medical School: Georgetown Univ Phone:593-8456 commit to at least two days and one Internship: University of Washington Medical School: Univ of Washington night at asthma camp. Please call Residency': University of Washington Internship: Univ of California, Irvine Penny Grellier at the American Residency: Univ of California, Irvine Lung Association of WA at (253) Lahrs, Anthony E., MD 272-8777. Diagnostic Radiology Thorpe, Robert J., MD Practices a t Tacoma Radiology, 3402 S Family Practice Clean Air for 18“', Tacoma 98405; Phone: 383-1099 Practices atSt. Joseph Medical Clinic, Medical School: University of Toronto 1708 S Y akirna, Tacoma 98405; asthmatic kids Internship: University of Toronto Phone:593-8456 An Asthma Outreach Worker Residency: University of Toronto Medical School: Univ of Oklahoma is available to assist families affected Fellowship: Hospital of University of Internship: University of Kansas by asthma. The Asthma Outreach Pennsylvania Residency: University of Kansas ■ Worker is part of the Clean Air for Long, Jeffrey P., MD Kids program, a partnership Radiation Oncology between the American Lung Practices at MultiCare Radiation Go shopping on Association of WA, Tacoma-Pierce Oncology, 1003 S 5th Street, Tacoma County Health Department and 98405; Phone: 403-4994 SuppoiiMj/Association.com local agencies. She helps families Medical School: University of Iowa identify triggers along with simple College of Medicine solutions, comply with or organize W ith ONLY Residencies: University of Arkansas an asthma management plan, and 24 hours in for Medical Sciences, University of communicate with healthcare the Louisville Hospital, University of Iowa providers about asthma issues. This Hospital day, W H E N service is available to families in d o Y O U Pierce County and is free of SHOP? charge to those who qualify. Please call Genevieve Schmidt at the American Lung Association of WA at (253) 272-8777.

12 PCMS BULLETIN June, 2000 PCMS Bicycle Club members pedal 50 miles

Ken Graham enjoys slrawbeny shortcake provided by From left, Drs. Nick Iverson, Henry Retail!iau, Pat Hogan the Tacoma Wheelman's Bicycle Club after completion and Ken Graham were among the 1200 riders in the of his miles Daffodil Classic

Do we have i e l o P C M S your e-mail address? _L ir'aint lacom a B eautiful please send it to us at: PCMS, along with numerous other pcmswa@pcms w a. o r g organizations and individuals will be help- ing"PaintTacoma Beautiful" this summer as we participate in the Associated Ministries program that helps low income people with house painting projects. About 75 homes will be painted this year. Please visit us on the Watch the PCMS FAX News and your PCMS homepage July Bulletin for details. We will be seeking volunteers on behalf of PCMS to help with painting in late July and August. p c m s w a @ Call PCMS, 572-3667 for early registra­ p c m s w a . o r g tion and more information.

June, 2000 PCMS BULLETIN 13 In My Opinion.... by John Stutterhiem, MD

Nostalgia of World War Two

This is the stray of the train station pace toward us. All die brakes Gubeng, in Surabaja, Java, during squealed and steam hissed at the February, 1942. Mother, Anton and I engine's side when she managed to had joined Dad in Surabaja, and we come to a stop. All the short boxcars i ^ were living with my Aunt Loes. Our were painted white, and covered by John Stutterluem, MD actual home was in Malang, but Mother red crosses on all sides and on top. wanted to be close to Dad, willing to This train was packed with wounded risk the dangers of the Japanese and survivors from various navies, bombardments. During die final days of rescued after the battle of the Java Sea. by the Japanese advance. They were February we were shocked by the I was thirteen and I will never forget diverted to Singosari, Java, eight km news of the defeat of the combined the commotion, die from m y hom e in Malang. He lost his naval forces, Australian, sight of all these plane due to bombardments, and was British, Dutch, and stretchers, bandages, being evacuated. We discovered that American. Hie battle of the smell of old both of us had been at Gubeng, at the the Java Sea had been fashioned iodoform, same time, each leaving that station in a an attempt to stop the nurses running different direction. He had boarded invasion of the Japa­ around, everybody that hospital train. nese. Dad now felt that it hying to bring water After a long delay the engine would be safer for and food. Even to this shrieked and set itself in motion, the big Mother to return to day, 1 can still see diis wheels slipping and grabbing atfirst, M alang 90 km to the scene and hear the given die immense weight it had to pull. south. moaling of the sailors At every rotation of its wheels pumping Our farewell was on the stretchers. out steam on the sides, hauling off this short and difficult; we M other squeezed our endless row of cars full of human did not see Aunt Loes hands, refused to let miser}', each car slowly passing by, until after die war again. go, but never said a revealed a different picture of Dad was not able to word. More soldiers wounded sailors through the opened bring us away; as a and United States doors. Several sat in the doorway, legs result the three of us airmen entered the dangling, resting against the doorpost. were waiting at the platform to board this So many of diem were smoking some pla tform of the rail way pitiful train. wrapped in bandages and some just station Gubeng. Surpris­ In the late staring. We then became even more ingly, Gubeng had been seventies I sutured aware of die disaster that had struck spared bombardments here in Tacoma the our defenses. The people who were from die Japanese arm of an older man, left behind were so quiet and many planes, in contrast with who had cut himself women had tears in their eyes. This the marshalling yards of widi a chainsaw. He train's destination was Tjilajap, the the harbor. Trains were recognized my accent harbor on die southern coast of Java, delayed. We had to wait and informed me that not sealed off yet by the Japanese. for two hours under the he had been a naviga­ Later on that day, we finally sun at its zenith. The temperature was tor aboard a B-17, a Flying Fortress. managed to catch a train packed full of over 100 degrees. Suddenly, coming Coming from Hawaii, dieir destination refugees heading for Malang. Mother from T andjung Perak, the na val had been Clark Air Force base on was silent, for she had left Dad behind. harbor, a long goods train, pulled by a Luzon, Philippines. Their traditional We were deeply influenced by the jumbo engine, steamed at a very slow route, Midway, Guam became blocked See "Nostalgia" page 16

14 PCMS B U LLE 1 IN June, 2000 -w Toomily Q/fl^dtcid ijfw'telif

In My Opinion.... by Teresa Clabots, MD

Dr. GENIUS and the RED SNAPPERS

I was training a t County Hospital in were always hunting for those little "red snappers." St. Louis in the 1970s, (long since it I was late to go look at my other closed). I had to get up at 5:00 a.m., shovel the snow, and drive all the way patient in the ICU, sick with pancreatitis outto County. It was a race behind the from binging on alcohol, [said, "hi" to Mr. Richards, grabbed his labs, and snowplow to get to the County Hospi­ / etvsa C/nhun. MO flew onto rounds. (Since being late to tal. I didn't dare pull off the road rounds was declaring professional sui­ fearing I would get stuck in a snow pile, so the window was always open in cide). If you were late to rounds you were sure to be picked on. I broke out "Well," he said as he started stroll­ case my nausea overwhelmed me (since I was pregnant). I thought as a in a cold sweat. My nausea from my ing down the hallway. "Let's go see Mr. medical student that we delivered pregnancy didn't help any. I felt fain t, Richards. I hope he's the only patient outstanding if not in fact superb, and started biting the inside of my who was not examined appropriately. medical care to these indigent patients cheek to stay conscious. As I moved to This morning, we shall ALL go to ex­ who were ever so grateful. This was dre back of the group to try to lean amine him " We followed him like little against the wall, my Resident said, probably one of the finest experiences ducklings into the ICU, which was al­ of my medical training career. The "What's wrong with you" with his eyes. ready full of glum faces. The patients attending was brilliant. He was knowl­ I whispered back, "I didn't get to see didn't like groups of doctors surround­ edgeable, thorough, and could spout Mr. Richards," in a tiny voice. He ing their beds. It was usually NOT good news. He lifted the sheet, and my out more answers than all ofusput looked at me with daggers and said, together. He knew the answers before "Fake it" God, there looked like there was this anybody else, and was always finding Much to my chagrin, Dr. Genius huge basketball inside his abdomen. I "zebras" in our diagnostic workups. I said calmly, "and who has Mr. Richard's was absolutely huge, tense, and swol­ always suspected he paid the mailman today?" I squeaked out, "I do, sir." "And len. He was not a happy camper. Dr. extra to get his New England journal how is he this fine morning?" Mr. Ge­ Genius smiled, and passed onto us his of Medicine delivered a day early. nius said. I looked at my Resident, pearls," ..for you see ladies and No one EVER asked questions on looked at Dr. Geni us, swallowed my gentlemen, if anyone of you had said rounds. panic, and said, "I am really, really they had examined Mr. Basketball I was particularly petrified of him. sorry sir, but I ran out of time, and 1 here, and missed this obvious pancre­ He liked to pick on girls. I had two pa­ didn't get a chance to see him but...." atic pseudocyst, well I would have had tients on the ward. The first was You could now hear a pin drop. I had to flunk them from my course." Tha t Hiawatha, a gentle alcoholic who also broken all of the rules. Everyone was my pearl from Mr. Pancreatic happened to have diabetes, and who waited to hear the tirade. Pseudocyst. Never ever "fake" it. I was female, I was pregnant, and loved to control his medications, his " Now, Ms. Garcia, do your examination now I hadn't performed my duties on I.V., his food, and his medical students. and join us in the hallway. You have 5 pre-rounds, (for which I was paying a minutes." He was particularly belligerent at night, That stuck in the back of my mind and tended to play with his I. V., discon­ hefty tuition to do) in ounces of my through thick and thin all of these nect it, making the floor sticky and mak­ blood that I sold to support myself. "Oh well, well." He turned to the years. Tire day was really not a total ing tine medical student clean it up in the morning. Resident. "Let's see, Dr. Resident. Did loss. Even though it was the last day of the service, after six weeks of taking My problem was that Hiawatha you examine the patient? Aren't you usually consumed all of my time, clean­ supposed to be supervising and help­ Hiawatha's sputum to tire lab on a daily ing his nightly flood, examining him, re­ ing Ms. Pregnant here?" I could have basis, he finally coughed up a good starting his I. V., tracking down his lab crawled under the tile. Not only was I one, and we found his " red snappers." I in deep, deep trouble, but also I was values, and catching his morning spu­ had been exposed to TB for all six tum with a daily run to the lab, checking now in double trouble, and now from weeks of my medicine rotation, while for TB. That was my morning job. We my Resident, and from my Attending. pregnant. ■

June, 2000 PCMS BULLETIN 15 B u i j.hTiN

Nostalgia from page 14 quiet, so still; but 1 knew some how that Did You they would never move again. I felt sight of that hospital train. again how desperate our situation had Remember? Upon our arrival in Malang, it become. I picked up a spent casing looked as though life had resumed its from a shell, but I had to drop it fast steady routine, until the next morning. I because it was so hot. happened to be in the front yard when Mother ran outside to round us all of a sudden two Zero Japanese up. She forced us unto the shelter a t ✓ fighters strafed the street and the park the very momen t that the "all clear" WAMPAC in front of our home, so close 1 could sirens sounded. My brother and I see the pilot's head. They flew in so started to laugh. That broke the ice. Washington Medical Political low that nobody could hear them We thought it was hilarious to get Action Committee coming. Two young native men would there at the wrong time. However, try to run for the shelter, but were mother placed two mattresses in the 1800 Cooper Point Road SW killed. 1 was stunned and at first could shelter and we had to sleep there B!dg7, Suite A not walk away. This was the first time every night. She was totally deaf to Olympia, WA 98502 that I had seen dead people. They our complaints. * 800-562-4546 (360)352-4848 were just lying there. They seemed so

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16 PCMS BULLETIN June. 2000 9/J(«w Tmmdu o4 U d tc< U if

COLLEGE Continuing Medical Education M ED ICAL GI Disease Course for Primary EDUCATION Care scheduled for June 2 The 5111 Annual Gastroenterology Specifically called "Nuts, Bolts and Course is set for J une 2,2000 at the Innovation in Gastrointestinal Disease" WashingtonStateHistory Museum. this course is organized in conjunction Watch for CME Co-directors of the course are Drs. with the Tacoma Gut Club. Gary Taubman and Richard Club members represent a diverse interest survey Tobin. group of expert physicians from Seattle This one-day course is designed to Olympia, both in academic and PCMS phy sidans are reminded to for tine primary care physician and private medicine. watch their mail for the College survey should also appeal to the specialists and A sampling of topics include that will ask you to help the College ancillary health professionals with an Management of End-Stage Liver Board set program priorities for then- interest in abdominal and gastrointesti­ Disease, Ethical Issues in End-of-Lif e new fiscal year, July, 2000 to June, nal medicine. The course emphasizes care, abdominal trauma, and Colon 2001. a practical and multi-disciplinary Cancer Surveillance in Inflammatory The survey seeks specific topics approach. Bowel Disease.* of interest within specialty areas, and specific physician interest for annual courses designed for primary care. The survey also seeks feedback D ates Program Director^ on possible topics for the annual Nuts, Bolts & Internal Medicine Review and Innovation: Gary Taubman, MD Surgery Update, solicits inputforbest Friday, June 2 times and days to schedule courses as Gastrointestinal Richard Tobin, MD well as probes for technology educa­ Disease V tional interests and needs.* CME at Hawaii includes education, family, and sun

CME at Hawaii, a College of This year's group included many Medical Education resort program was families taking advantage of their termed a huge success by conference school spring vacations. Participants participants. The program brought enjoyed Hawaii's opportunities for sun, together Pierce County physicians for swimming, golf, surfing, windsurfing, family vacationing and quality CME on tennis, exploring, great food and just theisland of Hawaii. relaxation. The program featured a potpourri The College continues to offer of educational subjects of value to all resort CME conferences both in ski specialties. Conference attendees locations and in sunny resort areas. particularly enjoyed the rare opportu­ The next ski program will likely be nity to have in-depth discussions about held again in Whistler, British Colum­ various case studies. bia in January of 2001. The next CME Out of the classroom, conference at Hawaii program will likely be David Magelssen, MD, Lakewood participants and their families enjoyed scheduled for spring vacation of exploring Hawaii, water sports and 2002. Ob/Gyn, addressed current therapies great weather. (More photos page 19) for ectopic pregnancy

June, 2000 PCMS BULLETIN 17 B u l l e t in

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18 PCMS BULLETIN June, 2000 Jim Rooks, MD, Lakewood otolaiyngologist and PCMS From left, Ann & Ron Taylor, MD; Debbie & Alex Mihali, MD, Secretary-Treasurer, spoke on advances in otolaryngology & Jim Fry, MD and his wife Janet enjoy the program reception

Dr. Frank Senecal andfamily enjoy the Hawaiian surf; front Amy Yu, MD (center) enjoys the hotel pool with her children; row from left, Clare andAidan; in back Maura and wife, Maty son David Jr., and daughter Laura

Left, Dr. Craig Rone and his wife Belinda with Dr. Mark Many physicians attending the conference enjoyed having Craddock and his wife Jinny at the welcoming reception theirfamilies accompany them

June, 2000 PCMS BULLETIN 19 B u l l e t i n

Reputation from page 9 credentialing probably costs 100 dollars you suspect will be able to stamp out opportunity to learn from their experi­ per physician. Since many hospitals hum an error? Will regulation be bettei ence. Another problem of the time was have merged, the paperwork is less, able to do it than reputation? the peddling of various patent medi­ but even if two hospital systems have to Here is some food for thought, a cines, usually harmless, sometimes poi­ credential the physicians every otiier fable by Aesop, titled "The Horse, sonous, seldom helpful. Over time, year, assuming tiiere are 400,000 prac­ Hunter and Stag": A quarrel had ariser these also disappeared. ticing physicians in the country, it costs between the horse and the stag, so the At first, the only requirement for 40 million dollars per year. Add to that horse came to a hunter to ask his help doctors was to take a test by the medi­ the credentialing by die insurance to take revenge on the stag. The cal examiners of the state to get a li­ companies, both health and liability, the hunter agreed, but said: "If you desire cense. For a long time that was suffi­ paperwork of other payors, the paper­ to conquer the stag, you must permit cient. Then hospitals started looking work on our end of it, the cost of this me to place this piece of iron between into the qualifications of physicians be­ exercise probably runs at 100 million your jaws, so that I may guide you with fore allowing them to admit patients. dollars per year. Then we have the these reins, and allow this saddle to be Then some physicians were accused of cost of the medical examining boards, placed on your back so that I may keej never opening a medical book after quality assurance commissions, medical steady upon you as we follow the en­ they completed their training, so con­ disciplinary boards, etc. This regula­ emy." The horse agreed to the condi­ tinuing medical education became a re- tory burden was intended to give us a tions, and the hunter saddled and quirementfor license renewal. sense of security. What, then, is that bridled him. Then, with the aid of the Almost at the same time, for legal noise about medical eirors? Why is the hunter, the horse soon overcame the reasons, hospitals were urged to re­ Senate investigating the matter? If our stag, and said to the hunter: "Now, get view the credentials of their physicians rocket scientists can mix up their centi­ off, and remove those things from my every two years. Soon afterwards, in­ meters widi their inches, how can we, m outh and back." "Not so fast, friend/' surance companies started contracting ordinary people with ordinary minds, said the hunter. "I have now got you physicians and had to go through the be expected to go through life without under bit and spur and prefer to keep same process of credentialing every making a mistake? What kind of law do youthatway." ■ few years. All of that was done in inter­ est of better patient care. Have we achieved it? One big argument for CME was the steep rise in malpractice claims. The idea was that if we could get rid of the few bad apples that spoiled it for all of us, things would be much better. I don't know whether we did ornot, but malpractice claims are still a big prob­ ER^SE lem, insurance a major part of our overhead, and the physician data THAT TATTOO banks are multiplying. WORRIED ABOUT WHAT YOUR SPOUSE, Granted, we got rid of the quacks YOUR FRIENDS OR EVEN YOUR BOSS and the patent medicines. Instead we THINKS ABOUT YOUR TATTOO? now have a variety of health care pro­ OR ARE YOU JUST TIRED OF viders, but at least they all are licensed. LOOKING AT IT? Most of them know their limitations and Today's newest Alexandrite laser, do a good job. We also have health will remove your tattoo food stores that sell unproven rem­ with minimal discomfort & edies, but they are food supplements less than 1% risk of scarring. or herbal teas. Most are harmless, some (’.all today Jar more information are poisonous, a few are helpful. Obvi­ PIERCE COUNTY ously we have made great strides for­ LASER CLINIC ward during die past century. What is the cost? Hospital Director IVccr K. Mjirsli M.l). (253)573-0047

20 PCMS BULLETIN June, 2000 Expedition leader to speak at September 12 General Membership Meeting Dramatic tale of high adventure Reserve Tuesday, September 12,2000,6:00 resolving 1924 mystery p.m. for an evening of high adventure as Eric Simonson speaks on, that set out to solve two Mallory. Two major television docu­ "FindingMalloiy." of exploration's greatest mentaries have focused on the Simonson, owner mysteries: Did George expedition. He will relate the myster­ and active partner in Mallory and Sandy ies, the quest to solve them, and what International Mountain Irvine reach the summit the expedition did at the September Guides (one of the of Mt. Everest in 1924, meeting. oldestmountaineering and what became of Simonson's climbing resume companies in the them? includes M t McKinley, Aconcagua in country) as well as This expedition Argentina, Cho Oyu in Tibet, Mt. owner and operator of stunned the mountain­ Elbrus in Russia, and Mt. Vinson in Mt. Rainier Alpine Guides will speak eering community with Anarctica. on the experiences of the expedition the discovery of the remains of Watch your mail for details. ■

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June, 2000 PCMS BULLETIN 21 B u l l E iit M

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22 PCMS BULLETIN June. 2000 v_ WuJtem 'Xptui'tifiu Q/'iicdeal (Sfwety

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June, 2000 PCMS BULLETIN 23 Wr;rt'*Wrtrr,'nyM@ ULLETIN

I"ly, 2000

Dale Overfield, MD (left), Puyallup neurologist passes the gavel to |ohn ]iganti, \,I_D, Tac6ma brthop_edil suigeon i-ncominf prediilent of the College of Me^dical Edu"cation

See story page 17

INSIDE: 3 Federico Cruz-Uribe, MD, weII received at June General Membership Meeting 4 Check out these medical dinectory errnrstt D- I-7252 Shall a state health benefit package be developed for Washington nesidentsP *Paint 6 Join PCMS eolleagues and Tacoma-Pience Beautiful" sfI Sound to Narrows continues to keep phpicians running I Ski to Sea, an 82 mile relay, challenging and newarding for Pierce Coun$r team L7 College of Medical Education welcomes new board membere and officers for 2OOO-2OOI B u l l e t i n

PCMS Officers/Trustees: W\<’yee ^ountif Q/:f(ed(ca/ (ifc-ciet)j Charles M. W eatherby, M D ...... P re s id e n t PatriceN. Stevenson,M D ...... President Elect S u sa n J. S alo , M D ...... Vice-President J. James Rooks, M D ...... S ec re ta ry fT re a su re r Lawrence A. Larson, D O ...... Past President Sabrina A. Benjamin, M D Drew H. Deutsch, MD K e v in K . G a n d h i, M D M ichael J. Kelly, M D Doris A. Page, M D July, 2000 Edward X. W alkley, M D Yolanda Bruce, PCM SA President

WSMA Representatives: Speaker of the House: Richard Hawkins, M D Trustee: Dav id Law , M D AM A Delegate: Leonard Alenick, M D W AM PAC Chair/6th District: M ark Gildenhar, MD W AM PAC 9th District: Don Russell, DO

Executive Director: Douglas Jackman

Committee Chairs: Aging, Richard Waltman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, John Jiganti; Credentials, Susan Salo; Emergency Medical Standards, Ted Walkley; Ethics/Standards Of Practice, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, William Ritchie; Table of Contents Legislative, William Marsh; Medical-Legal, Pat Donley; M embership Benefits, Inc., Drew Deutsch; Personal Problems Of Physicians, Robert Sands; Public Health/School Health, Sumner Schoenike; 3 Dr. Cruz-Uribe addresses June Meeting crowd Sports Medicine, John Jiganti. 4 Check out these medical directory errors! The Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce County Medical Society. Deadlines for submitting 5 1-725: Shall a state health benefit package be developed? articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. October 15 for the November issue). 6 Join PCMS colleagues and Paint Tacoma-Pierce Beautiful!

The Bulletin is dedicated to the art, science and 7 Sound to Narrows 2000 recap delivery of medicine and the betterment of the health and medical welfare of the community. The opinions herein are those of the individual contributors and do 9 Ski to Sea: an 82 mile relay not necessarily reflect the official position of the Medical Society. Acceptance of advertising in no 10 Updated DSHS Contact Numbers way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin and Pierce County Medical Society reserve the right 11 TPCHD: Breast and Cervical Cancer program update to reject any advertising. 12 Drs. Ron Goldberg and David Sparling honored Editors: MB! Board of Directors M anaging Editor: Douglas Jackman Editorial Committee: MBI Board of Directors 13 "The Yellow Brick Road" by Andrew Statson, MD

Advertising Representative: Tanya McClain 15 "The Silver Bullet" by Teresa Clabots, MD Subscriptions: $50 per year, $5 per issue

M ake all checks payable to: M BI 17 College of Medical Education elects new board members 223 Tacoma Avenue South, Tacoma WA 98402 253-572-3666, FAX253-572-2470 19 Classified Advertising

E-mail address: [email protected] HomePage: http://www.pcmswa.org

2 PCMS BULLETIN July, 2000 '^Pieire Hfamtif- oMeJical Cyouety

June General Membership Meeting Recap

Federico Cruz-Uribe, MD, you can bring interest and enthusiasm," Director of Health for the Tacoma- noted Dr. Cruz. Pierce County Health Department en­ He understands why he is contro­ tertained and educated over 50 mem­ versial. He believes that public health bers that attended the June 13th Gen­ is dynamic, while most heal th depart­ eral Membership Meeting at die Land­ ments follow the more traditional, status mark Convention Center. quo model. He believes that to solve In his humorous and easy-going problems communities have to change, manner, Dr. Cruz shared his personal issues need to change and people experiences regarding public health have to get passionate abou t solving and how he came to know that listen­ problems. ing, more listening and understanding Dr. Cruz was well received and is how you implement change in public found support and gratitude for his Dr. Federico Crtiz-Uribe answers health. "You cannot bring solutions, but non-traditional public health efforts. ■ questions regarding his tenure

Dermatologists Sid Whaley (left) and Bob Martin have an Dr. Joseph Clabots (left) asks a question o f Dr. Cruz while opportunity to visit after the meeting Dr. Teresa Clabots looks on

A, H U .^ li i'i %*'•■ ^s§, g i| l|f| f $ § | ; W* - '•Si "

From left, Drs. George Tanbara, Bob Ferguson and Ken PCMS President, Dr. Charles Weatherby, (left) visits with Graham enjoyed having time together Drs. George Krick and Rich Dehlinger on the deck

More photos page4

July, 2000 PCMS BULLETIN 3 Dr. Cruz (right) visits with Dr. John McCloskey, pediatric Phil Craven, MD, talks with Dr. Cruz while his son, Dylan, cardiologist and his wife, Susan who will go to Guatemala this summer, listens

Regence Provider Directory chock-full of errors

Editor's Note: The following is taken from the Regence Preferred Provider Directory (11/99) which was given to patients and physicians to help fin d referrals in the Gig Harbor area. It was forwarded to PCMS after a member noted a “couple o f mistakes. "

INFECTIOUS DISEASES PHYSICAL THERAPY KENDRICK, TONJA, CMFT DEAN, DIANA, CCC-S BERNDT, KATHERINE, ARNP O’CONNELL, SHELMAR, MD LIVINGSTON, ROBERT, MD BROWN, JAMES, MD OSTERGREN, GREGG, DO MARTIN, ROBERT J., MD DALE, CHARLES, OD PEARSON, MICHAEL, MD DAY, LAURA, CCC-A STUART, ROBERT, E, MD INTERNAL MEDICINE DEAN, DIANA, CCC-S ANDERSON, SHEILA, CMHC DEAN, WILLIAM, MD PODIATRY BLEIWEISS, MILTON, MD DIAZ, KIMBERLY, ARNP PINGREY, GARY, DO CARDILLO, TANYA, PT HAMMER, DORIS, ARNP ELDERKIN, PAMELA, CMHC HENRY, MELVIN, MD PSYCHIATRY______HNKLEMAN, LOWELL, MD KATSMAN, RALPH, MD HASSAN, DOUGLAS, MD FISHER-H AVENS, J., CMFT KENNEDY,KEVIN, DO KONICEK, STEVEN, MD HALLEY, J OAN, DO CRAMER, CAROL, CMHC KUNKLE, ROBERT, MD KRUMINS, PETER, MD LANG, TIMOTHY, MD SORENSEN, ALLAN PT MARTIN, ROBERT J, MD MURRAY, JOHN, OT SPORL, SUSAN, MSW MENDIOLA, DANIEL, OT O’BRIEN, MARY, MD STANLEY, SHARON, CMHC OTTO, RANDOLPH, MD OZOLIN, ARTHUR, MD YANCEY, ROBERT, MD PEIXOTTO, JOHN, MD PATTISON, MARILYN, MD PINGREY, GARY, DO SCHUBERT, TIMOTHY, MD RADIOLOGY______RAFTER, ROBERT, MSW TAUBMAN, GARY, MD HARRIS, CHRISTINE, ARNP SAMMS, JOHN, MD TRAN, KHAI, MD KOFFMAN, SANDRA, ARNP VENUTO, GAIL, MD WAGONFELD, JAMES, MD WORTHEN, EDWARD, OD WORTHEN, EDWARD, OD UROLOGY______BROWN, SHARON, CMHC NEUROSURGERY PHYSICIANS ASSISTANT DOWD, MICHAEL, MD JACKSON, WILLIAM B, MD DIMANT, JOHN, MD STUART, ROBERT, E..MD ■ FALOTTCO, GEORGANN, CMHC

4 PCMS BULLETIN July, 2000 'PPkwe %Mnty. oMeduxd Society

Initiative 725 - finds support and reservations

Editor's Note: The Initiative 725 campaign hopes to turn in 230,000 signatures by July 7 to qualify fo r the 2000 ballot. Following is a listing o f frequently asked questions prepared by Health Care 2000. More information is available on the website www.healthcare2k.org. Robert Fithian, MD a founding member o f Health Care 2000 appeared before the PCMS Board o f Trustees June 6 and discussed the initiative

per year in WA). We will save over 2 Initiative 725, if enacted, would es­ Official ballot title: billion alone in current administrative tablish a health security trust to operate Shall a state health agency be a health coverage system for state resi­ costs compared with the present sys­ created and develop a health dents not covered by federal pro­ tem benefits package for state grams. The trust would develop a Q. What will happen to Medi­ single uniform benefits package residents, funded by mandatory care? Until federal waivers are ob­ funded by mandatory premiums, a premiums, employer tained, Medicare recipients will con­ 9.75 % payroll assessment on employ­ assessments, and existing taxes? tinue to be covered under their cur­ ers, existing taxes and co-payments. rent plans. The Health Security Trust Payments to providers would be nego­ will replace Medigap policies for a $50 tiated. For residents keeping private in­ Q. Wouldn’t doctors lose monthly premium surance coverage, state coverage control of their practices? No, Q. I’ve got good health in­ would be secondary with premiums re­ Doctors have less control now than surance now. Why should I want maining mandatory. Funds would be they will under the new system. Pay­ a change? U nder the new health law, appropriated for fiscal 2001 and 2002. ments will be based on collective nego­ you can never lose your health insur­ In theory there appears to be tiations between the Trust Board and ance even if you lose your job, retire, broad based support for such a system. providers and facilities, not on take-it- or are unable to afford it if your em­ However, there are many concerns, or-leave-it one-sided contracts under ployer expects you to pay the cost of particularly in regard to funding. Many the current private profit system. rapidly rising premiums. And, you questions have been posed such as: Q. Will I have to pay for the never have to change doctors because Q. How much will it cost me: poor, unemployed, etc? You al­ your employer changes insurers. Premiums will be $75 per month for ev­ ready do under the current system For more informa tion on 1-725 eryone over 18 whose monthly income through taxes and through cost-shifting please contact PCMS, 572-3667. ■ is above 250% of the federal poverty by health providers. Since everyone is level (about $1666 for a single person, covered under the new plan, the poor $2083 for a family of four). Those mak­ will be more likely to seek care early Personal Problems ing 150-250% would pay reduced rates on before their conditions get worse of Physicians and those below 150 % pay nothing. which will resul t in net savings. Fur­ Your employer can pay the individual thermore, the costs will be spread out Gaminittee premiumforyou. Employers will pay over the entire population. Q. Isn’t this going to mean 9.75 % of payroll, which is less than Medical problems, drugs, alcohol, most are currently paying for health higher taxes? No, there will be a retirement, emotional, benefits. 9.75% payroll assessment paid by em­ or other such difficulties? Q. You’re going to turn ployers, much less than they are cur­ health care over to the govern­ rently paying for private profit driven plans. Your colleagues ment? No, 1-725 is not government want to help run health care. Its funding is indepen­ Q. Then you are making dent of the legislature and will be run businesses pay for health insur­ by an independent 'Health Security ance reform? No, businesses cur­ *Robert Sands, MD, Chair 752-6056 Trust' with its own board of trustees rently spend 12-15 % of payroll for Bill Dean, MD 272-4013 representing citizens, business, labor, health insurance so the new system will Tom Herron, MD 853-3888 and health professionals. actually save themmoney immediately. Bill Roes, MD 884-9221 Q. Won’t this system elimi­ Q. Will there be enough F. Dennis Waldron, MD 265-2584 nate competition? No, com petition money to pay for comprehensive will be based on quality as perceived services for everyone? Yes, the by the patient, not the insurance com­ estimated revenue from all sources will C onfidentiality Assured. panies' bottom line. cover the costs (presently at $16 billion

July, 2000 PCMS BULLETIN 5 Directory changes en Please make note o f the following changes to your 2000 PCMS Physician U r Directory. Updates will be made each month in the Bulletin. n e a .

Bennett, Randall, MD Change address to: 104 27th Ave SE Puyallup, WA 98374-1145 V olunteers neeaec

Biljan, William, MD h j p b ) i ? r'eyi 11 Change address to: 5814 Graham Ave >ai #100, Sumner, W A 98390-2756 i i o r Burrows, William, MD (Retired) Change address to: 7413144°’ Ave E Sumner, WA 98390-8255 PCMS, along with numerous other organizations Corliss, Robert, MD and individuals will be helping "Paint Tacoma- Change address to: 5814Graham Ave #100, Sumner, WA 98390-2756 Pierce Beautiful" this summer as we participate in the Associated Ministries program that helps low Cowell, Pamela, MD Change address to: PO Box 98865 income people with house painting projects. To Lakewood, W A 98498-0865 date, 112 homes, a record high, have been sched­ Deyo, Glen, MD uled for painting. Change office zip code to 98418 PCMS has been assigned a home near Tacoma Duffy, James P., MD (Pat) Mall, on South Puget Sound avenue and work Change address to: 5814Graham Ave #100, Sumner, WA 98390-2756 parties are being formed. The house is one story and will require minimal power washing, scraping, Edmond, Charles, MD Change address to: 104 27th Ave SE sanding, and priming prior to painting. Puyallup, WA 98374-1145

Leitz, Fred, MD Work crews are being scheduled for die first Change address to: 5814 Graham Ave week in July and the last week in July. #100, Sumner, WA 98390-2756

Sumner Schoenike, MD Family members and friends are welcome. Physician only phone to: 582-6477

Tan, Darryl, MD Call PCMS, 572-3667 for more information. Change Physicians only phone to: 582- 6477

6 PCMS BULLETIN July, 2000 Members complete Sound to Narrows 2000

On a day made for running, over­ lowed closely by colleagues Drs. Pe­ children, Eric and Laura, who finished cast and a light rain, 5,678 runners par­ ter Krumins w ith a 57:50 and Ian 4th and 8 th in their respective age ticipated and finished the 28th run­ Lawson at 1:01:49. Great times for all. groups. Eric, at age 18 had a 42:51 time. ning of the popular, but tough 12k race. Neurologist Pat Hogan improved Dr. Cordell Bahn, retired cardio­ Tacoma orthopedist John Jiganti, led his time three minutes over last year by vascular surgeon was one of a remain­ PCMS members by doing a tremen­ doing a 57:17. Pediatrician John ing few who has run in every Sound to dous time of46:47 and placing 58th Hautala had an excellent time of Narrows since the first one, 28 years overall. This was two seconds slower 1:00:42, but trailed badly behind his ago------thanhis time last year. More photos, page 8 Dr. Jiganti had a lot of competition from his fellow orthopedists. Dr. Tim Congratulations to PCMS finishers: Lang came in with a time of55:47 fol- Majeed Al-Mateen 1:01:33 Cordell Bahn 1:12:22 Loren Betteridge 1:18:00 Tom Charbonnel 1:07:50 Martin Goldsmith 58:05 Steve Hammer 1:04:38 John Hautala 1:00:02 Pat Hogan 57:17 John Jiganti 46:47 Gil Johnston 1:08:39 Peter Krumins 57:50 Tim Lang 55:47 Ian Lawson 1:01:49 John Lenihan 59:48 David Magelssen 1:03:55 Jim Schopp 58:09 Willie Shields 1:08:59 John Jiganti, MD, Tacoma orthopedist, finished 58th o f 5,678 Darryl Tan 1:04:58 runners in 46 minutes and47seconds Alan Tice 1:15:28

John Hautala, MD, Fircrest pediatrician, finished in one hour Jim Schopp, MD, Tacoma general surgeon, finished with an and two seconds, 18 minutes behind his son, Eric excellent time o f 58:09

More photos page 8 B u l l e t in

Sound to Narrows from page 7

John Lenihan, MD, Tacoma Ob/Gyn signals positively as Alan Tice, MD, infectious diseases physician, coming up the he finishes just under an hour in 59:48 hill after leaving the park, finished the tough 12k run in 1:15:28

Gil Johnston. MD, Tacoma cardiovascular surgeon finished Stevens Hammer, MD, (right) Tacoma general surgeon feeling good after a 1:08:39 run completed the course in 1:04:38

Allenmore Psychological Medical Placement Service...... owned and operated by: Associates, P.S. 752-7320 Pierce County Medical Society Do you have patients with difficult emotional *Permanent Full & Part Time Positions and stress-related problems? Psychiatric and ^Temporary Placements psychological consultations are available. Pierce County's “medically exclusive ” agency Union Avenue Professional Building 223 Tacoma Ave South, Tacoma...... 253-572-3709 ______1530 Union Ave. S„ Ste. 16. Tacoma______

8 PCMS BULLETIN July, 2000 Ski to Sea - seven modes of transport in nine hours

by Mark Craddock, MD

The Bellingham "Ski to Sea" cross-country skiers trying to jockey for race was originally a marathon position and ski on a cross-country run started in 1913. Participants could no larger than 10 feet across. About two take the train or a car to the start­ thirds of the way through that part of the ing point on Mt. Baker and then race I fell and broke a pole. I had to ski they were required to run to the the rest of the race with a broken pole in top of Mt. Baker and back. This my left-hand. I then handed off to Dr. race was stopped in 1913 when David Law. The intrepid Law then had one of the participants fell into a to hike 900 feet up the side of a ridge, crevasse and nearly died. The and then ski down. current race called the "Ski to At that point he handed off to Dr. Sea" was started in 1973. The Duane Hulbert (a U.P.S. music professor Ski to Sea Team: Front Row (from left, Dr. race involves seven legs. and concert pianist), who ran eight miles David Law and daughter Hillary, back The first leg is four miles of down the wet, windy mountain road. Mitch row Dr. Duane Hulbert, Mitch Blakney I cross-country skiing, the second Blakney, (a physical therapist with a practice Drs. Pat Hogan and Mark Craddock is 2.5 miles of downhill skiing. in Gig Harbor) rode bike 36 miles down to The third leg is running for eight the next hand off point at Nooksack River. miles down the Mt. Baker High­ Dr. Hetch Taylor and Hillary Law than ven­ which I had to carry my bike, slipping way followed by a 36 mile bike tured out into the river, for 18 miles of con­ and sliding in the loose embankment ride on the same road. The fifth tinuous paddling. Many canoes flipped after dirt. Finally I completed the nine miles ) leg is canoeing in the Nooksack their initial entry into the water but fortu­ and handed off to Dr. Pat Hogan at River for 18 miles, and the next nately were righted, and most were able to Squalicum Harbor. He then paddled is mountainbikingfor nine miles. complete the race. his kayak 5 miles to Marine Park and The seventh and final leg is a Among the things Hillary and Fletch saw the finish. We had started at 8:30 a.m. five mile kayaking trip across on the river was a canoe devoid of paddlers, and we finished at 5:20 p.m.! Bellingham Bay. floating half-submerged down the river. For­ We were tired, but happy! We had We got up at 5:00 a.m. and tunately, they made it to the next hand off finished the Bellingham Ski to Sea race drove up to the Mount Baker ski point. The mountain bike leg was muddy. At in a respectable time, without injury! area. The race started in cold, one point I carried my bike through a puddle We did lose a lifejacket, and of course blowing snow. I did the cross­ about fifteen feet across, up to my ankles in there was the broken ski pole. Next county skiing leg. Imagine 400 mud. There were also three bridges under year, we'll be a whole lot faster. ■

July, 2000 PCMS BULLETIN 9 X Updated DSHS Contact numbers:

Bill’PLUS...... 1-800-826-2444 CLIENT ASSIST/BROKER TRANSPORT/INTERPRETER INFORMATION...... 1-800-562-3022 COORDINATION OF BENEFITS HOTLINE...... 1-800-562-6136 DISABILITY INSURANCE...... 1-800-562-6074 DME PROSTHETICS & ORTHOTICS (PROVIDERS ONLY)...... 1-800-292-S064 ELECTRONIC BILLING QUESTIONS...... (360) 725-1267 FRAUD HOTLINE...... 1-800-562-6906 HEALTHY OPTIONS DISENROLL/EXEMPTIONS/COMPLAINTS (CLIENTS ONLY) 1-800-7944360 HEALTHY OPTIONS ENROLLMENT...... 1-800-562-3022 HOME HEALTH/P.O.T...... (360)725-1582 HOSPICE NOTIFICATION...... 1-800-54S-5392 PM&R AUTHORIZATION...... 1-80CHS34-1398 MEDICAL ELIGIBILITY DETERMINATION SERVICES/MEDS...... 1-800-204-6429 PHARMACY AUTHORIZATION (PROVIDERS ONLY)...... 1-800-848-2842 PHARMACY POINT-OF-SALE HELP DESK...... 1-800-3654944 PROVIDER RELATIONS HOTLINE (PROVIDERS ONLY)...... 1-800562-6188 TDD ONLY/DISENROLLMENT...... 1-800461-5980 TDD ONLY/ENROLLMENT...... 1-800^48-5429

Provider Field Representatives: Rita Hone 360-725-1024 Dee Dee Howden 360-725-1027 Peggy Strong 360-725-1022 Debbie Wingfield 360-725-1023 7ACOMA RADIOLOGY

Provider Enrollment: 360-725-1026 or360-725-1033 o r360-725-1032

Provider Field Representatives are available for one to two hour consultations in physician offices at no charge. Call one of the above numbers for more information. ■

TacomaRadiology launches web site DEXA Tacoma Radiology Associates (TRA) has developed a new web site. Detect osteoporosis The site provides extensive informa­ Assess fracture risk tion about the diagnostic examinations Quantitate bone mineral density changes and interventional procedures M onitor therapeutic response performed in the outpatient clinics, www. tacomarad. com MRI centers and hospitals served by the physicians of Tacoma Radiology. Allenmore Medical Center Lakewood Office Patients, medical personnel and physicians should find the site a (253) 383-2038 (253) 588-6083 valuable resource. Visit TRAatwww.tacomarad,com« VPievm 'tpounty oAiedieal Society

Federico Cruz-Uribe, MD The Health Status of Pierce County Director of Health

The Breast and Cervical Health Program of Pierce County provides low cost screenings

T A C O M A - P IE R C E C O U N T Y HEALTH Here are two statements that are women in Pierce County who would DEPARTMENT not new, not unique, but are very true normally not have been screened. in vital ways: Beginning in the year 2000, the 1) Early detection of breast state no longer works directly with suspects breast or cervical cancer. cancer and/or cervical cancer healthcare providers, but contracts with Unfortunately, BCFff supplies saves lives. the Tacoma-Pierce County Health screening only; treatment funds 2) Patients are more likely to Department to arrange for screening continue to be challenging for many get screened if a physician tells and diagnostic services outreach. women to find. Congress is currently them it is important to do. Healthcare providers subcontract with wrestling with this problem For both breast and cervical TPCHD to provide services and To make an appointment, women cancer, the factor that most increases chances for overcoming the disease is early detection. Finding the malig­ nancy early, through pap smears and Currently, seventeen sites throughout Pierce mammograms, greatly increases the County provide womens health exams, which ^ effectiveness of treatment. Convincing an individual to get include a pap smear and clinical breast exam screened is not always an easy and referral for a mammogram...... limited process. For some women, the extra nudge needed must come from resources allow some follow up diagnosis for someone in authority, often a medical abnormal results discovered in the exam if the provider. That sometimes puts phy si- dans in a difficult position, especially provider suspects breast or cervical cancer. when they know the individual has no insurance. Without insurance, a low- income woman's fragile budget can be reimbursement. can call the Health Department at (253) threatened by any medical care Currently, seventeen sites 798-2987. Operators will determine beyond real emergencies. throughout Pierce County provide eligibility, by checking age, income, The Breast and Cervical Health women's health exams, which include a and insurance coverage. If you know a Program of Pierce County (BCHP) Pap smear and clinical breast exam and canhelp. woman who should be screened but referral for a mammogram. During the who is hesitant because she has no Almost six years old, BCHP exam, the provider encourages women provides health exams and insurance, feel free to share this to begin or to continue monthly self­ information, and encourage her to get . mammogramsforwomenbetweenthe breast exams, teaching proper tech­ ages of 40 and 64 years, emphasizing screened. Our promotion of early niques, if necessary. In addition, limited early detection of cervical and breast detection is important, and the BCHP resources allow some follow up cancer. To date 18 cases of these can help to make that screening diagnosis for abnormal results discov­ cancers have been diagnosed in possible. ■ ered in the exam if the provider

►

July, 2000 PCMS BULLETIN U B u l l e t in

BRIEFS...... Go shopping on Home Care Siippc)rtAf//Association.com

Association honors With ONLY 24 hours in the Ron Goldberg, MD day, W HEN do YOU SHOP?

Puyallup oncologist Dr. Ron Goldberg was honored by the HomeCare Association of Washing­ ton (HCSA) at their April meeting in K+H Bellevue. Dr. Goldberg received the "physician of the year" award. He HIGHLINE COMMUNITY HOSPITAL serves as medical director for In- HEALTH CARE NETWORK Home Services. www.hchnet.ora Excellent opportunities for BE/BC Infectious Mary Lou Bresee, administrative SEATTLE, WA: Internal Medicine, Disease, Orthopedic Surgeon, and Critical Care Pulmonologist. Enjoy practicing director for In-Home Services, in a progressive hospital setting with an extensive network of health care providers nominated him for the award, explain­ and specialists throughout SW King County. Minutes from downtown Seattle, the ing that he is involved in patient care shores of Puget Sound and the Cascade Mountains. We offer state-of-the-art and physician education for Home resources, equipment and expertise to provide outstanding care for your patients. Competitive package. Please call 206-988-5780 for more information. Fax or e-mail Health and Hospice programs. She CVs to Gail Mumma at fax 206-431-3939 or e-mail [email protected]. w ent on to say that he is a very integral part of their care team. ■

David Sparling, MD receives City of Destiny award

On June 13, the Tacoma City Nationally Accredited Residential T reatment for Council announced the winners of the Chemical Dependency 14th annual City of Destiny awards. Dr. David Sparling received the Begins award in the adult leadership cat­ egory. Inpatient Treatment Dr. Sparling, a retired pediatri­ Recovery House cian, has been active on many local boards and comissions, as well as in Outpatient efforts to keep kids ou t of gangs and Family Education in school. He has advocated naming and Support those people diagnosed with HIV for the purposes of education and Relapse Prevention counseling and he arranged the State Certified shipment of $2.5 million in donated medical supplies to Russia. These are Diagnostic Assessment just a sampling of the projects and activities that Dr. Sparling dedicates his time and expertise to. A l l v e S t 8021 230th SW, Edmonds Winners received a glass H oiIS e www.allvesthouse.com sculpture created by students in the North 425 - 712-0505 Hilltop Artists-in-Residence program ■

12 PCMS BULLETIN July, 2000 In My Opinion.... The Invisible Hand by Andrew Statson, MD

The Yellow Brick Road

“The height of ability in the least able consists in knowing how to submit to the good leadership o f others. ” Due Francois de la Rochefoucauld (1665) Andrew Statson, MD

We harbor a child within us who is medicine. If we could remove the troubleshooting checklist approved by afraid of the dark, when the monsters threat of disciplinary action or malprac­ the FAA, the plane went d own into the under the bed come out and those out­ tice, people may come forward with a ocean. side the window come in, and they all report of errors. We can leam a lot The second story was about the threaten to devour us. To calm our from mishaps and errors, ours and success of many new high technology own children, we have devised a fairy those of others. As a result, we may also companies in Israel. It reported that tale world where good triumphs over be able to devise a system that elimi­ "Tine Israeli military, which is as infor­ evil, the good fairy overcomes the nates errors. Perhaps, butunfortu- mal as it is formidable, has served as the wicked witch, and everybody lives nately, airplanes still fall from the skies. incubator for a generation of hugely happily ever after. That way, they can On March 6,2000, The Wall Street successful startups. Limited in size and sleep through the night, without fear Joumal carried two stories, at first number, the Israeli Army has survived that anything bad will happen to them. glance unrelated. The first one dis­ by tapping every drop of its resources. For the child within us, we have cussed the crash of Alaska Airlines It gives enormous responsibility to devised algorithms. By following the flight 261. The landing is probably the relatively junior officers and encour­ yellow brick road, we will get to the most dangerous step of any flight. In ages them to use their guile and inge­ City of Emeralds. This is expressed in the presence of mechanical trouble, it is nuity to solve problems. The chain of our desire to have rules. Just follow even more dangerous, so the usual ap­ command is lean, unstructured and goal the procedures in the protocol, and ev­ proach is to keep flying, while follow­ oriented, typical more of a startup than ery thing will be fine. If something bad ing the protocol for troubleshooting the of a military bureaucracy." happens, no one can blame us. We fol­ problem. Pilots are trained to deal with Do you see the common poin t? lowed the instructions. We could not malfunctions, "but training sessions and The first story describes the failure of be at fault. "We followed the orders," cockpit maneuvers don't cover every the officially approved checklist. In said Hitler's lieutenants at their trial in possible problem. 'Unfortunately, in tine emergencies all bets are off. What Nuremberg. How simple, how enticing, life of an aviator, few things happen does that mean? That the checklist is a how so dreadfully wrong. precisely as those books describe,' said waste of time in tine face of a serious The people attempting to solve the Captain Edmond Soliday, vice-presi­ problem, perhaps. They pay pilots to problem of medical errors claim that we dent of safety at United Airlines. 'We use good judgment they say. What can leam from the airline industry. Pi­ pay pilots to use good judgment' Cap­ does that mean? To ignore the check­ lots and others have been encouraged tain Lindsay Fenwick, chief accident in­ list when they are really in trouble, to report incidents and errors without vestigator for the ALPA branch at perhaps. The second story describes the threat of punishment. In doing so, Northwest Airlines said, 'In emergency' the success of individual initiative and the airlines have been able to develop situations all bets are off.' One lesson daring. That is ho w Americans were in procedures and protocols to handle from this disaster is that mechanical the 19u’ century. That is how our ances­ various flight problems and reduce the problems deemed manageable can be­ tors tamed this continent of wilderness. risk of accidents. Perhaps we could do come unmanageable in an instant." So something similar in the practice of while the pilots were going down the See Road, page 14

July, 2000 PCMS BULLETIN 13 B u l l e t i n

they do so, and supported in their deci­ sions of what to do and when remain J L iU d X X from page 13 sions, not subjected to censure. A judg­ based on the individual judgment of the What happened to us during the ment call is a judgment call and only the people who are there and who have last 100 years? Why are we so afraid to person who is there can make it. the responsibility to make these deci­ make decisions? We got cowered into In obstetrics we were under a sig­ sions. The rules may be helpful for thinking we can't stand on our own two nificant amount of pressure to reduce people who don't know. They are an feet. We are so deathly afraid of failure the Cesarean section rates. No-one encumbrance and a hindrance for that we cling to our protocols, hoping to could say what the ideal section rate those who do. The best thing the be relieved of all responsibility when was, but the authorities in the field de­ people who don't know can do is to something goes wrong. Unfortunately, veloped protocols to define fetal dis­ recognize their situation, step aside the responsibility remains ours, if not tress, failure to progress in labor, or the and let those who know do what has to legally, at least morally, whether we ad­ other conditions that are considered to be done. mit it or not. Perhaps we don't care be indications for a section. Did that Yes, sometimes we will fail. Yes, about that any more. mean we needed to wait until fetal dis­ sometimes we will be wrong. If so, we When some authority has ap­ tress was demonstrable before we will be ready to accept the responsibil­ proved our procedure manuals, could do a section? If, in our clinical ity, and move on. Overall, we are more troubleshooting checklists and various judgment, we anticipated such a prob­ likely to be right and to succeed, than protocols and algorithms, we can relax, lem, why would we have to wait until are the rule makers who are far re­ we don't have to think. All we need do we could prove the baby was in m oved from the situation athand. Sure, is obey. We expect someone else to trouble? they will criticize us. Which Sunday tell us what to do and to solve our prob­ Life presents us with problems that game hasn't been on Monday morning. lems. Yes, it is very simple, very entic­ go from pure white to pure black But they weren't there, so they should ing, and so dreadfully wrong. Just fol­ through all shades of grays and colors. respect our decisions and let us do our low the yellow brick road. Do we re­ Life situations are a continuum. The work. If they claim they can do better, ally know where it will lead us? rule-makers try to draw a line here and let them take call in our emergency Granted, some people are not able there, but no matter how precise they rooms. There is nothing like direct per­ to make decisions. Then they should are in doing so, these lines remain arbi­ sonal experience to teach people some not be in positions where emergencies trary and unenforceable. The deci­ humility. ■ can occur. The burden of decision making should not be on their shoul­ ders. They do not belong in such an environment. Wherever they are, checklists and protocols will help them do their job. In general, checklists are useful in long, repetitive tasks. Follow­ ing them, we can remind ourselves to do certain things, which sometimes we ER^SE might forget, like ordering a laxative for a postoperative patient. THAT TATTOO Establishing rules on how to handle problems does not help, be­ WORRIED ABOUT WHAT YOUR SPOUSE, cause problems don't know they are YOUR FRIENDS OR EVEN YOUR BOSS supposed to happen according to the THINKS ABOUT YOUR TATTOO? rules. WHien all bets are off, the people OR ARE YOU JUST TIRED OF who are able to make decisions must LOOKING AT IT? Today's newest Alexandrite laser, feel free to make them. They need to will remove your tattoo have the knowledge and skill to do with minimal discomfort & their job or they shouldn't be at the less than 1% risk of scarring. controls, but once there, they must be (.dll today lor more inlornmdofi relied on to use their head and not be expected to follow a procedure proto­ PIERCE COUNTY col w hen there is no time for that. If LASER CLINIC they are paid to use their judgment, Director Pcicr K. Mnrsli M,l). they deserve to be respected when (253)573-0047

14 PCMS BULLETIN July, 2000 fierce %xmtu Q/fleJica! Citmetif

In My Opinion by Teresa Clabots, MD

The Silver Bullet (my dads 1959 Porsche)

My father always wanted us to be­ rather dark, and leaning against the come extremely handy at anything that light posts were a couple of young we did. So, in order for us to survive, men, laughing at his shocked surprise Teresa Clabois, MD he wanted us all to learn how to fix when he saw his car up on blocks. cars. Now, fixing cars to him meant Now, as you know it is not unusual to something totally different than what it find a car up on blocks in St. Louis, meant to us (his children). For him it which I consider the car thief Mecca I'm a doctor, what do you think I am?" meant rebuilding the motor, redoing of the world, (second only now to Mi­ They said, "Hey, doc. Wait a minute. the bodywork, and reupholstering the ami, which is getting even faster at Why don't you go back inside, and k inside. stealing cars). But, they don't usually grab yourself a cup of coffee or some­ He purchased a dead, old Porsche take your car in St. Louis. They just thing." (11:00 p.m.) He stormed into the from a junkyard that had been in an ac­ take your tires, and your battery and patient waiting area, grabbed himself a cident and rolled. It was our job to leave your car on blocks. Anyway, cup of make this thing run again. The majority here coffee, lit of the dirty, oily work fell to my brother comes upa and twin sisters, who are older than us. ny couple I They were in the garage, tinkering dad more with the engine, learning all about the after ciga­ intricacies of a 1959 German automo­ afull rettes bile engine. My sister and I were in­ day and stead charged with: A) Reupholstering of went the inside B) Carpeting the inside C) work outside Doing the putty work on the dents and to 30 min­ body work and D) Painting the dam find utes thing, which meant, of course, taping his later. everything, and praying that it wouldn't little silver Porsche up on all four There, by moonlight he could see rain. bricks. He was not a happy camper, that his silver Porsche had four brand Let me tell you that was no easy and the angrier he became, the more new tires. He laughed and said, "I can't task. But, we were very proud of our the young men laughed at him. believe this." accomplishment. Despite the fact that Standing by the car, leaning The young men passed by in their we had spent months doing the putty against the lightpole was a gang of car, waved at him, and said, "Good luck work, we were still annoyed to see a young men laughing at his face. When doc, next time park in the doctor's lot so drip in the paint, a spot of glue on the nervous, my father would light up a it won't happen to you again." carpet, or an uneven stitch. We were cigarette. Huffing, and puffing on his He chuckled to himself and said, very, very proud of the silver Porsche cigarette, he went over to the young "Que Sera', Sera' what will be will be," that he had bought from a junkyard and men and asked, "Do you know who hopped in his little silver Porsche, and | resuscitated. did this?" They said, "no." He said, took off. He was able to come home One weekend my father hap­ "damnit, damn it, damn it I'mnever that night with brand new tires for his pened to go to his weekend moonlight- coming back to this hospital again." Porsche. As he said, "at least there was ingjob at an inner city hospital. But, he They looked at each other for a one good thing about being a doctor, if came home to tell us that while in the minute, turned to my dad and said, they stole your tires, they can always hospital, he came out when it was "ya'll a doc here?" He said, "of course give you better ones." ■ I

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16 PCMS BULLETIN July, 2000 '^Piwce '%oumty. Q'ftediml (SFotidy

COLLEGE Continuing Medical Education MEDICAL College Board announces new board EDUCATION members and officers for 2000-2001 The College of Medical Education has new board members and a new presi- dentfor their 2000-2001 course and fiscal year. John Jiganti, MD accepted the president's gavel from Dale Overfield, MD, who has served as president since 1998. Dr. Overfield will serve one more year on the board, and will then have completed eleven years of service to medical education in Pierce County. Dr. Whistler CME Jiganti has served seven years. New board members are: Drs. Marjorie Krabbe and William Lee and urogram set for they will be replacing Drs. Robert Alston and Mark Ludvigson. Current board members includeDrs. J.D. Fitz, Barbara Fox, William Holderman, Steve anuary 24-28 Konicek, Gregg Ostergren, Brad Pattison, Judy Pauwels, Cecil Snodgrass, Virginia Stowell, Richard Waltman and Tod Wurst; Sister Anne McNamara representing the Franciscans, Victoria Fletcher from MultiCare The dates for the annual Whistler and Rick Campbell, Good Samaritan Hospital. Nine board members are appointed CME program have been set for by the PCMS Board of Trustees and serve three year terms while three members January 24-28,2000. A program serve one year terms and are appointment by the College Board. brochure with course details and In other business the board of directors approved the 2000-2001 operating registration will be available in Septem­ budget. The College finished fiscal year 1999-2000 with $176,433 in income and ber. Watch your mail! ■ $169,016 in expenses. The College reserve level is currently $22,618.1

TACOMA/PIERCE COUNTY Preliminary survey results suggest Outpatient General Medical Care. Full and part-time positions changes in course offerings available in Tacoma and vicinity. Very flexible schedule. Well suited The recent survey of the member­ #1 Infectious Diseases for career redefinition for ship regarding continuing medical edu­ #2 Gastroenterology GP, FP, IM. cation needs was utilized by the Col­ #3 Pain Management lege of Medical Education Board of Di­ # i Dermatology Contact Andy Tsoi, MD (253) 752-9669 rectors to set course direction for next #5 Pulmonary Disease or Paul Doty (Allen, Nelson, Turner & year's programs. #6 Orthopedics Assoc.), Clinic: Manager (253) 383-4351 Survey responses, as of their June #7 A tie between Cardiology 16 meeting, indicated that there was sig­ and Endocrinology nificant interest in a course on technol­ ogy. Specifically, the Internet and In addition to the new technology j 9 f > - J medical information, computers in the course that will be added to next yea/s (re a it | medical office, and how to respond to program schedule, a pain management "Internet educated" patients. Surgery. || program will be offered. These two Evening programs also were of in­ new courses will replace the Hawaii tliLnh | terest with 52% indicating a preference and Gastroenterology courses that are of us. | for attending at night rather than the traditionally held every other year. traditional work day offerings. Watch your August and Septem­ Union Avenue Pharmacy & | The ever popular infectious dis­ ber Bulletin for complete survey re­ Corset Shop t eases specialty again ranked number Formerly Smith's Corset Shop | sults and for announcement of the 2302 S. Union Ave 752-1705 % one in interest; the top eight were: 2000-2001 course calendar. ■ WOWKiWftWV.

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July, 2000 PCMS BULLETIN 19 B u l l e t i n V

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20 PCMS BULLETIN July, 2000 TIN August, 2000 Mt. Everest

I"’ # ^ " - V*

George Mallory on the descent of Descending the Southeast Ridge the Moine Ridge, August, 1909 May, 1998

More information- pag

3 Climbing Everest in the Search for Mallory & Irvine - September General Meeting 4 Mini-Internship teaches community leaders about the profession of medicine 5 PBS to feature Bill Moyers’ End-of-Life care program, “On Our Own Terms” 9 “The New Economy Math Just Doesn’t Add Up,” says David Roshkoph, MBA, CFP 10 Tacoma Youth Symphony goes to Carnegie Hall n Helping patients with tobacco cessation 19 College of Medical Education announces 2000-2001 program schedule Bu l l e t i n

PCMS Officers/Trustees: 'ico io iiif Q /((edim i So ciety Charles M. Weatherby, M D President PatriceN. Stevenson, M D ...... President Elect Susan J. Salo, M D ...... Vice-President J. Jam es R o o k s, M D ...... Secretary /Treasurer Lawrence A. Larson, D O ...... Past President Sabrina A. Benjamin, M D D r e w H. D eu tsch , M D K evin K . G an d hi, M D M ich ael J. K elly, M D D o ris A . P a g e ,M D Edw ard I. W alk ley, M D Yolanda Bruce, PCMS A President

WSMA Representatives: Speaker ofthe House: Richard Hawkins, M D Trustee: David Law, M D AM A Delegate: Leonard Alenick, MD W AM PAC Chair/6th District: Mark Gildenhar, M D W A M P A C 9th D istrict: D o n R u ssell, D O

Executive Director: Douglas Jackman

Committee Chairs: Aging, Richard Waltman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, John Jiganti; Credentials, Susan Salo; Emergency Medical Table of Contents Standards, Ted Walkley; Ethics/Standards Of Practice, David Lukens; Grievance, Lawrence A. Larson; Labor & Industries, William Ritchie; 3 "Finding Mallory" September General Membership Meeting Legislative, William Marsh; Medical-Legal, Pat D onley; Membership Benefits, Inc., Drew Deutsch; Personal Problems Of Physicians, Robert Sands; 4 The Alf Gunn Seattle to Spokane One Horse Relay Public Health/School Health, Sumner Schoenike; 4 Mini-Intem program teaches aobut the medical profession Sports Medicine, John Jiganti.

The Bulletin is published monthly by PCMS 5 PBS to feature Bill Moyer's End-of-Life program series Membership Benefits, Inc. for members of the Pierce 5 Draft of Fraud & Abuse Guidelines released County Medical Society. Deadlines for submitting articles and placing advertisements in The Bulletin 6 Applicants for Membership are the 15th of the month preceding publication (i.e. October 15 for the November issue). 6 Directory changes

The Bulletin is dedicated to the art, science and 7 "Full Disclosure" by Andrew Statson,MD delivery of medicine and the betterment of the health and medical welfare of the community. The opinions herein are those of the individual contributors and do 8 New Members not necessarily reflect the official position of the Medical Society. Acceptance of advertising in no 9 "The New Economy Math Just Doesn't Add Up" way constitutes professional approval or endorse­ by David Roskoph, MBA, CFP ment of products or services advertised. The Bulletin and Pierce County Medical Society reserve the right to reject any advertising. 10 Tacoma Youth Symphony goes to Carnegie Hall

Editors: MBI Board o f Directors 11 TPCHD - Helping Patients with Tobacco Cessation Managing Editor: Douglas Jackman Editorial Committee: MBI Board of Directors 13 "At First Do No Harm and the Airplane Ride" Advertising Representative: Tanya McClain by Teresa Clabots, MD Subscriptions: S50 peryear, $5 per issue

Make all checks payable to: MBI 15 "Nostalgia of World War II" by John St u Iterhei m, MD 223 Tacoma Avenue South, Tacoma WA 98402 253-572-3666, FAX253-572-2470 19 College of Medical Education

E-mai 1 address: pcmswa@ pcmswa.org HomePage: http://www.pcmswa.org 23 Classified Advertising invites you and your spouse/guest to the September Genera! Membership Meeting

Tuesday, September 12, 2000 Landmark Convention Center S o c ia l H o u r: 6 :0 0 p m Temple Theatre, Roof Garden Dinner: 6:45 pm 47 St. Helens Avenue Program: 7:45 pm T a c o m a

FEATURING: ERIC SIMONSON

FINDING MALLORY:

A 1924 MYSTLRY

Join us for an evening of amazing tales, told by the man who lived them . Eric Simonson shares his personal experiences in solving two of exploration's greatest mysteries: Did George

Mallory and Sandy Irvine reach the summit of Mt. Everest in

1924, and what became of them? Simonson, whose climbing

resume includes Mt. McKinley, Aconcagua in Argentina, Cho

Oyu in Tibet, Mt. Elbrus in Russia, and Mt. Vinson in Antarc­ tica led the 1998 expedition. The team stunned the m oun­

taineering community with their findings. The expedition set

out searching for answers. Join us at the September meeting

to hear what he discovered! Photo bv Eric Simonson

(Registration required by September 8. Return this form to: PCMS, 223 Tacoma Ave S, Tacoma 98402; FAX to 572-2470 or call 572-3667) Please reserve______dinner(s) at $20 per person (tax and tip included)

Enclosed is my check for $ ______or my credit card # is ______

Q Visa [^Master Card Expiration Date ______Signature ______

I will be bringing my spouse or a guest. Name for name tag:______

Signed:______B u l l e t i n

The Alf Gunn Seattle to Spokane One Horse Relay by Marsden Stewart, MD Anesthesiologist, St. Joseph Hospital

On June 17, Dr. Marsden went around and around. Stewart and others participated in the Fortunately, only one dented first and only " Alf Gunn Seattle to spoke, wheel still in true, no Spokane One Horse Relay." In further damage. Totaled the essence this is a take-off of how two water bottle-which had a little cowboys used to ride one horse in the hole in it. So they rode on. old days: one cowboy would start Team 1 drove fromEaston running while the other would ride the to Ellensburg, and started horse for a ways, hobble the horse and riding to Vantage. They then start walking himself. When the Above, Team I members Marsden Stewart, first cowboy would arrive at the horse, See Relay, page 18 and Dave & Leslie Pearce at Ryegrass he would mount up, overtake the other cowboy, leave the horse for him farther down the trail, and in this manner they would arrive at their destination. Our Mini-Intern program teaches community destination was Spokane, and our " trail" was 1-90. leaders about the profession of medicine We had eight riders divided into team work required in treating patients. two groups of four: Marsden and In June, four community leaders experienced medicine from a different The team work was remarkable," he Leelee Stewart and another couple, perspective. All were partnered with added. Bill Harrison, Mayor of Lake­ Dave and Leslie Pearce, were one team. Alf Gunn, Rob Argyle, Mark physicians of four different specialties wood noted that" the paperwork re­ to see how the practice of medicine is quirements are overwhelming." Caviness, and Ryan Fisher, 15, com­ prised the second team. We actually carried out on a day to day basis. The Mini-Intem program, imple­ used two vans for support, full of food Rick Allen, President of United mented by PCMS in 1992has helped and drinks. Way of Pierce County; Karl Anderson, educate many community leaders, such Team 2 started riding at the park at President, Concrete Tech; Bill as legislators, media, attorneys, etc. the west end of the 1-90 bridge bike Harrison, Mayor of Lakewood; and about medicine. It is an effective way to tunnel, at 4:50 am. The sunrise was Debbie Winskill, Tacoma silhouetting the Cascades, and there School Board member had ------was a full moon. It was beautiful. They the opportunity to spend a didn't have to get onto 1-90 until the far half day each with Drs. end of Issaquah, then it was easy to get Marsden Stewart (anes­ to North Bend, where the vans were thesiology), Lawrence waiting. Marsden and team 1 had A. Larson (pediatric al­ driven to North Bend, then started lergy/ immunology), riding over Snoqualmie Pass. For the Philip Craven (infec­ lastfew miles up to the pass, the route tious diseases) and Carlos bypassed the freeway using Denny Garcia (cardiovascular- Creek road. Unfortunately Denny thoracic surgeon). Drs. Brad Pattison, Larry Creek Road was gravel, so Team 1 got trout left: Interns, Karl Anderson, Rick Allen and Vercio and Jim DeMaio in several miles of single-track mountain Debbie Winskill, Drs. Charles Weatherby and also served as physician biking that day as well. Larry Larson, and Intern Bill Harrison Team 2 rode Easton to Ellensburg faculty. as it got warmer. Alf was spared some "It was a great experi­ major grief when his downtube water ence," said Rick Allen of United Way. show lay people about the profession. bottle cage came off and went into the His sentiment was also echoed by the " I got an exceptional view of the sys­ rear wheel spokes, crumpled up and other interns. "I was mostly impressed tem," noted Allen, "and it was ugly - but by the amount of detective work and the people were exceptional!" ■

4 PCMS BULLETIN August, 2000 PBS to feature Bill Moyers’ special on end-of-life care

'On Our Own Terms/ a national insurance coverage, the training of Franciscan Health System. Successful four-part 90-minute PBS series pro­ doctors, and building communities of programs and people, including pa­ duced by Bill Moyers' Public Affairs volunteer caregivers to relieve the tients and caregivers, will be high­ Television will report on the national burden on families of the dying. lighted to demonstrate how improve­ movement to improve care at the end of "These programs will present cen­ ments can be made, she added. life and showcase models of where it is tral stories and focus on the challenges For more information about the being done well. The series will pre­ we face to improve care," said Mimi series " On Our Own Terms" visit the mier September 10-13,2000 and will air Pattison, MD, Medical Director of websitewww.thirteen.org/onourown- on KCIS Channel 9, from 9:00 to 10:30 Palliative Medical Services for terms orwww.pbs.org/ onourownterms. ■ each night. Program highlights include:

Program I: Living with Dying OIG releases draft version of its This program explores America's search for new way s of thinking about fraud and abuse guidelines death. It focuses on people - patients and caregivers - who are finding ways The Office of the Inspector Gen­ 1. CODING AND BILLING: Billing for services never rendered, to overcome the fear and denial that eral recently released a draft version billing twice for the same service and dominate mainstream American culture of its long-awaited compliance pro­ upcoding the level of service provided and open a conversation that helps us gram for physicians in solo or small are among the most frequently investi­ live with dying. group practices. The draft includes an outline that physicians and their staffs gated coding and billing practices, OIG Program II: A Different Kind of can use to help detect and prevent er­ says. Care rors, fraud and abuse in dealings with 2. PROOF OF THE NEED FOR A second program examines the government health care programs, SERVICES: evolution of a new kind of care - com­ such as Medicare and Medicaid. monly referred to as ''palliative care." The new plan has adapted to the When asked, physicians must pro­ Leaders in this movement emphasize a physician's office the same key ele­ duce documentation, like a patient's full spectrum of pain management, ments found in compliance plans the medical record or physicians' orders, symptom relief and support- including OIG has released for other sectors of that show that a service was "reasonable physical, psychological and spiritual the health care industry including: and necessary" for die diagnosis and care. •creating written policies and proce­ treatment of a patient. dures Program III: A Death of One’s •designating a compliance officer 3. DOCUMENTATION Own •conducting effective training Among other things, patient Dying well to many, means a mea­ •developing effective lines of commu­ records should include the reason for sure of control over how we die. We nication the encounter; relevant history; physi­ fear dying in pain; we fear that too •auditing and monitoring cian examination findings; prior diag­ much will be done to keep us alive, or •enforcing standards througli well- nostic test results; assessment, clinical we fear that not enough will be done. publicized disciplinary guidelines impressions or diagnosis; plan of care; This program will look at the issues sur­ •responding to and acting on detected date; and legible identity of the ob­ rounding efforts to control how we die offenses. server. and the implications for family, institu­ With many physician offices un­ 4. RELATIONSHIPS tions and communities. able to afford a full-time compliance of­ ficer, they may appoint another staff Problems here could lead to allega­ Program IV: A Time to Change member to be responsible for over­ tions of kickbacks, inducements or self­ This program will follow crusading seeing the compliance mechanism. referrals. Violations arise from office individuals who are working to change The top four areas most in need and equipment leases with entities to public policy to improve care of the dy­ of internal checks and balances to pre­ which the physician refers patients or ing. They are creating models for vent Medicare payment errors and from accepting gifts at more than their change that deal with issues including possible fraud are: nominal value from those who could benefit from a physician's referral. ■

August, 2000 PCMS BULLETIN 5 V B u l l e t in

Applicants for Membership

Baker, James M, MD Kwon, Eun K, MD Nerkar, Manisha S, MD Family Practice Family Practice Internal Medicine Practices at Gig Harbor Medical Clinic, Practices at Community Clinics of Practices at St Joseph Medical Clinic, 6401 Kimball Dr, Gig Harbor 98332; Pierce County, 11225 Pacific Ave, 1708 S Yakima Ave, Tacoma 98405; Phone:858-9195 Tacoma98444 Phone:627-9151 Medical School: State University of Phone:531-6198 Medical School: Indira Gandhi Medical New York at Buffalo Medical School: Ponce School of College Internship: Providence Hospital Medicine Internship: Thomas Jefferson Residency: San Bernardino County Residency: North Shore University University Episcopal Hospital General Hospital Hospital Residency: Thomas Jefferson University Episcopal Hospital Dobbins, Jill M, MD Kwon, Eunhee, MD R adiology Family Practice Practices at Diagnostic Imaging Practices at Community Clinics of Directory changes Northwest, 22215th Avenue SE, Pierce County, 3418 E McKinley Ave, Puyallup 98372 Tacoma 98404 Please make note o f the following Phone: 841^353 Phone:404-0737 changes to your 2000 PCMS Directory. Medical School: Ponce School of Medical School: University of Lynne P. Clark, MD Medicine Washington School of Medicine Change address to: 6002 N Westgate Residency: North Shore University Internship: Maine Medical Center Blvd #150 Tacoma, W A 98406 Hospital Residency: Maine Medical Center Phone: 752-8882Fax: 752-8907 Fellowships: University of Florida DSHS# 1110477 Medical Center

Fahmy, Jana L, MD Diagnostic Radiology Practices at Tacoma Radiology, 1901 South Cedar #108, Tacoma 98405 Phone:383-1099 Medical School: Loma Linda University Internship: Loma Linda University Medical Center Residency: Loma Linda University E Medical Center Fellowship: Childrens Hospital of Los ATTOO Angeles WORRIED ABOUT WHAT YOUR SPOUSE, YOUR FRIENDS OR EVEN YOUR BOSS Ge, Zheng, MD, PhD THINKS ABOUT YOUR TATTOO? N ep h ro log y OR ARE YOU JUST TIRED OF Practices with Gerard W Ames MD, PS, LOOKING AT IT? 1802 South Yakima #208, Tacoma 98405 Today’s newest Alexandrite laser, Phone: 627-5755 will remove your tattoo Medical School: Shanghai Medical with minimal discomfort & University less than 1% risk of scarring.

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6 PCMS BULLETIN August, 2000 In My Opinion.... The Invisible Hand by Andrew Statson, MD

Full Disclosure

“Surely the glory o f journalism is its transience. ” Malcolm Muggeridge (1966) Andrew Statson. MD

The Atlantic Monthly from April the reason. I don'tknow whether such What will happen when a hospital 2000 carried an article on regulation by reports have affected hospital admis­ in the area is declared as having the shaming. After discussing a California sions and have made a difference in lowest complication rate? Even if the law requiring disclosure of toxic patient choice. The idea sounds physical structure of the hospital would compounds in various products or attractive. As most ideas it is not new. allow an increase in the census, our emissions and federal laws doing the Let me show you how it worked in one hospitals are badly understaffed same, the article stated, "momentum for instance. already. Any one of them will have national disclosure of serious medical When a medical student in France, difficulty handling a significant increase mistakes has been growing rapidly I spent a year as a resident in the in volume. The quality of care is since the Institute of Medicine, part of public hospital of Dieppe, a city of already marginal for the volume they the National Academy of Sciences, 20,000 in Normandy. We served the have, so it will drop rapidly with any reported lastNovember that44,000 to surrounding villages within a radius of increase. The good rating may also 98,000 people die each year as a result 20-30 miles and a population of 60,000. bring in sicker patients, so the compli­ of medical errors. Several states We had four surgeons in town, in two cation rate will go up and by the time of require hospitals to disclose mistakes groups of two. the next rating, the hospital will be that result in death or serious injury. One of tire surgeons told me their down the list For example, New York recently referrals from the various villages Referrals will come in waves, just revamped its reporting system to came in waves. For a while they would as they did in Dieppe. The ratings will release such information on the have a number of patients from one be obsolete by the time the various Internet when the state takes action village. Then something would companies that want to use them run against a hospital. General Motors, happen, they would ha ve a complica­ the data through their committee General Electric, and six other large tion or a problem patient, and suddenly structures and get around to acting on employers have said that they will steer the referrals from that village will go to them. Eventually people will realize employees toward those hospitals that the other surgical group. This system what the effect is of the rating system make the fewest mistakes." worked through word of mouth. There and will start going to hospitals that are For several years our hospitals were no reports, no published rates of lower on the list, or disregard the have been exposed to such pressure complications, no inspections, just word ratings altogether. In the long run the to disclose complication rates and of mouth. The sea of human beings acts ratings will be another exercise in deaths after heart surgery. Length of like the ocean, tire waves going back futility, as the many others we have stay and other data have appeared in and forth, back and forth. already witnessed. The Consumer the press already. Of course, the A few years ago Money Magazine Union is a testing organization which hospitals were concerned that such rated Bremerton as the best place in has rated products for many years. data might be misinterpreted. I don't the country to live. That was an How many people base their purchas­ know whether they have been or not. ephemeral glory. Every year since ing decisions on those reports? Not too long ago, there was a report then a different city was so rated. This Our reputation is based on the that patients covered by managed care means that the ratings, which are based quality of the services we provide to plans were directed toward the on past performance, are outdated our patients. Whether our results are hospitals that had a higher rate of almost as soon as they are published. medical errors. I suspect you can guess How useful! See " Disclosure" page 12

August, 2000 PCMS BULLETIN 7 New Members

Colombini, Rose-Marie J, DO Lazarus, Marlene L., MD Louie, Douglas H., MD, PhD Family Medicine C ardiology Family Practice/Geriatrics Practices at Lakes Medical Center, Practices at 1408 3rd Street SE, #100, Practices at Franciscan Medical Group 19820 Hwy 410 Ste 101, Bonney Lake Puyallup 98372 1708 S Yakima Ave, Tacoma 98405 98390 Phone: 864-6848 Phone: 593-8456 Phone: 862-9969 Medical School: Rush Medical College Medical School: Univ of Washington Medical School: Western University of Internship: LAC USC Medical Center Internship: Univ of California, Irvine Health Sciences, College of Residency: LAC USC Medical Center Residency: Univ of California, Irvine Osteopathic Medicine of the Pacific Internship: San Bernardino County Long, Jeffrey P., MD Thorpe, Robert J., MD Medical Center Radiation Oncology Family Practice Residency: San Bernardino County Practices atMultiCare Radiation Practices at Franciscan Medical Medical Center, Arrowhead Regional Oncology, 1003 S 5th St, Tacoma 98405 Group, 1708 S Yakima, Tacoma 98405 Medical Center Phone: 403^994 Phone:593-8456 Medical School: University of Iowa Medical School: Univ of Oklahoma Jenner, Carrie L, MD College of Medicine Internship: University of Kansas Pediatrics Residencies: Univ of Arkansas for Residency: University of Kansas Practices at Franciscan Medical Group, Medical Sciences, Univ of Louisville 1708 S Yakima Ave, Tacoma 98405 Hospital, Univ of Iowa Hospital Phone:593-8407 Medical School: Georgetown Univ Internship: University of Washington Residency: University of Washington

Lahrs, Anthony E., MD Diagnostic Radiology Practices at Tacoma Radiology, 3402 S 18^’, Tacoma 98405 Phone: 383-1099 Medical School: University of Toronto Internship: University of Toronto Residency: University of Toronto Fellowship: Hospital of University of Pennsylvania

TACOMA/PIERCE COUNTY

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8 PCMS BULLETIN August, 2000 In My Opinion..... by David Roskoph, MBA, CFP

The New Economy Math Just Doesn’t Add Up

One of the things that makes down a screen. Access to a variety of investing an art, at least as much as a goods never before available has sent science, is the fact that the financial consumers on a buying spree and the markets are only tangential to reality. lack of salespeople has sharpened PiTiv. j A-tfiA. CFP At times, there are only brief glimpses their shopping skills. Let's look at two of rationality between the other icons of the New Economy that arrived periods of alternate mania or depres­ early and dominated their arenas, other shoe of New Economy will sion. Right now I'd say our financial Amazoncom and Ebay.com. Their eventually fall; few of the hundreds of markets are in some kind of mania. The share prices soared, then swooned distributors, all vying for the same mania has (once again) been dubbed a then....anyway, Amazoncom is still consumeds dollars, will succeed. new economy and is (once again) spending $1.53 for every $1.00 of Those who do will have to advertise heralded as a time when conventional revenue it takes in and Ebay is trading heavily just to hang on because the and traditional means of valuing future at over twelve hundred times its cashflows just don'tfitthenew model of stock HISTORIC VALUATION RISK: valuation. For a DJIA P/E S&P 500 P/E NASDAQ P/E while any fad can resemble rational

behavior and, 60-Yr Norm 87* 60-Yr Norm 98 14-Yr Norm 98 with enough ‘ 87th percentile means the DJIA has been more overvalued only 13% of the time. participants, the theories will POTENTIAL LOSS: actually look Ftisk-to-Norm: -30.2% (DJIA ® 7367) -50.9% (S&P 500 ® 722) -80.6% (NASDAQ @ 776) valid. Sooner or Investcch research http://www.investech.com later this party will end. That it has carried on this long and to this earnings. Although they were first, ask friction to compete has also been extentis a testament to the willing yourself what makes their market share removed. How much advertising will suspension of disbelief evidenced by secure? There are no proprietary have to be done and how low will the public and marketing that would goods, no big patents, in other words, prices eventually have to go to get the makeP.T. Bamum proud. However, nothing that cannot be duplicated. business? And after all that, will there there are two elements to this New Competitors need only set up a few be any loyalty as more competitors Economy that warrants closer examina­ computers and a web presence to enter the arena? The ultimate question tion because they just don't add up - erode their business. Consumers need investors must ask - where's the profit profit margins and corporate finance. only SEARCH for a new and more margin? The euphoria surrounding a The Internet undisputedly provides aggressive competitor with a simple change to Internet distribution has two major improvements in getting click of their mouse. Herein lies the created an a-historic overvaluation of goods to consumers: 1) it opens up a fundamental problem with this New the Dow Industrials, S&P 500 and most heretofore-unimaginable plethora of Economy: once distribution is univer­ notably the NASDAQ. With no pricing choices and, 2) it reduces the transac­ sal, items become commoditized. As power whatsoever, how can this tional friction thus lowering prices. commodities, there is no pricing, and bubble sustain? In a rush reminiscent Consumers who once strolled through certainly no monopoly power. Profit of the great Tulip mania, investors a mall, now more efficiently scroll margins must continue to shrink. The See "Math" page 14 B u l l e t in

Tacoma Youth Symphony goes to Carnegie Hall

On May 7,2000 the young musi­ New York. cultural landscape of this city. In the 35 cians of Tacoma Youth Symphony As­ "OurYouth Symphony played with years since it was formed, the organi­ sociation realized a dream that every true inspiration," said Dr. Fox, who at­ zation has grown from a group of 50 classical musician shares; to play at tended the concert. "The usually reti­ students practicing in a church base­ Carnegie Hall. After a competitive au­ cent New York audience gave an im­ ment, to one of the premier Youth Sym­ dition in 1998, tine TYSA was invited to mediate standing ovation in response to phony organizations in the country. perform in one of the world's most re­ the enormous emotion and intensity of The TYSA serves over 500 students of nowned musical venues. Conductors the performance." As a result of the all races, religions, and economic back­ Paul-Elliott Cobbs and Dale Johnson, outstanding quality of the concert, the grounds from all over the Puget Sound over 100 student musicians and staff Tacoma Youth Symphony has been in­ area, extending from Bellingham to made the trip to New York to perform vited to represent the United States a t Chehalis. "The community is really be­ Shostakovich's "October" and the Cultural Olympiad immediately pre­ hind these kids," Dr. Fox said. "The Tchaikovsky's "Francesca daRimini." ceding tine Olympic Games in Greece Tacoma YouthSymphony is one ofthe Three members of the Pierce in 2004. Three American Youth Sym­ im portant reasons why our city is a County Medical Society (Leslie phonies were selected for this honor, great place to live." ■ Fox, MD - board president, the New York Youth Philharmonic, the James Billingsly, MD - former Houston Youth Symphony and the president, and Vita Pliskow, MD) Tacoma Youth Symphony. To be in Editor's Note: Tacoma Youth are members of the Tacoma such company is an amazing honor for Symphony members provide musical Youth Symphony Board of Trust­ a small city the size of Tacoma. enjoyment each year at the PCMS ees who helped raise the money The Tacoma Youth Symphony As- Annual Meeting in December at the to send the Youth Symphony to sociation is a very important part of the Sheraton/Tacoma Hotel Will a disability put you out of commission?

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10 PCMS BULLETIN August, 2000 !^{€''PC€' Q-4'i^/tCfd

Federico Cruz-Uribe, MD The Health Status of Pierce County Director of Health

Helping patients with tobacco cessation

The Public Health Service distrib­ cans will try to quit (smoking) this uted the following news release in year...Regrettably,mostof diem will try June, 2000 encouraging health profes­ to do so on their own," Dr. Michael C. T ACOM A-PIERCE COUNTY sionals to take action against tobacco Fiore, guidelines panel chairman, said HEALTH DEPARTMENT use. The Health Department has re­ during a briefing here Tuesday." As a sources for you to access to respond to result, only 1 million of them will be this Public Health Service request. able to quit and stay tobacco-free," he WASHINGTON June 27 added. guideline advises healthcare profes­ (Reuters Health) - The US Public " Effective cessation treatments are sionals that they should be consistently Health Service (PHS) urged all now available and every patient who identifying, documenting and treating healthcare professionals to make smok­ uses tobacco should be offered these tobacco users at every visit. The ing cessation a top priority in treating treatments," said Fiore, who is also di­ guideline labels tobacco dependence patients. rector of the Center for Tobacco Re­ as a "chronic condition" that demands To back up this call, a new set of search and Intervention and the Uni­ repeated treatment efforts until absti­ guidelines issued by the PHS provides versity of Wisconsin Medical School in nence is reached, and that "every to­ clinicians with new tools to help smok­ Madison bacco user should be offered at least ers kick the habit. "The treatment recommendations brief treatment." U.S. Surgeon General Dr. David outlined in the guideline.. .will substan­ "The science is pretty compelling," A. Satcher said helpful and proven tially increase the success rate," Fiore said Dr. Mark W. Banks, president and strategies aimed at getting smokers to said. "In fact, if every doctor, nurse, CEO of Blue Cross and Blue Shield of quit can take as little as 3 minutes of a dentist or other healthcare provider Minnesota. The Blue Cross plan was physician's time per patient during a and health plan uses this tool in practice the first, and still one of the few health visit across America, we can more than plans, to cover smoking cessation. “Starting today, every doctor, double quitrates." "This is a no-brainer. (Smoking cessa­ nurse, health plan, purchaser and " (We) need to call tobacco depen­ tion) saves lives, improves health and medical school in Am erican dence what it is - a chronic disease not saves money." should make treating tobacco de­ unlike high blood pressure or diabe­ The Tacoma Pierce County pendence a top priority,” Satcher tes," Fiore said. "This recognition pro­ Healtli Department has a.n effective ap­ said in announcing an updated clinical vides clinicians with a model for help­ proach for talking with clients about guideline to treat tobacco dependency. ing their patients quit." their use of tobacco. The 4 A Model in­ The guidelines, which demonstrate President Clinton also instructed volves a short series of questions, with the effectiveness of smoking cessation federal agencies "to encourage federal ideas for tracking the discussion in the efforts that combine medication and employees to stop smoking to promote patient's chart, and following up a t sub­ counseling is designed to allow physi­ greater use of available smoking cessa­ sequent visits. Training is offered cians and other health professionals to tion programs, and to review current regularly throughout Pierce County, more easily incorporate smoking cessa­ federal tobacco cessation programs in or Network Nurses can meet with you tion programs into their practices. light of these new guidelines," accord­ and your staff in your office to provide Only about half of all US ing to the Department of Health and information about the model. Also, the smokers who see a physician Human Services. And the Office of Health Department has packets of ma­ have been urged to quit, even Personnel Management will also send a terial clients can access for no charge. though smoking is the single greatest copy of the guideline to all health plans If you would like more information, talk preventable cause of illness and prema­ enrolling federal workers encouraging with the Network Nurse who visits ture death in the country. them to promote smoking cessation. your office, or call Nancy McKindsey Approximately 20 million Ameri­ The updated, evidence-based atTPCHD: (253) 798-6461. ■

August, 2000 PCMS BULLETIN 11 B u l l e t in

100,000 peryear. For the pills in her physicians. This will be another straw Disclosure from page 7 age group it was 0.5. In women who on the camel's back. did not use any birth control it was 22.5. The main concern would be that known by word of mouth, through the How does that compare with a death the data would be manipulated by newspapers or through radio and rate from a car accident per year? For competitors to put them in a better light television broadcasts, is irrelevant. 1995, in this country, it was 16.5 per Even then, the likelihood that patients Patients already compare notes and 100,000. Perhaps the difference in the would be swayed one way or the other experiences. We all hear comments death rate between the pills and the is small. People look at the data, one or abou t the service at this or that hospital. IUD was significant enough for her to several things ring a bell, and they They have a reputation, too. It usually make her change her mind. Or she make their decision on that basis, is built on their performance over a may have had other reasons to decide without a dear view or understanding long time, not just the lastyear or two. It against an fUD, which, perhaps, she of the whole picture. may not be in the newspapers, but it is did not want to mention You probably read the write-up in in the grapevine. When people want to Neither we nor the hospitals have The News Tribune. How useful did know, they ask around and they find much to fear from making public more you find the data? We see patients out. When something bad happens, and more data about medical outcomes. come to the office and ask for this people learn about tha t, too. There is the problem of costs. The product or that treatment, because they People want to know how we have people who compile and publish the have seen it on TV or a friend of theirs performed before they come to us and data will have to be paid. Depending is taking it, w ithout knowledge of the the information is always available. Hie on how encompassing are the require­ possible side-effects, cross-reactions or services we provide are very personal ments for disclosure, the cost can easily other considerations. The best we can and the patients' choice of physician is run into the millions of dollars. Some­ do is give them as much information as usually based on many factors, not least one will have to pay for that and it is we can and let them make their of which is the comfort level they have likely to be the hospitals and the decisions. ■ in their interpersonal communication with the physician. Since that varies from patient to patient, it is not some­ thing that can be described by the method of ratings, which is statistical. It has been said that we are in the information age and we suffer from information overload. That is a misno­ mer. We are in the data age and suffer Nationally Accredited from data overload. Data do not Residential Treatment for become information until they are Chemical Dependency interpreted properly. Unfortunately, Begins many people are not able to do that They misinterpret the data and end up with misinformation. Eventually, they Inpatient Treatment give up, ignore the data and do what Recovery House they were going to do anyway. Giving them more data is not likely to change O utpatient the situation very much. Itis more Family Education likely to confuse people even more, and Support rather than to help them. Of course, well infonned patients are better able Relapse Prevention to make decisions and to participate in State Certified their care. Confused patients are not. Diagnostic Assessment As an example, one patient requested to have an IUD inserted. She and her husband read the informa­ 8021 Edmonds tion booklet and decided the IUD was Allvest 230th SW, too risky, because she could die from H o ilS e www.allvesthouse.com it. The death rate was listed as 0.8 per North 425-7X2-0505

12 PCMS BULLETIN August, 2000 In My Opinion by Teresa Clabots, MD

At First Do No Harm and the Airplane Ride

We enjoyed our annual family va­ to Aspirin." I asked the stewardess, "Do cation, and we were all returning ex­ you have any Benadryl on this plane?" hausted on an airplane from a hard The stewardess answered, "Yes we working vacation. My baby was sure do." I asked if she would go and Teresa Claboi.s, MD stretched out across my lap, when the get it. I gently adjusted the oxygen ding-dong sounded. "If there is a doc­ mask over the lady and looked at the tor in the house, please come forward, canister. It was empty. The lady looked weneed your assistance immediately." at me with eyes wide with fear. She I looked around me, and I could see said, "No, no Benadryl, no Benadryl." I Benadryl. (I have heard of rare cases that my husband was half asleep. So, I asked, "Whynot?" Shesaid, "I am aller­ of patients being allergic to Benadryl.) gently moved the baby over to his lap, gic to Benadryl." I sat down beside her A month later I was sitting at a dinner and went to the front of the cabin at the seat that her husband had va­ conference and talking to one of the where the commotion seemed to be cated, held her hand, and felt her hospital pharmacists, and telling him this happening. There was an elderly lady pulse. She wasn't clammy, her pulse very interesting story of being up in an who was short of breath, huffing and was rapid but steady, and she was airplane with a lady who was allergic to panting. She was also coughing inter­ breathing a little bit easier with the new Benadryl. He said, "Well, it's a good mittently. I tried to judge how old she oxygen canister. I thought to myself thing you didn't give her any epineph­ was, Hrran, multiple wrinkles, triple what did I get myself into: rine." I was stunned. I asked, "Why chin, blonde dyed hair fluffed up. As 1.1 am a pediatrician, what in the not?" He said, "Well, believe it or not, far as I could tell she was anywhere world am I doing here with a geriatric there are people that are also allergic between 60-80, and she was a massive patient. 2. She is not having a heart at­ to epinephrine." By this time I was woman tightly squeezed into her chair. tack; she doesn't say she has chest shocked. I said, "Are people allergic to The man next to her, who I presumed pain. 3. Atfirstdo no harm. 4.1 wonder steroids? What do you give to some­ to be her husband, was trying his best if we're flying over a state where The one who is allergic to epinephrine? to look cool and ignore the whole situa­ Good Samaritan law takes effect. 5. Am Steroids?" He said, "No, there are tion. I squeezed into the opening of I liable for anything that 1 do in the air­ people that are also allergic to ste­ the aisle, and asked her what kind of plane as a Good Samaritan? 6. As soon roids." I replied, "Gee whiz, what do medicines she was taking. With the as the stewardess came back, she took you use on those people?" He said, oxygen mask to her face, she pulled down my name, medical licaise num­ "Well, a lot of luck, prayer, fluids, and out a 33-gallon freezer Ziploc bag from ber, and she wanted to see my DEA some sort of special steroid prepara­ her monster purse. (They looked like number. I thought, oh great, I am liable. tion." After talking to my friendly aller­ horse pills to me. There must have She said, "Oh, it's just for record keep­ gist, Pierre, I found that metabisulfite is been 30 different rainbow colored pills, ing. We'll probably send you a free both in epinephrine and some steroid gels, and spansules.) She said, "Oh ticket or something." (They never did.) preparations. Methylparaben is also in these are my morning medicines, pills, 7.1 finally decided that the best thing to epinephrine, Lord knows what for. As and herbs, and I didn't get a chance to do was to give her oxygen, and wait I was getting off the plane, a well- take them. So, I got a headache, and until the ambulance got there. We dressed lady approached me and said, asked the stewardess for an Aspirin be­ raced through the sky and got to the "I am so glad that you went out to help cause the coffee was so bad." So I airport a little earlier. When the ambu­ first." I said, "Why?" She said, "Because asked, "Oh, so the stewardess gave lance got to the end of the ramp, the I am an internist, and I didn't really you an Aspirin?" She said, "Yes, the lady and I walked off, and the first want to help out" My new motto: At coffee they were serving was nasty, I thing I told the attendant was that this First Do No Harm. I sure wish I had had to take an Aspirin for my head­ lady is allergic to Benadryl, so for gotten a free airplane ticket, or an up­ ache." I said, "So you must be allergic God's sake, don't give her any grade to first class out of it. ■

August, 2000 PCMS BULLETIN 13 B u l l e t i n

reason so many live the ballistic life of a out of the blocks and demand a very IV J. d LI 1 from page 9 signal flare is because the euphoria high yield, and banks generally need surrounding most of them is subverting some assurance of receiving payment could not get enough new paper hitting the normal flow of corporate finance. of principle let alone interest. What the street. New paper refers to Initial Once the companies spend all the most investors don't understand is that Public Offerings (IPO's) in which money they raised in the IPO, they're 60-80% of the new paper is sold to billions were invested last year. IPOs painted into a comer as far as new institutional buyers and the remainder are generally a good bet for investors money is concerned. Companies have of the float goes to the brokerage's because the underwriter (who finances three basic means of gaining finance: loyal, royal few. Only the chosen get the company by buying the stock to be 1) sell stock - which dilutes their the stock for its IPO price, the frenzy offered) prices the issues to sell out equity, that then ensues finds them selling to quickly. After carefully calculating the 2) float a bond - which places a hen the unwashed public, who have been

AMZN (Amazon.com) Two year price history charts EBAY (Ebay.com)

EBflY l u i l y - 7/14/00 135

http:Wwww.Bigcharts.com company's worth, they may give the on their assets or bidding the companies up as if they had company $10/ share and offer the stock 3) go to the bank for the money. some sort of pricing power, not to at $11 / share thus collecting their Presently, companies are able to offer mention earnings. This scenario, which commission. Last fall, new issues were stock easily to a voracious public; worked so well last year, is about to be doubling, tripling or more above their which is the least expensive and least rolled out again with approximately 12 offering price, which led many to restrictive way to get the cash. Usually, billion dollars of new issues just waiting believe they were being priced too as companies continue to expand, they for confidence to re-inflate the low. Although that sentiment has don't want to sell more shares because NASDAQ. It takes two sets of partici­ tempered somewhat, the market is that would only dilute their equity as pants to make this equation work, A) again primed to receive billions of well as that of their existing sharehold­ frenzied public, and B) parties inter­ soon-to-be worthless IPO's. The ers. Bonds, however, would be junk ested in maintaining thatfever pitch. Proponents of the digital age would have us believe that the economy is now primed for explosive growth. That UNION AVENUE PHARMACY the medium of the Internet has broken all boundaries to each and every Professional Compounding Center of Tacoma, WA endeavor a business uses to produce goods and services. However, when markets become this volatile, emotion is Vaginal Suppositories Gel, Ointment, and Cream usually the overriding force. Forty Rectal Suppositories IV Services percent swings without change in Urethral Inserts Capsules fundamental monetary policy or Sublingual Troche Lip Balms leading economic indicators show no rationality. Such extreme movement rarely ends well. ■ 2 3 0 2 South Union Avenue 7 5 2 - 1 7 0 5 David Roskoph, MBA, CFP is a fee- based investment advisor in Gig Harbor

14 PCMS BULLETIN August, 2000 VPvww ^ w m ty oM eM cal S o c ie ty

In My Opinion.... by John Stutterheim, MD

Nostalgia of World War II

John Stutterheim, MD, is a retiredfamily physician. He was living in Indonesia with his family prior to WWII and is writing a book about his WWII experiences

This is the story of our liberation, Suddenly the Javanese Hei-Ho's were I \ after Japan surrendered on the 15“’ of replaced by ten Japanese soldiers on August, 1945.1 was one of the 1400 kids the eighteenth. On the following two John Stutterheim. MD in Camp Bangkong, Semarang, Java, a days we were sent to the patjol fields teenage boys' labor camp. Around mid- (15 acres of swamps where we worked August, the Japanese guards' behavior with hoes), but only to harvest veg­ from these aircraft and fluttered and suddenly deteriorated; arrogance and etables and they were all for our own sailed through the air slowly, past tine camp, missing us totally. I wondered how they knew aboutour camp's location or its existence, for that matter. The Japanese just stood there silently and did nothing. For once they were as helpless as we had been for so long. The two Mitchells circled over us three times. Later on we found out that they flew a triangle over the three camps in Semarang; Halmaheira, Lampersari, and Bangkong. They apparently knew the locations of each camp. After a TK.-S. moment of deep silence and admiration for the passing aircraft, we understood: hrutishness were replaced by volatility use! As a further reward, we received "The war was over!" The entire group and an immeasurable nervousness. a double ration of food. A bigger of boys went uncontrollably wild, we They hit us at the slightest provocation miracle came yet when two days later danced, jumped, and screamed until we and seemed always to be looking over 180 pounds of meat was carried became hoarse. We climbed on each their shoulders. We were ordered to through the gate together with twenty other's shoulders to wave at the planes. dismantle the sawmills and we accom­ pounds of bones. We were so sur­ Sick kids had crawled onto the veranda plished that in three days, a record prised and elated that we could not in order not to miss anything, some with time. We were happy to be able to use believe our eyes. Good food! I ran tears in their eyes. Still there were the the wood of the dismantled mill in the outside to look and in no time hun­ real ill, who remained inside unable to kitchen where we desperately needed dreds of us were crowding the parade witness this exhilarating event. All the dry fuel. It never occurred to me that grounds. Two bombers were circling nuns came outside and for the first time we were eradicating the evidence of over our city, flying lower and lower. did we see them all together. They teenage hard labor by destroying It became apparent that they were started to sing the Dutch national those mills. Nobody was called upon looking for something. Then it dawned anthem. This solemn ceremony quieted anymore to work in the fields. There on us, they were looking for our camp! the boys down. Then the reality set in was a change in the air and we could Finally these planes flew so low and again. The planes were gone. There only guess why. Hope became almost thundered right over us. They were so was a sinister quiet, followed by a tangible. On the sixteenth of August close that we could see the head of the grumbling. We wanted more than this some adult male prisoners were pilot, and the tail gunner wiggling his ending; we needed food, medicines, brought in. They spread the rumor that two machine guns in salute. The planes and much more. We demanded for the American troops had landed in western were B-25's, Mitchell's, with red, white gates to be opened. The Japanese Java. I found I could not believe them. and blue markings. Leaflets separated See War, page 16

August, 2000 PCMS BULLETIN 15 B u l l e t in

which they would certainly win. Was lying on his mat, too weak to realize the W ar from page 15 this the seed of revenge, or was it the scene. I stood fairly close to the front old arrogant Bushido attitude? We main gate and looked at the people were confounded and could not outside. They were normal human refused, but this time they did not beat absorb what we had just heard. The beings, people who were not sick, not anyone to show their superiority. We commandant bowed and descended. emaciated, but properly dressed, with could not understand why. That All the Japanese went inside, not to shoes or slippers on their feet. I could afternoon in the dry, blistering heat of appear anymore. Crowds of Javanese not feel a part of them. Emotions around 100 degrees, we were herded and Chinese gathered outside the bubbled up, tears came to my eyes. together by the guards. This was the barbed wire. Without interference Was it possible that the war was truly last time that they forced us to obey. from the Japanese who apparently over? The end of this terrible, deadly We had to face the camp commandant, intended to remain in camp with us, we cam p had come? Could we start to live Beautiful Charles, as he stood before pulled tine bilik, tine woven bamboo, out a normal life again? The thought of any us on a three-foot platform. He told us of the barbed fences in order to normalcy seemed absurd when I that a terrible bomb had been dropped communicate with the outside world. turned to look around me in camp. on Japan, that Nippon had lost the war Some persons on the outside started to There were so many sick kids, many of and had surrendered on the fifteenth throw djeroeks, orange-like fruits, whom were so severely malnourished of August. We looked at each other, over and through the barriers. They that other diseases like malaria had laid shocked, for it was now the twenty- looked so good and they were so them motionless on their cots or on the third of August. However, Beautiful welcome! We had not tasted those for floors. Hundreds of other boys had Charles continued, the Japanese were years. To me the juice was a delicacy already preparing for the next war, and I saved some for Anton, who was See War, page 17

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16 P'JMS BULLETIN August, 2000 for Anton. Later that same afternoon, tion that he was not breathing, thathe W e l l from page 16 when it was time to get in line for food, had died, brought tears to my eyes. In I walked under the long overhang of anguish, I asked other kids when this minor ailments, but even so, were still the school. A few doors down from our happened, but they shrugged their barely able to function. Nearly all of us room I spotted an easy chair, one of shoulders and kept moving. He must needed medical attention, and some of the few we had in camp. The chair was have died there in the comer, all the boys needed long-term care. That pushed into a comer where a flight of alone. So many had become callous to first afternoon I spent with my brother stairs would lead to the second floor. death, they could not afford to care who was still so terribly ill that he was On that chair lay on his back my former anymore. I did not know how long scarcely aware of the events of the past neighbor from Malang, Du trie van Dutrie had been dead. I wondered if days. He was emaciated, and bedrid­ Haaf ten, who was just a year older. I he had seen the planes and if at least den, and harbored symptoms of stopped and noticed how beri-beri had he had experienced the joy of know­ malaria, amebiasis, anemia, beri-beri, made his body so swollen that onhis ing the war had ended, but I realized pellagra, and scurvy. At the time, I legs the skin had cracked and body as I stood there that I would never wondered if the war had ended too late fluids oozed out. The sudden realiza­ know. ■

Bangkong's gate, seen from the pa/adc grounds From L.lo R.; Church, death room and guard house, gale and the two tier classrooms Above il all the woven bamboo with barbed wire. Once we stood there for over 24 hours dressed only in shorts That evening it rained and the mosquitos ate us alive. No wonder malaria was rampant.

August, 2000 PCMS BULLETIN 17 B u l l e t i n

arrived with the cars, Team 1 threw Health Care 2000 Relay from page 4 their bikes on the rack and took off for Sprague, WA. Team 2's last leg, Campaign short climbed to Ryegrass (seen in the starting at about 7 pm, was only 24 picture) then went screaming down to miles. Ryan, going strong, went with on signatures the Columbia river at Vantage by 12:45 the other team, and Rob and Alf PM, just after team 2 had arrived. Both enjoyed the cooler evening and Initiative-725 supporters failed to teams shared lunch. smooth pavement to Sprague, their gather the required 179,248 valid Team 2's third leg was the killer finish. They then drove into Spokane. signatures to place the measure on the leg- Vantage to Moses Lake, 43 miles, Team 1 was now racing daylight, November ballot. However, they have starting at lpm . Darned hot, with a side and two more flat tires didn't help. re-filed the measure as an Initiative to wind from the south, sometimes in the They rode from Sprague toward the Legislature, and it is now known as face. After two difficult flats, they Spokane. After fixing a flat, Ryan, 1-245. This campaign will once again dragged into Moses Lake at 5:15 pm. Marsden and Dave Pearce flew like seek the same amount of signatures, Mark was wasted from the heat, and put the wind as it grew dark, trying but they m ust be new as transfers are himself on the disabled list. (successfully) to catch Leelee and not allowed. The deadline for gather­ Marsden's team was in great spirits; Leslie. They finished riding at 9:30 pm. ing the new signatures is December they had done most of their climbing Team 1 had ridden 142 miles, and 29th early. After leaving the cars in Moses Team 2 rode 139 miles. Seven flats for If the Initiative receives certifica­ Lake, they rode a fairly flat stretch to team 1 and two flats for team 2. tion, the Legislature must act on it by Ritzville. There, they were forced to Everyone said it was a great ride. ad opting it as proposed, rejecting it and wait for the automobiles to arrive. This But Alf said it is a great one to do once, placing it on the next general election did nothing for morale, as the day was brag about forever, and never do it ballot, or approving an amended marching on. As soon as Team 2 again, i version, which must be placed on the ballot along with the original version.!

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18 PCMS BULLETIN August, 2000 Continuing Medical Education COLLEGE C.O.M.E. Board Announces 2000- MEDICAL 2001 CME Program Schedule The College of Medical AMA and AAFP Category I credit. KIIKATIOV Education's Board of Directors an­ A course calendar identifying the nounced its CME schedule for 2000- course title, dates, brief description and 2001 at their June meeting. Courses are course directors will be mailed in early offered in response to local physician September. For additional information interest and are designed and directed on next year's offerings, please call the by local physicians. All courses offer College at 627-7137. ■ Common Office Problems CME 2001 Whistler CME Program set January 24-28 The annual Whistler CME program as last year. A program brochure with will be held has been set for January 24-28,2001 at course details will be available in Sep- October 20 tlie Aspens Condos, with rates the same tember. Watch your mail! ■ D a te s Program Directorfs') Topics are set for the College's Common Office Problems CME Common Office Friday, October 20 Mark Craddock, MD scheduled for Friday, October 20,2000. P ro b lem s The conference will be held at St. Joseph Medical Center, Rooms 1 A&B. Infectious Diseases Friday, November 20 David McEniry, MD The program will offer 6 Category U pdate I CME credits and is again directed by Medicine & Mental Mark Craddock, MD. Friday, December 1 David Law, MD This year's course will cover: H ealth

Cardiology for Primary ❖New Antibiotics TBA (evening) Gregg Ostergren, DO ❖Congestive Heart Failure C are ❖Evaluation of New Onset Seisures Wednesday-S unday in children CME at Whistler Richard Tobin, MD ❖Irritable Bowel Syndrome January 24-28 ❖Common Knee Problems Advances in Women's ❖Hormone Replacement Update Friday, February 9 John Lenihan, Jr., MD M ed icin e ❖Treatment of LumbarRediculopathy ❖Prostate Cancer Friday, February 26 Pain Management TBA The course is designed for the Thursday-Friday Internal Medicine primary care clinician and focuses on Ulrich Birlenbach, MD M a rch 8-9 Review 2001 practical approaches to the most common dilemmas faced in the daily Saturday, April 28 Surgery Update 2001 Glenn Deyo, MD routine of medical practice. Look for the registration brochure in the mail Allergy, Asthma & just after Labor Day. Friday, May 4 Pulmonology for Alex Mihali, MD For more information, please call Primary Care the College of Medical Education, 627- 7137 between 7:45 and 5:00 p.m.! Tuesday, May 16 and Tuesday, May 23 Medical Technology TBA (e v en in g s)

August, 2000 PCMS BULLETIN 19 B u l l e t i n

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20 PCMS BULLETIN August, 2000 Before Online Services Will Work in Healthcare, They Need to Work Like Healthcare.

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August, 2000 PCMS BULLETIN 21 B u l l e t in 'V

ADVANCED TRAINING IN MANAGEMENT FOR PHYSICIANS AND OTHER CLINICAL PRACTITIONERS The University of Washington Department of Health Services in the School of Public Health and Community Medicine (in cooperation with the UW School of Medicine and UW Educational Outreach) invites you to learn more about its Certificate Program in Medical Management. This evening program is designed to assist clinicians and other experienced health care professionals in developing management knowledge and skills applicable to their everyday work situations. It is comprised of four three-credit courses, each of which focuses on distinct and important aspects of management (medical practice quality measurement and management, leadership and change management, strategic management of health care organizations and financial management). The program curriculum provides participants with basic knowledge and practice-oriented skills in health services management, and helps them to determine if they would like to go further in their management training. Each cohort goes through the sequence of courses together -- providing its participants with the additional benefit of learning through their sharing of experiences and management problems. Courses are taught by UW faculty in conjunction with professionals from the local health care field. CME* and CNE credits may be earned. To learn more about this program, please contact the Program Office at [email protected] or 206-616-2976.

* (The University of W ashington School of Medicine is accredited by the Accreditation Council for Continuing M edical Education to sponsor continuing m edical education for physicians. The University of W ashington School of M edicine designates this continuing m edical education program for up to 30 credit hours per course in Category 1 of the Physician's Recognition Award of the Am erican M edical Association.)

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22 PCMS BULLE1 IN August, 2000 ^Sou-nty Q^i-edizal

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Puyallup medical office space MEDICAL LICENSURE ISSUES available. 1300 sq. ft. second story, lift access, 2732East Main. Build to suit. Mr. Rockwell is available to represent physicians and other health care providers with issues of concern before the State Medical Quality Assurance $1800/mo utilities included. Call Linda Commission. Mr. Rockwell, appointed by Governor Booth Gardner, served for Jensen 253-841-0523. 8 years as the Public Board Member of the Medical Disciplinary Board from 1985-1993. Since then, Mr. Rockwell has successfully represented over 60 Lakewood office space available. physicians on charges before the MQAC. Mr. Rockwell's fees are competitive Directly across from St. Clare Hospital. and the subject of a confidential attomey-client representation agreement. Plenty of parking and private entrance. Call Carolyn at 253-581-9313 or 1-800- Gregory G. Rockwell 606-9416. Attorney at Law & Arbitrator 3055 - 112th Avenue SE, Suite 211 Bellevue, WA 98004

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August, 2000 PCMS BULLETIN 23 B u l l e t in

Concerns Come First

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24 PCMS BULLETIN August, 2000 September, 2000 R e sto rin g H e a l t h to Health Care

Washington State Medical Association 2000 Annual Meeting Wenatchee, WA September 22-24

More information page 4

INSIDE: 3 Presidents Page: Vote YES for Health Care 4 Expedition leader to speak at September General Membership Meeting 5 Many thanks for volunteers who painted Tacoma-Pierce Beautiful 7 Hats Off to Candidate Interviewers! 7 Pierce County Adult Trauma Center celebrates its operation 9 Influenza Vaccine Availability for 2000-01 Season 11 September is Women in Medicine Month B u l l e t in

PCMS Officers/Trustees: Charles M. Weatherby, M D ...... President Patrice N. Stevenson, M D ...... PresidentElect Susan J. S alo, M D ...... V ice-P resid en t J. Janies R o o k s, M D ...... Secretary/Treasurer Lawrence A. Larson, D O ...... Past President Sabrina A. Benjamin, MD Drew H. Deutsch, MD K evin K. G andhi, M D M ich ael J. K elly , M D September, 2000 D o ris A . P age, M D Edw ard I. W alk ley, M D Y olan d a B rucc, P C M S A President

WSMA Representatives: Speaker ofthe House: Richard Hawkins, MD Trustee: David Law, MD AM A Delegate: Leonard Alenick, MD W AM PAC Chair/6th District: MarkGildenhar, MD W AMPAC 9th District: Don Russell, DO

Executive Director: Douglas Jackman

Committee Chairs: Aging, Richard Waltman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, John Jiganti; Table of Contents Credentials, Susan Salo; Emergency Medical Standards, Ted Walkley; Ethics/Standards Of Practice, David Lukens; Grievance, Law rence A. 3 President's Page: Vote Yes for Health Care Larson; Labor & Industries, William Ritchie; Legislative, William Marsh; Medical-Legal, Pat D onley; Membership Benefits, Inc., Drew Deutsch; 4 Expedition leader to speak at September Meeting Personal Problems Of Physicians, Robert Sands; 4 WSMA Annual Meeting: Restoring Health to Health Care Public Health/School Health, Sumner Schoenike; Sports Medicine, John Jiganti. 5 PCMS V olunteers Paint T acoma-Pierce Beautiful T h e Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce 7 HATS OFT to Candidate Interviewers! County Medical Society. Deadlines for submitting articles and placing advertisements in The Bulletin 7 Adult Trauma Center Underway are the 15th ofthe month preceding publication (i.e. 7 Cascade Regional Blood Services meets needs of community October 15 for the November issue). 8 Seven Steps to Avoiding Fraud & Abuse The Bulletin is dedicated to the art, science and delivery of medicine and the betterment of the health and medical welfare of the community. The opinions 9 TPCHD: Influenza Vaccine availability for 2000-01 Season herein are those of the individual contributors and do not necessarily reflect the official position of the 10 Influenza Vaccine Schedule Medical Society. Acceptance of advertising in no way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin 11 September is Women In Medicine Month and Pierce County Medical Society reserve the right 11 SupportAfyAssociation has new services to reject any advertising.

Editors: MBI Board of Directors 12 Hepatitis C information from the Surgeon General Managing Editor: Douglas Jackman Editorial Committee: MBI Board of Directors 13 Invisible Hand: "The Patient and the Disease"

Advertising Representative: Tanya McClain Subscriptions: $50 peryear, S5 per issue 15 Seattle-to-Portland Bike Riders Face Head Wind

Make all checks payable to: M BI 17 College of Medical Education 223 Tacoma Avenue South, Tacoma W A 98402 253-572-3666, FAX 253-572-2470 19 Classified Advertising E-mail address: [email protected] Home Page: http://www.pcmswa.org

2 PCMS BULLETIN September, 2000 Presidents Page by Charles Weatherby, M.D.

Vote Yes for Health Care

The Democratic and Republican conventions are making their quadrennial appearances. Regardless of the outcome, we are guaranteed a new President. Have you made your decision yet? We will soon be witnessing Presidential and Vice-Presidential debates. Once again, health care will be one of the major issues. Do you want the Democratic plan or the Republican plan? Why not for once can there just be a health care plan? After the smoke of the political rhetoric and partisanship clears, will there finally be a plan for national universal health coverage? Will there be a prescription drug coverage plan for Medicare recipients? Will there be anational patient "bill of rights"? Will there be a national plan regarding health care plan liability? Some states have grown weary of national politics and are passing their own health care laws. Our own state had a plan for universal coverage, in the form of Initiative - 725 (HealthCare 2000), which fell short of the requirement of valid signatures to be placed on the November ballot. This initiative was an initiative to the people, which meant that its passage would have made the initiative into law. The initiative is now being reintroduced as an initiative to the legislature. If this initiative process gathers the necessary valid signatures, there are three options for our state legislature.

(1) Immediate adoption of the initiative and placing it into law. This would be similar to if the original Initiative - 725 had the valid number of signatures and the voters ratified it (2) Rejection of the initiative, but placing it on the ballot for the voters to accept it or reject it (3) Development of an amended version, however, placing both die amended version and original version on the ballot and letting the voters decide

If nothing else, if enough signatures are gathered, it would force discussion and debate in our legislature to hopefully get more serious about our health care concerns. With our current state House of Representatives deadlocked at 49 Democrats and 49 Republicans and with a Democratic co-House Speaker and a Republican co-House Speaker, its going to require bipartisanship compro­ mise. We are, however, fortunate, that oux state legislature has been more progressive than many states with regards to the passage of health care legislation. Much of the credit can be given to our own WSMA leadership and our legislative lobbyists. ■

September, 2000 PCMSBULLEUN 3 B u l l e t i n

Expedition leader to speak at September Meeting

Reserve Tuesday, Septem ber 12, Mallory and Sandy Irvine reach the relate the mysteries, the quest to solve 2000,6:00 p.m. for an evening of high summit of Mt. Everest in 1924, and them, and what the expedition did at adventure as Eric Simonson speaks on, wha t became of them? the September meeting. "FindingMalloiy." This Simonson's Simonson, owner and active expedition climbing partner in International Mountain stunned the Dramatic tale o f high adven­ resume Guides (one of the oldest mountaineer­ mountaineer­ includes Mt ing companies in the country) as well ing commu­ ture resolving 1924 mystery McKinley, as owner and operator of Mt. Rainier nity with the Aconcagua in Alpine Guides will speak on the discovery of Argentina, Cho experiences of the expedition that set the remains of Mallory. Two major Oyu inTibet, Mt. Elbrus in Russia, and out to solve two of exploration's television documentaries have Mt. Vinson in Anarctica. greatest mysteries: Did George focused on the expedition. He will Call 572-3667 to register.!

WSMA Annual Meeting -Restoring Health to Health Care

llGtli Annual M eeting will be held in W enatchee

The Washington State Annual Meeting will be held September 22-24, Mamta in Electronic Friday - Sunday, at the West Coast Gautam, MD, a Medicine, Addic­ Wenatchee Center Hotel in psychiatrist in tion Medicine, Wenatchee. private practice in HIV/AIDS,End- The 2000 meeting will feature a Ottawa, Canada of-Life issues, multi-faceted program that speaks will address Allergy & Asthma, directly to the needs of the medical techniques for MQA Training, profession and patients. The theme of dealingwith Ophthalmology this year's meeting, "Restoring Health to physician stress Psychiatry, Health Care" is an extremely timely and and burnout in a rapidly changing Women in Medicine, Health Care apt focus for the programs and delib­ environment. Dr. Gautam is a specialist Economics, Reducing Your L&I erations that make up the meeting's in physician stress. Hailed as the Headaches, and the annual Senior content. "Doctor's Doctor," over 99% of her Physicians Meeting & Luncheon. This year the meeting has been patients in clinical practice are The W AMPAC Luncheon will changed to begin on Friday afternoon physicians. She serves as a special feature incumbent Governor Gary with reference committee meetings on consul tantto the University of Ottawa Locke square off against his Republi­ Saturday. Scientific sessions will run Dean's Task Force on Faculty Stress, can challengers to discuss their Friday and Saturday, while the primary as well as to the Task Force for the perspectives on health care issues. A House of Delegates session will be on Provision of Emergency psychiatric question and answer period will follow. Sunday. Care to Physicians. This presentation The WSMA is member driven. The opening session will feature a is designed to assist physicians in The Annual Meeting is an open and panel of heal th care experts offering identifying their own sources of stress, democratic process. The House of their opinions of what should be done and learning how to better manage it. Delegates sets the broad policy course to restore health to the health care The opening session is accredited for for the Association. Your participation system. They will articulate health care 3 hours of Category I CME. is welcomed and encouraged. system reform options and their relative Scientific sessions of the meeting Please call PCMS for more trade-offs. will include Risk Management Issues information, 572-3667.

4 PCMS BULLETIN September, 2000 Thanks for'Painting Tacoma-Pierce Beautiful’

PCMS Members Drs. Mian Anwar, Teresa Bell, Ken Gra­ ham, David Judish, Eric Luria, Philip Perkins, Rick Schoen, Roger Simms, Maureen Smith and Dwight Williamson; volunteers Jennifer Larson and Denise Zirrno from NPN; Janice Ritala, Jena Rivero, Tracey Sanabria and Fred Simmons from the office of Dr. William Shields, along with PCMS staff members Sue Asher, Deborah Pasqua, Angela Kraemer, Juanita Hofmeister Doug Jackman and Melissa Schimmel contributed many hours helping the Medical Society participate in the 'Paint Tacoma-Pierce Beautiful' program sponsored by Associated Ministries of David Judish, MD, Puyallup Physical Dwight Williamson, DO, retiredfamily Pierce County. Med & Rehab, expertly paints the back planning, scrapes loose paint in side o f the house via ladder See “Paint Tacoma-Pierce" page 6 preparation for primer and new paint

Drs, Ken Graham, (top) retired family physician and Phil Dr. Eric Luria, Gig Harbor family physician goes high Perkins, psychiatrist, visit as they paint atop their ladders while Mian Amvar, retired anesthesiologist, goes low

Philip Perkins, DO, reaches new heights as he preps the Tracey Sanabria (front) and Janice Ritala, both from Dr. upper trim for new paint William Shields' office, were great contributers

September, 2000 PUVIS BUILEI IN 5 V B u l l e t i n

Paint Tacoma-Pierce (from page 5)

Deborah Pasqua, PCMS Placement Coordinator, took on From left, Drs. Phil Perkins, Mian Anwar, Juanita Hofmeister, the meticulous task of scraping old paint from the back Melissa Schimmel, Jena Rivero, Tracey Sanabria, Denise door f-ame Zirmo, Angela Kraemer and Jennifer Larson

These volunteers worked four evenings painting a small home near tire Tacoma Mall. The home is owned by an 86 year-old widow with a limited income and numerous heal th problems. The home owner was extremely appreciative of the time and effort so generously given by these volunteers and is happy to have a freshly painted home for the first time in 15 years. PCMS extends a big thank you to all participants. ■

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6 PCMS BULLETIN September, 2000 VPirnw Q /tledical S o c ie ty

HATS OFF to Candidate Interviewers!

Many members spent long 25th Legislative District Interview­ Dermatologist, Robert M artin; and evenings interviewing candidates for ers: Internist, Greg Blackburn; Anesthesiologist Ali Afrassiabi. the state legislature from their particu­ Family Physicians, Bill Marsh, Steve 27th Legislative District Interview­ lar legislative districts. The interviews Duncan, Ron Morris, Becky ers were: Richard Hawkins, Pat are for the WAMPAC Board to get Sullivan and Doug Robson. Hogan, Don Russell, Richard recommendations and feedback from Emergency Medicine, Michael Schroeder and George Tanbara. the members in the local districts. The Brooks. No interviews were conducted interviewers can recommend to the 26th Legislative District Interview­ where an incumbent was in the race. ■ Board that a certain candidate receive ers: Radiologist Scott Carleton; financial support from WAMPAC in the primary or general elections. Each candidate is asked the same series of questions dealing with their Adult Trauma Center Underway campaign and healthcare issues. The interviewers can ask questions on any issue that interests them. Each candi­ Tacoma General Hospital and St. Health presented the designation date is given about 40 minutes to state Joseph's Medical Center hosted a certificates to Tacoma General their position on the various issues. celebration in honor of the opening of Hospital, St. Joseph Hospital and Health care issue questions centered the Adult Trauma Center. George Madigan Army Medical Center. around funding for Medicaid patients; Brown, MD, Vice President, Many dignitaries were on hand to scope of practice issues, tort reform, MultiCare, moderated the hour and a contribute to the celebration. Robert particularly with the statute of limitations half program that acknowledged the Winchell, MD, Director of the clause and mental health parity. contributions of many organizations Trauma Center, introduced his staff of Special thanks go to the following and individuals in bringing about the Drs. Teresa Bell and Lori Morgan and members who gave their time and adult trauma center to Pierce County PA-C's James Martin, Kathleen summer evenings to participate in this and Region V. There were many McDaniel, Ralph Mitchell, and Carlos very important cause. They are: smiles of satisfaction and accomplish­ Vasquez. Dr. Winchell noted that in ment surrounding the nearly 100 the first month of operation, die trauma attendees at the Landmark Convention center had seen over 100 patients, far Center. surpassing the original estimate of Did You Mr. Ron Weaver from the perhaps 400-500 anticipated trauma WashingtonState Department of patients in a year. ■ Remember? Cascade Regional Blood Services V gears to meet needs of community With the recent opening of the new trauma care services in Pierce County, WAMPAC Cascade Regional Blood Services (CRBS) has worked to increase donations by Washington Medical Political increasing their volunteer base. They have notified more than30,000 active volunteer donors that their continual support is needed. The need for additional Action Committee blood and blood products has increased just because of the area's population 1800 Cooper Point Road SW increases over the last few years, as well. According to Charles Drummond, Executive V.P., "we are well prepared to meet the needs of our community." Bldg 7, Suite A Olympia, WA 98502 In further efforts to prepare for the increased demand, CRBS raised funds for a new five-bed bloodmobile. With the majority of their blood supply coming in 800-562-4546 (360)3524848 because of mobile units and on-site drawing programs, CRBS will begin seeking funds for a three-bed unit. ■

September, 2000 PCMS BULLETIN 7 X" Seven Steps to Avoiding Fraud and Abuse

The office of Inspector General, own reading is seldom sufficient. Each 6) Enforcing standards Department of Health and Human employee should be made to under­ through well-publicized disci­ Services, will publish the final version stand that compliance is a condition of plinary guidelines of the "Compliance Program Guidance continued employment Noncompliant conduct should be for Individual and Small Group 4) Developing effective documented by date, name of report­ Physician Practices," produced to help communication ing party, name of responsible person doctors develop and implement Employees must report conduct and follow-up action. compliance programs to adhere to that a reasonable person would 7) Responding to detected federal health care and private believe to be fraudulent or errone­ offenses and developing correc­ insurance program requirements. ous, and there must be a user-friendly tive action initiatives Although the OIG recognizes that mechanism for reporting, such as an Fraudulent or erroneous conduct smaller practices may have limi ted anonymous drop box. It must be that has been detected, but not cor­ resources, they clearly expect all noted that failure to report is a rected, can seriously endanger the physician practices to implement violation of the compliance program. reputation and legal status of the appropriate compliance policies and 5) Auditing and monitoring practice. It is imperative that the person practices. The OIG does believe that Policies and procedures should responsible for compliance take every compliance program should periodically be reviewed as well as decisive steps to correct any problem begin with a commitment by the bills and medical records to ensure that is discovered. ■ physician practice to the following compliance with requirements. An seven elements. annual audit should follow. Reprintedfrom AMNews, July 31, 2000 1) D eveloping written poli­ cies and procedures The key here is written policies and procedures. These are essential to all practices, regardless of size and capability. In particular, is development and availability to employees of a written compliance manual, and up­ dated clinical forms to make sure they elicit the data required for different levels of coding. The policies should also address relevant fraud and abuse risk areas. 2) Designating a compliance o fficer The practice should identify an individual responsible for the compli­ ance program. The person should be independent in his or her position to protect against any conflicts of interest in assigned duties. Compliance activities may be divided among Detect osteoporosis employees, provided that duties are Assess fracture risk well defined. Quantitate bone mineral density changes 3) Developing effective Monitor therapeutic response , training wunvUacornaraa.com Training can be provided in- house or by an outside source. Simply Allenmore Medical Center Lakewood Office giving individuals documents for their (253) 383-2038 (253) 588-6083

8 PCMS BULLETIN September, 2000 Federico Cruz-Uribe, MD The Health Status of Pierce County Director of Health

; | l i Influenza Vaccine Availability ' % for 2000-01 Season

It appears that the distribution of health-care workers. These plans T A C O M A -P IE R C E C O U N T Y flu vaccine will be delayed this year. should be available for implementation HEALTH The Centers for Disease Control if a vaccine shortage develops. DEPARTMENT and Prevention (CDC) published a Once vaccine is available, it should notice titled "Delayed Supply of be given to persons at high risk for Influenza Vaccine and Adjunct ACfP complications from influenza as is ment - does not anticipate a Influenza Vaccine Recommendations normally done. In the United States, 70 shortage of flu vaccine this for the 2000-01 Influenza Season" in to 76 million persons are at high risk for season. However, we need to the July 14,2000, issue of the MMWR. serious complications from influenza emphasize that flu vaccine Production problems are ex­ infections, including hospitalizations through this program is available pected to cause a significant and deaths. This figure includes: only to high-risk children, not to delay in the distribution of approximately 35 million persons aged their siblings or provider’s office influenza vaccine and possibly more than 65 years; 33 to 39 million staff. substantially fewer total doses of persons aged less than 65 years with In previous years, the ACIP has vaccine for distribution than last high-risk medical conditions; and 2 recommended that organized cam­ year. million pregnant women paigns take place during October The CDC's recommendations state In 2000, ACIP broadened its through mid-November. Flu vaccine that influenza vaccine recommenda­ administered after mid-November can 1) Implementation of organized tions to include all persons aged still provide substantial protective influenza vaccination campaigns 50-64 years. This recommendation benefits. For the 2000-01 season, it is should be delayed until early to mid- was based, in part, on an effort to particularly important for vaccine November. The purpose of this is to increase vaccination coverage of providers to continue to administer minimize cancellations of vaccine persons in this age group with high-risk vaccine after mid-November. campaigns and wastage of vaccine conditions. In the context of a possible Minimizing wastage of influenza doses resulting from delays in vaccine vaccine shortage, it would be appropri­ vacdne is important. In particular, delivery. ate for contingency plans covering this influenza vaccine purchasers 2) Influenza vaccination of age group to focus primarily on should refrain from placing persons at high risk for complications vaccinating persons with hi gh-risk duplicate orders with multiple from influenza and their close contacts conditions rather than this entire age companies to minimize the should proceed routinely during group. amount of vaccine that is re­ regular health-care visits. Routine Influenza vaccine is routinely turned to a manufacturer and influenza vaccination activities in recommended for persons in close discarded. Options to promote clinics, hospitals, nursing homes, and contact with anyone at high risk for redistribution of vaccine that otherwise other health-care settings (especially complications from influenza because would be returned or discarded are vaccination of persons at high risk for of the ease of transmitting the virus. being developed. complications from influenza, health­ Vaccination of health-care workers has According to the report, CDC and care staff, and other persons in close been highlighted in particular because the FDA will continue to issue updates contact withpersonsathigh risk for they have frequent and close contact as new information becomes available. complications frominfluenza) should with many different high-risk persons If an influenza vaccine shortage proceed as normal with available at a time when high-risk persons are appears imminent, CDC and ACIP will vaccine. particularly vulnerable. issue further recommendations. 3) Provider-specific contingency The Vaccines for Children Please refer to the chart on page plans for an influenza vaccine shortage Program - state-supplied vac­ 10 for a prioritized vaccination should be developed to maximize cines distributed by the Tacoma- schedule. vaccination of high-risk persons and Pierce County Health Depart- See "Vacdne Schedule" pagelO

September, 2000 PCMS BULLETIN 9 B u l l e t i n

CDC and ACIP Recommended Prioritized Influenza Vaccination Schedule

NOTE: 1) This applies to the 2000-2001 vaccination season only. 2) Utilize this schedule only if delays/shortages in influenza vaccine supply are experienced.

Vaccinate during: |Risk Category October (November iDecember IJanuary

National Coalition for Adult Immunization, Bethesda, Maryland, July 2000.

* Refer to A C IP Guidelines to determine risk for influenza-related complications.

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10 PCMS BULLETIN September, 2000 Women in Medicine - Making a Difference September is Women in Medicine Month

Representation of female physi­ of female physicians, they are younger men by specialty. The percentage of cians in medicine continues to show than their male counterparts. In 1998, women in pediatrics was 15%, while steady increases. In 1970, women the greatest percentage of women men comprised 5%, and ob/ gynwas the comprised 7.6% of the physician force, physicians, 36%, were between 35 and choice of 7.3 % of women, but only 5 % in 1980,11.6% of the physician force 44 while the percentage of men in this of men. were women, but by 1998 they category was 25 %. Women physicians For more information about accounted for 22.8% of the total age 44 or under represented 65 % of Women in Medicine you may contact physician population. In 1997, the female physicians, while male physi­ die AMA Women Physicians Services AMA WomenPhysicians Congress cians in this same age group repre­ at312-464-5622 or join on line at (WPC) was formed to enhance the role sented 39% of male physicians. www.ama-assn.org/WPS. Or, contact and influence of women in organized Two specialties, ob/gyn and PCMS if you are interested in local medicine and the profession. The pediatrics, were the exception to a activities for women in medicine, 572- WPC addresses critical women's health higher total number and percentage of 3667.« and professional issues. Its goals indude:

• Increasing the percentage of SupportMyAssociation.com has women physicians in leader­ ship positions. new Member Services Portal • Providing a forum for mentoring and networking among women physicians S u p p o rt^ Association.com (SMA) With ONLY 24 hours in • Advancing the womens health affords PCMS members the benefits th© agenda of shopping online with over 200 of the d ay, • Monitoring trends and emerging world-wide-web's top merchants, all WHEN do issues that affect women in the consolidated into one, easy to use YOU profession shopping portal. PCMS benefits by SHOP? • Increasing the membership/ receiving a royalty from every participation of women in purchase made from die numerous organized medicine merchants. • Enhancing professional options Members receive various forbalandngfamily/career promotions and specials. Shopping is responsibilities easy and prices are competitive. Best Price Guarantee and Free Next Day Go shopping on They are meeting with success. In Shipping is granted on all orders over SupportM/Association.com 1998, Nancy Dickey, MD became the $25. first woman AMA President while SMA has added a new program SMA, but will log on to WSMA'sfirstwomanpresidentwas tha t allows each individual a page www.PCMSmembers.com Another Anna Chavelle, who served in 1992- called My PAGE consisting of areas benefit is free email service, with the 1993. Pierce County Medical Society such as My LINKS and MySTORES same extension for your address, (i.e.: was led by their first woman president, that can be customized. The concept [email protected] Eileen Toth, MD, also in 1992 and allows for the member to be one click Be sure and check out the new will see their second woman leader away from anywhere on the Internet service of SMA. You can begin by next year, as Patrice Stevenson, on a consistent basis. MyPAGE also going to the PCMS homepage, MD, Puyallup Physical Med & Rehab includes a personal address book and www.pcmswa.org and clicking on the physician will be installed at the calendar. SMA.com logo. December Annual Meeting. And, for ease in shopping, Please call PCMS and let us know In keeping with the growing trend members no longer have to log on to how you like the upgraded services.*

September, 2000 PCMS BULLE I IN 11 B u l l e t i n

Hepatitis C information from the Surgeon General (Please post for patients)

Dear Citizen: Our country is facing a silent epidemic in the form of Hepatitis C, a liver disease caused by the Hepatitis C Virus (HVC). An estimated 4 million Americans have been infected with HCV, and a majority of them probably are not aware that they are infected. With that in mind, Members of Congress have joined with the Office of the Surgeon General to distribute this letter so you can take the appropriate action for yourself and your family. Hepatitis C spreads by contact with an infected person’s blood. You should get tested if you:

• have ever injected illegal drugs, even if you experimented a few times many years ago • received a blood transfusion or solid organ transplant before July, 1992 • received a blood product for clotting problems produced before 1987 • have ever been on long-term kidney dialysis • have ever been pricked with a needle that has infected blood on it • or were bom to a mother with hepatitis C

In rare cases, you can get hepatitis C by having sex with an infected person, especially if you or your partner have other sexually transmitted diseases. You can NOT get hepatitis C by shaking hands with an infected person, hugging an infected person, kissing an infected person, or sitting next to an infected person. While some people with hepatitis C experience flu-like symptoms, many don't have any symptoms. If you think you might have been exposed to hepatitis C, go to a doctor. The doctor will test your blood. For many people, hepatitis C is treatable with a drug called interferon, taken either alone or in combination with the drug ribavirin. It is important to get help, because over time, hepatitis C can cause your liver to stop working. For more information, please contact the Centers for Disease Control and Prevention's Hepatitis C Hotline at (888) 443-7232 or check the following websites:

http://www.cdc.goV/ncidod/diseases/hepatitis/c/index.htm http://www.niaid.nih.gov/information/search.htm

Sincerely,

David Satcher, M.D., Ph.D. Assistant Secretary for Health and Surgeon General

12 PCMS BULLETIN September, 2000 In My Opinion.... The Invisible Hand by Andrew Statson, MD

The Patient and the Disease

“It is more important to btow what sort o f patient has the disease, than what sort o f disease the patient has. ”

William Osier Aiulrsw Statson, ,\fL)

Once upon a time, not too long cost effective, meaning cheaper, and ago, die powers that be decided to the results are better. Treatment ennoble primary care. This was going decisions are made according to the treatment of asthma, congestive to be the basis of our medical care evidence based medicine and every­ heart failure and cancer. system. The fields of family practice, thing is wonderful. One aspect of disease manage­ internal medicine and pedia tries were According to the Disease Manage­ ment is that it checks on physician named as primary care specialties. The ment Association, the goal is to identify performance to make sure the recom­ authorities pumped money into the tine population at risk for a disease or mended tests and procedures are primary care residencies. The students already affected by it, to treat it so as to done. In diabetic patients, for instance, were urged to choose those fields. The prevent future complications and to it requires annual examinations for road we traveled was paved with the improve the quality of life for the retinopathy, neuropathy, hypertension good intentions of total care, gate patients, while saving money for the and tests for cholesterol and urine keeping, capitation and cost contain­ insurance companies. Disease manage­ albumin. Such examinations were ment ment is a technique of managed care. It performed by a minority of family Treatment by specialists was is a prospective approach to chronic physicians prior to the establishment of declared overrated and wasteful. The d iseases, involving the identification of disease management. primary care physicians were profiled patients, the treatment according to Most of the information above is and gently chided for referring to evidence based medicine and the from the May-June 2000 issue of specialists anything but the most follow-up, including results of care, to Physician Practice Digest. As I complicated and serious problems. prove that the system is working and understood it, the patients remain They were expected to do a variety of saving. "The aim is to prevent the under the care of their family physi­ procedures for their capitated patients, costly complications of chronic dis­ cians and the disease management from eye examinations to sigmoido­ eased down the line by managing the company provides its treatment scopies. Managed care and other patients in a conservative manner algorithms for the physicians to follow insurance plans required the medical today." and helps with patient education. They groups which they contracted to have a American Heal diways is one show an improvement of care com­ minimum number of primary care company specializing in the treatment pared with the care given in die past by physicians. of diabetes. "All patients are assigned to the family physicians. That still does not Like other roads paved with good a nurse manager, who teaches self­ tell us whether diis type of care is intentions, this one did not lead us to management techniques and identifies better and cheaper compared to the healtli heaven either. Now managed patients at high risk for complications. care of diabetic patients by an endocri­ care is discovering disease manage­ High risk patients are assigned to a nologist ment. Various groups, specializing in complex case manager, who works The good aspect of disease the management of diabetes or asthma, with the physician and patien t to modify management I see is the collection of are contracting with the insurance risk." According to American evidence and the performance plans to treat these conditions. This is Healthways their program showed a evaluation of the physicians. The not only specialized care, it is savings of 50 dollars per patient per knowledge of treatment results in our superspecialized. They claim it is more month. Other companies specialize in See "Patient" page 14

September, 2000 PCMS BULLETIN 13 Patient from page 13 remain so. Evidence based medicine larly. Any treatment has to be adjusted notwithstanding, the treatment of the not only to the individual patient and patients compared to others is helpful. disease will have to be modified to fit his lifestyle, but also to the day to day In order to improve our outcomes we the patient who has it. In medical school variations in his condition, is his need to know how others handle we learned to treat diseases. In activities, in his life. certain problems and what seems to practice we treat patients. There is a In his book Man the Manipulator work best in our type of practice. Now significant difference between the two. Everett Shostrom relates the story of a this information comes to us from our We could disregard the wishes of school teacher. After a number of professors, from studies done in the patients and impose on them the group therapy sessions, she was able to university settings, with clinic patients. treatment protocols determined by see her students as human beings, with This is not the type of population we evidence based medicine. If that is their individual interests and abilities. serve in private practice. what their insurance companies will As a result, she changed the way she In the 1930s, a professor of cover, the patients will take it, at least taught them. "I used to teach math, now medicine at the University of Paris was for a while. However, the claim that all I teach children," she said. This is the quoted as saying, "The generations of patients with a certain condition are potential pitfall of disease management. physicians that preceded us were the best treated the same way, because that It treats diseases, but diseases don't artists of medicine. We are the crafts­ is what evidence based medicine has exist independent of patients. men. The generations that will follow established, is wishful thinking. The aphorism of Osier was much us will be the assembly line workers." If you have tried to take a pill at more significant in his time than it is in Disease management is the the same time every day for any length ours. We have powerful tools to treat expression of the assembly line. of time, or worse, three or four times a diseases, which he did not have. In However, the present day assembly day, at predetermined times, for more acute conditions, the kind of patient is lines are much different from the early than a few days, you must know that it is probably not as important as it was then ones. At the time, Henry Ford declared practically impossible to achieve by In chronic conditions, however, the that a car could be any color, just so it any active person leading a reasonably kind of patient still makes a big differ­ was black. This dogmatic position normal life. Even our hospital patients ence in the success or failure of the allowed General Motors to develop don't get their medications that regu­ treatment ■ and grow, so that eventually it over­ took Ford Motor Company. Today the assembly lines can produce customized cars with the options the buyers have requested. That is what the market wanted. It remains to be seen whether a disease management company can give individualized service better and E cheaper than the treatment the special­ ist can give in his private office. The ATTOO patients are individuals and they will WORRIED ABOUT WHAT YOUR SPOUSE, YOUR FRIENDS OR EVEN YOUR BOSS THINKS ABOUT YOUR TATTOO? OR ARE YOU JUST TIRED OF I LOOKING AT IT? brea&t Today’s newest Alexandrite laser, will remove your tattoo 6 urcj.eri^ avith minimal discomfort & tliinb less than 1% risk of scarring. of- u i. (.ail today for more injonnatioti % Union Avenue Pharmacy & | PIERCE COUNTY |f Corset Shop 1 LASER CLINIC |S Formerly Smith's Corset Shop jf Dircctur I’eK-r K. Mnrsh M.D. | 2302 S. Union Ave 752-1705 jf (253)573-0047

14 PCMS BULLETIN September, 2000 Seattle-to-Portland Bike Riders Face Head Wind

Several PCMS members took part in the 21st Annual 200 mile Seattle-to-Portland (STP) Bicycle Classic Ride July 8-9. Most of the 9000 riders stay the first night in Centralia or Chehalis, which is 94 miles from the University of Washington starting point. About 1500 of them do the ride in one day and that is what Neurologist, Pat Hogan did this year. Pat had a time of 12 hours in the saddle. Not only did he do it in one day, but the riders had a continuous head wind most of the way down Congratulations Pat!! General Surgeon Bill Martin and his wife Karyl were among those who rode to Longview the first day. Joining them 4# / in Longview were: Pathologists Sam Insalaco, George "5^ •— - ■ :I & J Hodges and Mike Flaherty; Pediatrician Richard Ory, [ . ).£& Emergency Room physician Jim Fulcher, Internist Henry From left, pathologists Mike Flaherty, George Hodges Retailliau and his 16 year old son Daniel.■ and Sam Insalaco replenish lost liquid during their ride

Dr. Sam Insalaco, at the finish line o f STP 2000 Dr. George Hodges at the finish line o f STP 2000

Allenmore Do we have •5$L Psychological your e-mail address? Associates, P. S. , 752-7320 ■ please send it to us at: Do you have patients with difficult emotional and stress-related problems? Psychiatric and [email protected] psychological consultations are available. Union Avenue Professional Building ______1530 Union Ave! S.. Ste. 16. Tacoma

______^ September, 2000 PCMS BULLETIN IE V B u l l e t i n

Organ &Tissue DONATION

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16 PCMS BULLEI IN September, 2000 COLLEGE Continuing Medical Education Common Office Problems CME MEDICAL offers timely Primary Care Topics Registration is underway for the Common Knee Problems, Hormone very popular Common Office Problems Replacement Update, Treatment of EDUCATION CME program. This year's conference Lumbar Rediculopathy, and Prostate is scheduled for Friday, October 20, Cancer 2000. The conference will be held at The course is designed for the St. Joseph Medical Center, Rooms 1 primary care clinician and focuses on A&B. practical approaches to the most CORRECTION: The program will offer 6 Category common dilemmas faced in the daily I CME credits and is again directed by routine of medical practice. Look for ID Update CME Mark Craddock, MD. die registration brochure in the mail This years course will cover: New just after Labor Day. set November 10 Antibiotics, Congestive Heart Failure, For more information, please call Evaluation of New Onset Seizures in the College of Medical Education, 627- The annual Infectious Diseases Children, Irritable Bowel Syndrome, 7137 between 7:45 and 5:00 p.m.i Update is set for Friday, November 10, 2000, NOT November 20lh as printed in the calendar in the August Bulletin. Dates Program D ire c to rs ) The very popular course will be held Common Office at the Sheraton Tacoma Hotel. The Friday, October 20 Mark Craddock, MD P ro b lem s program is directed by David McEniry, MD and will feature Infectious Diseases F riday, N o v em b er 10 David McEniry, MD specialists and sub-specialists from the U pdate community joining Infections Limited Medicine & Mental physicians as they give presentations Friday, December 1 David Law, MD on specific disease areas. The course H ealth is designed as an update on common Cardiology for Primary outpatient and inpatient infections. TBA (evening) Gregg Ostergren, DO The registration brochure will be C are mailed in September. ■ Wednesday-S unday Richard Tobin, MD CME at Whistler January 24-28 John Jiganli, MD

Advances in Women's Friday, February 9 John Lenihan, Jr., MD Whistler CME M ed icin e Program set TBA Pain Management David Paly, MD Thursday-Friday Internal Medicine Ulrich Birlenbach, MD January 24-28 M arch 8-9 Review 2001 Saturday, April 28 Surgery Update 2001 Glenn Deyo, MD The annual Whistler CME pro­ gram has been set for January 24-28, Allergy, Asthma & 2001 at the Aspens Condos, with rates Friday, May 4 Pulmonology for Alex Mihali, MD the same as lastyear. A program bro­ Primary Care chure with course details will be avail­ able this month Watch your mail! ■ Tuesday, May 16 and Tuesday, May 23 Medical Technology TBA (ev en in g s)

September, 2000 PCMS BULLETIN 17 .Bu l l e t i n

Need office help in a hurry?

r a v e lL e r S Pierce County Medical Society Health Service Medical Placement Service A s e rv ic e o f Northwest Medical specialties, PLLC INTERNATIONAL TRAVEL CAN BE HAZARDOUS TO YOUR HEALTH the solution for all vou r • PRE-TRAVEL CARE • POST-TRAVEL CARE staffing needs HOURS CALL EARLY WHEN PLANNING MON - FRI 9-5 253-428-8754 or 253-627-4123 For more information: A SERVICE OF call Deborah Pasqua: 572-3709 INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph’s Hospital)

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Tacoma, WA 98405 Allenmore Medical Plaza Presented by K id d e r M a th e w m Joining these existing tenants: Building features: & S e g n e r In c Pacilic Northwest Eye Associates, PS David V. Pratl, MD and Troy J. Woodman, MD Class "A” Building with high quality finishes Contact: Bill Frame, CCIM Allenmore Ambulatory Surgery Center Located near the Allenmore Hospital Campus 253-383-5693 State-of-the-art Building [email protected] Tenant Improvement Allowance

The in to manor* contained herein has been given lo us b y the owner or sources that we deem reliable. We havo no reason to doui’jf ift; accuracy, but wq do not guarantee it Prospective tenants should caretully verity all information contained herein. Call for more information.

18 PCMS BULLETIN September, 2000 Classified Advertising

POSITIONS AVAILABLE OFFICE SPACE

Tacoma/Pierce County out­ Puyallup medical office space Lakewood office space available. patient general medical care at its best. available. 1300 sq. ft. second story, lift Directly across from St. Clare Hospital. Full and part-time positions available in access, 2732East Main. Build to suit. Plenty of parking and private entrance. Tacoma and vicinity. Very flexible $1800/ mo utilities included. Call Linda Call Carolyn at 253-581-9313 or 1-800- schedule. Well suited for career J ensen253-841-0523. 606-9416. redefinition for G.P., F.P., I.M. Contact Deluxe Office Space. 1700+ sq. Andy Tsoi, MD (253) 752-9669 or Paul ft., large parking lot. Fircrest. 564-8784. Doty (Allen, Nelson, Turner & Assoc.), Clinic Manager (253) 3834351.

GENERAL MEDICAL LICENSURE ISSUES Mr. Rockwell is available to represent physicians and other health care Drs. W. Jackson and K. providers with issues of concern before the Stale Medical Quality Assurance Scherbarth looking for partners in 47 Commission. Mr. Rockwell, appointed by Governor Booth Gardner, served for ft. motorboat and Mooney airplane. 8 years as the Public Board Member of the Medical Disciplinary Board from 253-752-6965. 1985-1993. Since then, Mr. Rockwell has successfully represented over 60 physicians on charges before the MQAC. Mr. Rockwell’s fees are competitive and the subject of a confidential attomey-client representation agreement. Gregory G. Rockwell AMERICAN LUNG ASSOCIATION* Attorney at Law & Arbitrator ofWjshrngton t 3055 - 112th Avenue SE, Suite 211 Bellevue, WA 98004 1-800-LUNG-USA (425) 822-1962 • FAX (425) 822-3043 email: [email protected] • website: “ggrockwell.wld.com” Lung Information Service Line

Providing patient Multi Care £3 education materials Do you have patients suffering from Lymphedema? The Lymphedema Clinic at Tacoma General Hospital offers TACOMA/PIERCE COUNTY the latest treatments by the only certified Lymphedema Therapists in Pierce County. Outpatient General Medical Care. Full and part-time positions • Compression bandaging available in Tacoma and vicinity. • Manual lymphatic drainage Very flexible schedule. Well suited • Lymphedema exercises for career redefinition for • Skin/Wound care GP, FP, IM. • Custom tit compression sleeves and stockings Contact Andy Tsoi, MD (253) 752-9669 or Paul Doty (Allen, Nelson, Turner & To learn more or to refer a patient to the Lymphedema Clinic, please call 253 403-1040. , Assoc.), Clinic Manager (25.3) .383-4351 ' *- (•.' MiiliiCurc 2

September, 2000 PCMS BULLETIN 19 BULLETIN

er Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether it’s a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and in the future, is to help physicians, clinics, and hospitals remain successful. | F Physicians h" Insurance Western Washington 1-800-962-1399 A Mutual Company Eastern Washington 1-800-962-1398 Created and spon5<'rcd by the W ashington Stale Medical Associ.Hton Oregon 1-800-565-1892 Seattle, WA © Physicians Insurance 1999

Pierce County Medical Society PRESO RTED 223 Tacoma Avenue South STA N D A RD Tacoma, WA 98402 US POSTAGE PAID TA C O M A , W A PERMIT NO 605 Return service requested

20 PCMS BULLETIN September, 2000 October, 2000 The Neighborhood Clinic...... Bringing Health Care to the People

See story, page 3

INSIDE: 3 The Neighborhood Clinic-Bringing Health Care to the People 5 High Adventure of the Mallory/Irvine expedition draws big crowd at October Meeting 7 Members complete the 163 mile Courage Classic bicycle ride 9 Robert Winchel, MD to give Adult Trauma Center update at November General Meeting 11 Pierce County’s Community Health Status Report released 18 College of Medical Education plans Whistler course for January, 2001 - Register now! 21 Yoder lecture Friday afternoon, November 10 B u l l e t i n V.

PCMS Officers/Trustees: T i l - 'ifatmfy Q ^ledica Charles M. Weatherby, M D ...... P resid en t PatriceN. Stevenson, M D ...... President Elect S usan J. S a lo ,M D ...... Vice-President J. Jam es R o o k s, M D ...... Secretary/Treasurer b U L L E r Lawrence A. Larson, DO ...... Past President Sabrina A. Benjamin, M D Drew H. Deutsch, M D K ev in K. G andhi, M D M ich ael J. K e lly , M D D o ris A . P age, M D October, 2000 Edward I. Walkley, M D Yolanda Bruce, PCMS A President

WSMA Representatives: Speaker of the H ouse: Richard Hawkins, M D Trustee: David Law, M D AM A Delegate: Leonard Alenick,M D W AM PAC Chair/6th District: Mark Gildenhar, MD W AM PAC 9th District: Don Russell, DO

Executive Director: Douglas Jackman

Committee Chairs: Aging, Richard Waltman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of Medical Education, John Jiganti; Credentials, Susan Salo; Emergency Medical Table of Contents Standards, Ted Walkley; Ethics/Standards Of Practice, David Lukens; Grievance, Lawrence A. 3 The Neighborhood Clinic-Bringing Health Care to the People Larson; Labor & Industries, William Ritchie; Legislative, William Marsh; Medical-Legal, Pat Donley; Membership Benefits, Inc., Drew Deutsch; 5 High Adventure draws big crowd at October meeting Personal Problems Of Physicians, Robert Sands; Public Health/School Health, Sumner Schoenike 7 Members complete Courage Classic

The Bulletin is published monthly by PCMS Membership Benefits, Inc. for members of the Pierce 8 Richard Wohns, MD and son complete STP on tandem County Medical Society. Deadlines for submitting 8 PCMS Executive Director announces retirement articles and placing advertisements in The Bulletin are the 15th ofthe month preceding publication (i.e. 9 Trauma Update scheduled for November General Meeting October 15 for the November issue).

The Bulletin is dedicated to the art, science and 10 Applicants for Membership delivery' of medicine and the betterment of the health 10 Directory changes and medical welfare of the community. The opinions herein are those of the individual contributors and do not necessarily reflect the official position of the 11 TPCHD: Community Health Status Report Medical Society. Acceptance of advertising in no way constitutes professional approval or endorse­ 12 Organ Donation website offers resources and information ment of products or services advertised. The Bulletin 12 and Pierce County Mcdical Society reserve the right CPT-5 Project lays groundwork for Electronic Future to reject any advertising. 13 Physicians should covert to limited liability partnerships Editors: MBI Board of Directors; Drew Deutsch, MD, President 15 M anaging Editors: Douglas Jackman/Sue Asher Invisible Hand: "Saving on Penicillin" Editorial Committee: MBI Board of Directors 17 "Nostalgia of World War Two" Advertising Representative: Heather Benson Subscriptions: $50 peryear, $5 per issue 18 College of Medical Education - Whistler CME set Make all checks payable to: MBI 19 College of Medical Education 223 Tacoma Avenue South, Tacoma WA 98402 253-572-3666, FAX253-572-2470 21 The Edwin C. Yoder Lecture E-mail address: [email protected] Home Page: http://www.pcmswa.org 23 Classified Advertising

2 PCMS BULLETIN October, 2000 / N\ . ______, - / 'fflieme Q-4(eJiml Society,

Special Feature by jean Borst

The Neighborhood Clinic...... Bringing Health Care to the People

Its presence in the community is “ It’s hard to say no to people who have limitless needs.” limited with services available only a few hours, two evenings a week. But John VanBuskirk, D.O. on the Neighborhood Clinic for the short time the Neighborhood Clinic opens its doors each week, its im­ pact and presence is far-reaching and significant only a few minutes at the clinic to see the community. It's a huge piece of "Each time I work at the clinic," how broken the health care system is." what works for me." says John VanBuskirk, D.O. "I hear "It was a way to work with people Humble Beginnings stories from people, have the opportu­ with real needs," recalled Joan nity to work with other dedicated vol­ Hailey, D.O., who w as a resident The Neighborhood Clinic was es­ unteers, and see fascinating medical withTacoma Family Medicine when tablished in 1983 to provide free medi­ problems and issues. I come away feel­ she began working at the Neighbor­ cal care to those in need who lacked ing energized, and I am continually re­ hood Clinic over ten years ago. "And, medical insurance, Medicare or public minded that it's the right thing to do." as a resident doctor, it was a place to assistance to cover medical costs. The Dr. VanBuskirk, who has been associ­ work hard and be appreciated." Dr. brainchild of a local RN and a Jesuit ated with the clinic since 1989, was Hailey is now a family practice physi­ priest, the clinic opened its doors on a originally encouraged by friends to cian with Peninsula Family Medical shoestring budget, providing limited volunteer some time with the project. "I Center in Gig Harbor, but continues heal tli care. While supported by St. really couldn t imagine how I would be her volunteer time at the clinic. Leo's Parish and the surrounding com­ able to do it, he recalls. "Likemostphy- "Very few physicians go into the munity, the clinic and church have no sicians, I was swamped. But, it didn't field of medicine saying, 'I'm doing this formal affiliation take me long to recognize its impor­ because I want to be rich and famous,'" "We've come a long way," noted tance. Dr. Hailey noted. "They do it because Dr. Hailey, who recalled that the clinic Since that time, he has regularly they want to use their skills and abilities was originally housed in the basement volunteered at least one night a month to help other people. For me, that's of St. Leo's. Sheets and bookcases at the clinic, located at1323South never changed." separated exam areas, and water had to Yakima,indowntownTacoma. His in­ Like Dr. VanBuskirk, Dr. Hailey be heated in a coffeepot because there volvement wasn't exactly a reach for is at the clinic about once a month and was no hot water available in the build­ him, however. Dr. VanBuskirk has attends monthly board meetings. Both ing. Today, the clinic is located in the been helping underserved patients physicians agree that balancing volun­ remodeled Mt. Tahoma building and throughout his career. He worked four teer time, a full-time practice, and fam­ features four exam rooms, a waiting years for the Tribal Health Authority ily life is challenging. "Family time is an room, two toilets and a play area. The before joining Tacoma Family Medi­ issue," Dr. Hailey said. "An evening at clinic rents the space from the building cine. In addition to serving the urban the clinic is another night away from owners at a low rate. underserved population at his practice, home. But when I think that it's only Today, the Neighborhood Clinic he also trains residents to provide care once a month, two to three hours at a continues to serve the homeless, unem­ to the same population The clinic, he time, I realize that there's no question ployed and the "working poor" - those notes, is an excellent outlet for that that this is something I can do. I can who are employed but do not have in­ training. give up other commitments to be at the surance benefits. The facility is open "For residents," he said, "this is clinic" Monday and Thursday evenings. No wonderful exposure to health care. It's Time is an issue for Dr. fees are charged, and patients are seen a whole different world thatnew physi­ VanBuskirk, as well, but "my family on a first-come, first-served basis. Any- knows how valuable this is to me and to cians should be exposed to. It takes See "The NdghborhcxxiClinic" page4

October, 2000 PCMS BULLETIN 3 B u l l e t i n

The Neighborhood Clinic from page 3

one who walks in the door will be seen. clearing house, the clinic makes refer­ Patients are primarily young adults. rals for eye care, dental care, shelter, "The Neighborhood Clinic There are very few pediatric or OB pa­ food and clothing. Clinic Coordinator tients, Dr. VanBuskirk notes. "These Ruth Roath, who runs the facility and is grounded on the belief coordinates staffing, is at the clinic people are eligible for state resources. that healing occurs where Basically, it's difficult for society to say Mondays and Thursdays to review 'no' to children and pregnant women" charts and determine follow up. physical/medical care is Approximately 8-15 patients are seen In addition to two to three primary each night. While most visits are short care physicians - typically family prac­ accompanied by consistent and directed, mentally ill patients and titioners - the clinic is staffed by desk emotional support and a those clients with sexually transmitted volunteers, volunteer nurses, nursing diseases require additional time. Dr. students, and other health care profes­ regard for the whole VanBuskirk estimates that approxi­ sionals with day jobs. Some specialists person. mately half the patients they see each are involved and active in the clinic, night are new to the clinic. Clients come and some assistance comes from physi­ Therefore, in response to primarily from downtownTacoma, but cal therapists, counselors, massage the clinic also sees patients from as far therapists, and education service sup­ the gospel o f Jesus and the away as Roy, Purdy, Lakebay and port specialists. call o f the spirit, we Olympia Last year alone, physicians, physi­ The clinic offers routine care and cian assistants and nurse practitioners endeavor to meet each treats such cases as flu, colds, sprains, provided over 370 hours of free care. patient as an individual, to etc. Providers draw blood, order EKGs, Numerous uncounted hours of free make referrals, and dispense medica­ care was provided by community heal, to bind up wounds, to tion. "We cannot take care of ongoing medical specialists for needs that chronic problems," Dr. Hailey noted, couldn't be met in the clinic. The do­ teach and to advocate for "but we can get those people connected nated hours of care would have cost those in need. We strive to to the appropriate agencies to get help." over $50,000. Student nurses volun­ "Medication is the biggest issue in teered 180 hours, and Ruth Roath foster an emotionally the community," Dr. VanBuskirk ex­ noted that nursing hours were too nu­ su pportive at) nosphere, plained. "We can provide chronic medi­ merous to calculate. cations for one or two months, then re­ The clinic is a 501(c)(3) nonprofit focusing on holistic care for fer the patient to an outside clinic, phy­ organization and is funded by United sician or appropriate agency. In many Way contributions, private donations, all o f those we welcome cases, when the medications run out, grants, annual support from the PCMS through ou r doors. ” the patients don't have the ability to pay Auxiliary and local parishes/churches. for more." The success of the program depends Mission Statement, "We try to get people to an agency on the support of volunteers and gen­ The Neighborhood Clinic that can help them, but often the ser­ erous contributions from St. Joseph's vices really aren't out there," Dr. Hailey Hospital, Tacoma Radiology, AKE added." Invariably, we see them again Laboratories, local pharmacies, phar­ after their medications are gone. We maceutical company representatives, has been amazing. Without them, we have people who have been coming to and medical suppliers throughout the couldn't do what we do." the clinic for five years. They try to get Tacoma community. The key to the clinic's success, the services they need, but they're still Thanks to the generosity of the Drs. VanBuskirk and Hailey agreed, is here. What can we do?" medical community, the clinic is able to ongoing support from the medical com­ Drs. Hailey and VanBuskirk ask stock ample supplies. "St. Joseph's has munity. Many of the facility's volun­ that ERs and clinics do not send people been a miracle for the clinic," says Dr. teers are residents and staff members to the Neighborhood Clinic for pre­ Hailey. "We send clients to their lab from Tacoma Family Medicine who al­ scription medication "We simply can't for tests at no charge. They also offer ready have daily experience with indi­ help them/' Dr. Hailey said. cut-rate pharmacy costs, selling us gent health care. "It's of great value, Operating much like a resource meds at a low rate. Their generosity See "The Neighborhood Clinic, page 14

4 PCMS BULLETIN October, 2000 Tale of High Adventure on Mt. Everest Brings Big Crowd to October General Membership Meeting

Over 175 attendees at the October General Membership meeting were taken back to 1924, for the third time that the British had tried to scale Mt. Everest. They tried in 1921 and 1922, both unsuccessfully, and for their third attempt in 1924, the eyes of the entire nation were upon them. George Mallory and Andrew Irvine led the expedition. Mallory, who had been on both previous attempts informed his friends that he did not intend to come back undefeated. While all eight men on the 1924 attempt were strong and determined, just getting to Mt. Everest in 1924 was in itself a challenge. They took a boat from England to India, then once in Bombay, had to travel all the way across India on a train. Once they reached Kathmandu, India they walked for the bet­ ter part of another month just to get to base camp. They set their base camp on the north side of the moun­ Right, Eric Simonson autographs his book for Dr. Sam lnsalaco, tain, in Tibet, the exact same spot that 75 years later, Eric left and his wife, Sandra. PC MS placement Coordinator Simonson and his team would set their base camp in search of Deborah Pasqita, standing, helps his assistant with book sales their remains. Part of their team climbed to 28,000 feet without oxygen, an amazing accomplishment which was not exceeded until1978. On June 8,1924, Mallory and Irvine attempted their sum­ mit bid and they were last seen on the summit ridge by one of their climbing partners, as just a few minutes later they were quickly obscured by fast moving clouds and they were lost to history. Did they make the summit? What happened to them? This mystery has prevailed for 75 years. In 1999, two Everest historians approached Eric Simonson and asked him to lead an expedition. He agreed, buttherewas one small problem. About $300,000 to fund the expedition. In the fall of 1998, he started fund-raising. And, just like the Brit­ ish did in1924, he raised funds by selling film and photo rights. He quickly raised 200,000 then went to tire outdoor industries Steven Litsky, MD inspects an oxygen tank that Simonson’s and slowly raised the last $100,000. crew found on the mountain from Mallory and Irvine's climb He organized the team, including Sherpa support, but mostly a searching team, not just a summit team Late March, 1999 they placed their camp and were the first expedition of the year. They had exceptional conditions, which they needed to find Andrew Irvine. They were looking for Irvine because his ice axe had been found and they were looking for his camera and could hopefully develop pictures that would unravel the details of the 1924 adventure. Although they were not successful in finding Irvine, they did find George Mallory, his watch (which still worked) and other paraphernalia. And, their search for Irvine will continue in the spring of2001 as they attempt another climb to locate his remains. For more information about Eric Simonson and his moun­ tain dimbingadventures, visitwww.moutainzone.com or From left, Drs. Jonathan Hurst, Needham Ward and Doug Gant www.pbs.oig. ■ wait in line to have their books autographed More photos page 6

October, 2000 PCMS BULLETIN 5 B u l l e t i n

October General Membership meeting brought out the crowds.

Dr. Henry Retailliau, internist, (right) visits with Dr. Phil Drs. Vern Nessan, Puyallup pulmonologist, center, gets his Craven , and his wife, Karen, after the meeting. Dr. Craven's book autographed while Drs. Jonathan Hurst and Needham specialty is infectious diseases Ward prepare to meet Eric Simonson

Dr. Susan Salo, PCMS Vice President, visits with Trustee Dr. Sam Insalaco, Tacoma pathologist and his wife, Sandra, Dr. Mike Kelly. Both are fam ily physicians, Dr. Salo is with peruse Eric Simonson’s book prior to meeting with him and Group Health and Dr. Kelly practices in Lakewood having him autograph their copies o f the book

Allenmore Bo we have jRSGfi Psychological your e-mail address? Associates, P.S. . 752-7320 ■------please send it to us at: Do you have patients with difficult emotional and stress-related problems? Psychiatric and [email protected] psychological consultations are available. Union Avenue Professional Building ------1530 Union Ave. S.. Ste. 16. Tacotna______

6 PCMS BULLETIN October, 2000 caw

Members Complete Courage Classic

Over 100 flat tires set the tone for the first day of the Ninth Annual Courage Classic. Dr. Richard Ory, his wife Jan and brother Peter, and Dr. Dan Niebrugge had nine flats with 15 miles remaining before reaching Cle Hum at the end of a 57-mile day. Glass and small pieces of wire from shredded tires were the big culprits. Most of the flats occurred while the riders were on Interstate 90. Kathy Eddinger, NW Specialties and spouse of WSMA's chief lobbyist, Len Eddinger, had three herself. She is one of twelve riders who has ridden in all nine Classic rides. The three-day ride took the 520 riders from the Snoqualmie Winery just west of North Bend up Snoqualmie Pass (old highway) to the football field of Jack Stewart, Tacoma orthopedist, on the second day o f the Cle Elum High School for the first day. ride. He and his wife, Teri have done the ride several times The second day takes you through the beautiful Teanaway Valley and the "gentle" ascent of Blewett Pass as described by the Courage Classic brochure. It was beautiful, but not necessarily "gentle." The night is spent in Leavenworth with another superb meal and entertainment at the Bavarian Beer Garden. PCMShas some pretty sharp dancers amongst its ranks. The third day of riding finds you riding through gorgeous Chumstick Valley. It is worth the hills to see this lovely spot. On to Stevens Pass at the 45 mile mark The remaining 15 miles are all virtually downhill to Skykomish to catch a bus back to North Bend and call it a day. The proceeds of the annual event go to Mary Bridge Children's Hospital and the Children's Trust Foundation, which is devoted to the prevention of From left, Drs. Bill Martin, Jack Stewart and Don Shrewsbury child abuse and neglect throughout the state of on the summit o f Stevens Pass. The remaining 15 miles o f the Washington. 163 mile ride will be downhillfor them Other PCMS riders were: Anesthesiologist Marsden Stewart and his wife, Internist LeeLee; OB/Gyn Patty Kulpa, who was also a major sponsor of the event. Internists Henry Retailliau and Steve Stringfellow; ENT Don Shrewsbury, Pediatric Oncologist, Dan Niebrugge; Pediatri­ cians Richard Ory and his wife Janice Sack-Ory and Karen Holdner. Orthopedist Jack Stewart and his wife Ten, General Surgeon Bill Martin and wife, Kaiyl and Physical Med & Rehab physician, Steve Settle.! More pictures page 7

Editor's Note: The Bulletin staff invites pictures and articles on activities involving members. Be it sailing, tennis, golf, camping, etc., please send us the Anesthesiologies Marsden Stewart and his wife, internist information. You may review copy before publication. LeeLee at Stevens Pass. This year they rode on a tandem

October, 2000 PCMS BULLETIN 7 B u l l e t in

Courage Classic shots,

Tacoma Pediatrician, Richard Ory awaits the bus ride back to From left, internists Steve Stringfellow and Henry Retailliau his car after pedaling 163 miles over three mountain passes. His with son, Daniel Retailliau, get ready fo r the third day after wife, Janice Sack-Ory also completed the ride breakfast in Leavenworth's City Park

Richard Wohns, MD and son complete Seattle to Portland bicycle ride on tandem

Dr. W ohn’s said. "Anthony and I trained during the spring and early summer with tandem rides around Seattle. Tacoma and in the Methow Valley. He is a great stoker and appeal's to enjoy hills! We did the ride in two days. We spent the first night at the Red Lion Inn in Longview/Kelso. Riding time was around 15 hours. Anthony is now only riding his own little mountain bike and would like to do the STP again, but next lime on his own bike. I told him that I would like to draft behind him !" ■

PCMS Executive Director to Retire

Doug Jackman, PCMS Executive Director since 1984 informed the Board of Trustees at their September meeting that he planned to retire effective Please visit us at the January 1,2001. Patrice Stevenson, MD, President-Elect has been named to chair a PCMS homepage national search committee. Other members of the search committee are past presidents, Lawrence Larson and David Law; Michael Kelly, Doris wwvv.pcmswa.org Page and Sabrina Benjamin. ■

8 PCMS BULLETIN October, 2000 invites you and your spouse/guest to the

November General Membership Meeting

Tuesday, November 14, 2000 Landmark Convention Social Hour: 6:00 pm C e n te r Dinner: 6:45 pm Temple Theatre, Roof Garden Program: 7:45 pm 47 St. Helens Avenue Tacom a Adult Trauma Update

Robert Winchell, MD Director, Adult Trauma Services The Adult Trauma System has been operational in Pierce County since June. Plan to attend the November meeting to hear about the new system, what is working, and what isn’t. And:

♦ Adult Trauma System ■ Successes, Failures ♦ Availability of Surgical Suites ♦ Impact on Trauma Call Roster ♦ Hospital Rotation • is it working? ♦ Funding Outlook

sgistration required by November 10. Return this form to: PCMS, 223 Tacoma Ave S, Tacoma 98402; FAX to 572-2470 or call 572-3667

Please reserve ______dinner(s) at $20 per person (tax and tip included)

Enclosed is my check for $ ______or my credit card # i s ______

□ Visa □ Master Card Expiration Date ______S ig n a t u r e ______

I will be bringing my spouse or a guest. Name for name tag:______.Bu l l e t in

Applicants for Membership Personal Problems Brown, George J, MD Pickett, James D, MD of Physicians Gastroenterology C ardiology Committee Vice President, MultiCare Health Practices at Cardiac Health Specialists, System, 315 Martin Luther King Jr 1802 S Yakima #307, Tacoma 98405; Way. Tacoma 98405; 403-1855 627-1244 Medical School: Boston University Medical School: Baylor College of Med School o f M edicine Residency: St Joseph Hospital Medical problems, drugs, alcohol, Internship: Fitzsimons Army Medical Fellowship: Baylor College of Medicine retirement, emotional, C e n te r or other such difficulties? Residency: Fitzsimons Army Medical Thomas, Kathy J, MD C e n te r Family Medicine Fellowships: Walter Reed Army Practices at CHC - Parkland Clinic, Medical Center 11225 Pacific Ave S, Tacoma98444; 531-6198 Your colleagues Fahniy, Raed N, MD Medical School: University of want to help C a r d io lo g y Pennsylvania School of Medicine Practices at Cardiac Health Specialists, Internship: Swedish Family Medicine 1802 S Yakima #307, Tacoma98405; Residency: Swedish Family Medicine 627-1244 *Robert Sands, MD, Chair 752-6056 Medical School: George Washington Bill Dean, MD 272-4013 U niversity Directory changes Tom Herron, MD 853-3888 Internship: UCLA —SFVP Bill Roes, MD 884-9221 Residency: Loma Linda University Please make note of the following F. Dennis Waldron, MD 265-2584 Medical Center change.'; to your 2000 PCMS Directory. Fellowship: UCLA - SFVP LoGerfo, Peter, MD Hirota, William K, MD Change address to: PO Box 731009 Gastroenterology Puyallup, WA 98373-0030 Practices at Tacoma Digestive Disease Phone: 770-7600 Confidentiality Center, 1112 6,h Ave #200. Tacoma Fax:864-6144 Assured. 98405:272-8701 Medical School: Georgetown Univ. Moore, Jane MD Internship: Walter Reed Army Med Ctr Change address to: 6002 N Westgate Residency: Walter Reed AMC Blvd#l 60Tacoma, WA 98406 Fellowship: Walter Reed AMC Phone: 759-9902 Fax: 759-5504

: AMERICAN LUNG ASSOCIATION.- UNION AVENUE PHARMACY afVfanhirgtan Professional Compounding Center of Tacoma, WA 1-800-LUNG -USA Vaginal Suppositories Gel, Ointment, and Cream Lung Information Rectal Suppositories IV Services Urethral Inserts Capsules Service Line Sublingual Troche Lip Balms Providing patient education materials 2302 South Union Avenue 752-1705

10 PCMS BULLETIN October, 2000 The Health Status of Pierce County Federico C raz-U ribe, M D D irector o f Health

■ m Community Health Status Report

County, California; The District of Co­ TACOMA-FIERCE COUNTY Ever wonder what an organization HEALTH outside of Pierce County might say lumbia; Orange County, Horida; Balti­ DEPA R TMENT about the health of this community? more City, Maryland; Multnomah Ever wonder how Pierce County, County, Oregon; Milwaukee County, use, and make appropriate choices Washington, compares to other com­ Wisconsin. (which may help to avoid teen preg­ munities with similar demographics? If The Health Department's mission nancy, suicide, and violence). so, your curiosity should be satisfied. is to improve health across Pierce * Family-Based Services: Public The Health Resources and Services County. Evenfor categories that are fa­ health nurses visit families in their Administration (HRSA), part of the US vorable, compared to peer counties or homes, encouraging effective pre- and Department of Health and Human Ser­ the nation, the agency would like to im­ post-natal care and monitoring child vices, has released their annual Com­ prove statistics in the future. Relevant development; families deemed to be at- munity Health Status Report for Pierce activities that will hopefully make a dif­ risk by hospitals and Child Protective County. The report shows that in many ference in these numbers include: Services are referred to the Family- categories, Pierce County is healthier • Adolescent Health: Youth who Based Services for follow-up. (comparing specific standards) than are at-risk dropping out of school, get­ • Prevention Priorities: Staff are many of our peer counties and even of ting involved with gangs, and other po- involved with communities throughout the national median. Categories that tentially-dangerous behavior are coun­ the county, to find ways to prevent or show Pierce County to be favor­ seled, with their families, on ways to im­ cease tobacco use, alcohol misuse, and able compared to peer counties prove their self-image and social skills, violence (such as locking up guns or are: Black infant mortality, post- stay in school, avoid or cease substance See " Health" page 20 neonatal infant mortality, breast cancer, and lung Category Pierce County Compare: Compare: US cancer. Peer County For key ar­ BIRTH MEASURES Numbers are percentages per total births. eas, however, Low Birth Weiqht (<2500 q) 6.1 6.4-10.8 7.5 Very Low Birth Weiqht (<1599 q) 1.1 Pierce County 1.1-2.4 1.4 Premature Births (<37 weeks) 10.0 9.8-15.6 11.4 ranks lower than Teen Mothers (<18 years old) 4.4 4.4-7.8 12.7 other communi­ Older Mothers (>40 years old) 1.5 1.4-2.6 2.1 ties. Categories Unmarried Mothers 29.7 29.7-48.3 32.4 that fit into this No care in First Trimester 26.3 12.9-35.1 17.0 status are: no INFANT MORTALITY Numbers are incidents per 1,000 live births. care in the first Infant Mortality 6.9 5.4-11.3 7.2 trimester, White White Infant Mortality 6.4 5.0-7.8 6.0 infant mortality, Black Infant Mortality 15.0 9.6-18.8 13.7 stroke, and sui­ Neonatal Infant Mortality (<29 days) 4.3 3.3-7.9 4.8 cide. Post-neonatal Infant Mortality (1-12 months) 2.6 1.7-4.1 2.5 The chart at DEATH MEASURES Rates are age-adjusted to year 2000 standard; per right gives the statis­ 100,000 population tics and compari­ Breast Cancer (Female) 30.6 24.0-36.6 28.6 sons to peer coun- Colon Cancer 19.1 17.9-26.2 21.6 ties and the nation. Coronary Heart Disease 214.1 170.7-263.9 216.0 Peer counties in­ Homicide 7.0 5.8-21.0 7.2 clude: Fresno Lunq Cancer 60.1 45.3-72.9 58.1 13.0 7.7-21.8 County, California; Motor Vehicle Iniuries 15.8 Stroke 75.9 49.9-75.9 62.0 San Francisco Suicide 17.0 6.4-16.8 11.4 Unintentional Iniury 17.9 12.6-28.1 33.3

October, 2000 PC-MS BULLETIN 11 B u l l e t in

Organ Donation Website CPT-5 Project continues offers Resources and to lay groundwork for other Information Electronic Future

With Hundreds of thousands of Americans currently With physicians and insurers increasing their use of awaiting an organ or tissue transplant the AMA encourages the Internet and other electronic management tools, the you to educate y oui patients about becoming organ donors. American Medical Association is continuing its efforts to The AMA's Organ Donation Program Web site offers visitors make significant improvements to electronic versions of its resource links to organ donation coalitions, Council for Current Procedural Terminology coding set (CPI). Scientific Affairs reports, frequently asked questions and The CPT-5 Project aims to enhance the ability of more. For more information, go to http://www.ama- users to find the correct code more quickly, allow for assn.org/ama/pub/categorv/1945.html ■ researchers to effectively use the codes, and better integrate CPT with electronic products. In a move that will help minimize physicians' administrative burden, the U.S. Department of Health and Human Services recently announced that it would be using the CPT coding set as a Our Apologies national standard. Go to http://www.ama-assn.org/ama/pub/ The PCMS Bulletin apologizes to Drs. Rick article/1616-3050.html for more information. ■ Schoen and Phil Perkins for an error in the September issue. Dr. Schoen was inadvertently identified as Dr. Perkins in a photo on page 6. The photo identified several people that participated in Paint Tacoma/ Pierce Beautiful organized by PCMS. Both Drs. Perkins and Schoen volunteered for the project. PCMS apologizes for the error. ERJffiE THAT TATTOO WORRIED ABOUT WHAT YOUR SPOUSE, YOUR FRIENDS OR EVEN YOUR BOSS THINKS ABOUT YOUR TATTOO? OR ARE YOU JUST TIRED OF LOOKING AT IT? Today’s newest Alexandrite laser, will remove your tattoo with minimal discomfort & less than 1% risk of scarring.____

('ait todnyJtH' more in/ontuuion PIERCE COUNTY LASER CLINIC Director IVier K, Mnrsli M.l), Ten Years Experience (253)573-0047 Full Practice Management Electronic Claim Filing

12 PCMS BULLETIN October, 2000 V Q ^ to d ic & l

Why physicians should convert to limited liability partnerships

by Adrew Dolan, JD

states, established limited liability other physicians in the practice and Are you and your practice companies and shortly thereaf ter, company debts. partners still using the partnership limited liability partnerships. Physicians can form limited liability model as your form of legal organiza­ These new entities meant that companies or limited liability partner­ tion? Physicians are encouraged to physicians could enjoy the limited ships. The conversion usually costs consider converting to limited liability of corporations and still be less than $1,000 in attorney fees if there liability partnerships. Here's why: taxed as partnerships, as with subchap­ is an existing partnership agreement Before 1995 in Washington, ter S corporations, without complying that is otherwise satisfactory. There is physician groups that wanted to be with all the requirements for subchap­ virtually no legal reason not to convert, taxed as partnerships under federal ter S election. With limited liability and the additional insulation from the law had to accept the liability implica­ partnerships, physicians can still be catastrophic liabilities is usually more tions of being a partnership. That liable for their own professional than worth any cost. ■ meant that the physicians and their negligence and the liability of those personal assets were vulnerable to the they supervise. However, under Andy Dolan is an attorney in Seattle. liabilities of the partnership, including corporate liability principles, there is He specializes in medical issues and malpractice, debt and so on. However, no personal liability for the other works extensively with the WSMA. in1995, Washington, like all other liabilities of the company. Examples of this other liability would be premises Reprinted from WSMA Reports, liability, for the negligence of most September, 2000

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October, 2000 PCMS BULLETIN 13 B u l l e t in

The Neighborhood Clinic from page 4

however, for other members of the Clinic continues to play a critical role in special invitation to retired phy­ medical community to experience the the lives of many. Medical volunteers, sicians interested in offering clinic. It's important for doctors and particularly specialists, are always their services. The Washington medical office personnel to come to the needed and welcomed at the clinic. Retired Provider Program makes clinic, see the needs that exist, and go "We have a small network of amazingly it possible for retired health-care back to their practices with an aware­ generous people in the community who providers to offer an important ness of what's out there." have provided their services - cardi­ and much needed service to low- N ow in it's 17thyear, the clinic ologists, dermatologists, gastroenterolo­ income residents in the commu­ continues to serve a tremendous need gists. But we can always use more. Just nity. While you do not receive in the community. "Overall," Dr. one person makes an incredible differ­ compensation, the program pays VanBuskirknotes, "access to health ence in what we can do." for malpractice insurance. All non- Dr. VanBuskirk extends a care is the biggest need of all. These See"The Neighborhood Clinic" page20 patients need to feel they are important and valued by society. Having volun­ teers at die clinic who care makes them feel as if they do have value." MultiCare/3 Last year, over 1,000 patients vis­ ited the Neighborhood Clinic - 56 per­ Do you have patients suffering from Lymphedema? cent were first time visits; over 60 per­ cent were Caucasian; 15 percent were The Lymphedema Clinic at Tacoma General Hospital offers African American; and 15 percent the latest treatments by the only certified Lymphedema were of mixed racial background. Therapists in Pierce County. Over 50 percent of the patients seen were women. Twenty percent were • Compression bandaging from the Hilltop area of Tacoma. • Manual lymphatic drainage In her annual report to the Board • Lymphedema exercises of Directors, Ruth Roath noted, "I know that there will always be a need • Skin/Wound care for places like the Neighborhood • Custom fit compression sleeves and stockings Clinic. The causes for their presence To learn more or to refer a patient to the Lymphedema among us are too numerous for us, as a Clinic, please call 253 403-1040. small clinic, to fix entirely. So, probably our best bet is to provide medical treat­ ment and most medications for episodic illness, cure when we can, palliate when we cannot cure, advocate for MEDICAL LICENSURE ISSUES those with chronic needs and continu­ ally challenge ourselves to tackle some Mr. Rockwell is available to represent physicians and other health care of the causes for the lack of care providers with issues of concern before the State Medical Quality Assurance among the needy. As always, we pro­ Commission. Mr. Rockwell, appointed by Governor Booth Gardner, served for vide a safe place for our patients to 8 years as the Public Board Member of the Medical Disciplinary Board from gather in their need and receive com­ 1985-1993. Since then, Mr. Rockwell has successfully represented over 60 passionate care, hopefully, without the physicians on charges before the MQAC. Mr. Rockwell’s fees are competitive discomfort that judgement can bring." and the subject of a confidential attorney-client representation agreement.

A Need that Won’t Go Away Gregory G. Rockwell When health care reform came to Attorney at Law & Arbitrator the forefront a few years ago, Dr. 3055 - 112th Avenue SE, Suite 211 VanBuskirk was cautiously optimistic Bellevue, WA 98004 that there would be no further need for the clinic's services. However, that (425)822-1962 • FAX (425) 822-3043 wasn't the case, and the Neighborhood email: [email protected] • website: “ggrockwell.wld.com”

14 PCM-S BULLETIN October, 2000 Ypoimty- oMedical

In My Opinion.... The Invisible Hand by Andrew statson.MD

Saving on Penicillin

"f

A textbook on obstetrics from 1934 recommended that women withheart “A man often pays dear disease do not marry; if married, do not for a smallfrugality. ” get pregnant; if pregnant, get aborted. Em erson Those who refused abortion had a Andrew Statson. MD mortality rate in excess of 60%. In 1960, two percent of pregnant women had rheumatic heart disease. Most of them tell us withinminutes whether a signifi­ still got well without a significant differ­ went through their pregnancy without cant streptococcal load is present. It is ence in length of treatment or of hospi­ too much difficulty. The incidence of also true that the longer the delay from tal stay. The dosing of penicillin went congestive heart failure was about two the onset of infection to the onset of from every 3 hours to every 4; of ampi- per thousand. Fortunately, if women in treatment, the more likely is a child to cillin, from 4 to 6; of cefazolin, from 6 to congestive heartfailure could be develop rheumatic fever. 8; of cefotetan, from 8 to 12. That re­ called fortunate, most of them had mitral Our rapid tests are positive only duced dosing worked most of the time stenosis and responded well to commis­ when there is a large number of cocci and we thought we saved a lot of surotomy. The mortality rate was "only" present. We don't know whether viral money. about 5%. The patients with mitral re­ pharyngitis could stimulate bacterial Within the past few years we gurgitation or aortic valve disease still growth in colonized children. We don't started hearing much about antibiotic frequently were aborted, or if not, had know how fast a subthreshold coloniza­ resistance. Some strains of organisms a mortality rate approaching 50 %. tion can become a full-blown infection. have shown resistance to all antibiotics During the past 20 years, in my We don't know whether viral pharyn­ at our disposal. These occurrences are practice, I have seen several pregnant gitis can change the mucosal perme­ still very rare, but they are worrisome. women with congenital heart disease, ability and the immune system so that a We are urged to cut down on antibiotic but not one with rheumatic heart dis­ larger amount of toxin could be ab­ use even more, in order to avoid the ease. The current medical textbooks sorbed from a subclinical number of or­ development of resistance. confirm that in this country rheumatic ganisms. We may be able to safely re­ Bacterial resistance to antibiotics fever has virtually disappeared within duce the number of children treated develops through 3 mechanisms, plas­ the past 50 years. We no longer see with penicillin, but we don't know mid exchange, conjugation and muta­ the usual sequellae, rheumatic heart whether our tests can tell us where to tion. When bacteria are in a favorable disease, chorea of Sydenham and draw the line. There is no animal model environment, they grow and divide. acute glomerulonephritis. Perhaps the we could study to answer this question. For instance, E. coli would easily un­ main reason was the indiscriminate use The only experiments we could carry dergo 500 or more divisions before of antibiotics. out have to be on humans. What we do they would feel the need to conjugate. Starting at about1950, and prob­ know is that what we have done in the Bacteria in an unfavorable environ­ ably even a little before that, most chil­ past obviously has worked. ment, as when exposed to sublethal dren with a sore throat or a cold were There are two objections to what doses of antibiotics, are much more treated with penicillin Probably many has been called the indiscriminate use likely to seek plasmid exchange or of them did notneed the antibiotic. of antibiotics, cost and resistance. conjugation. Dead bacteria don't ac­ However, the cost of penicillin was a When the economic squeeze of the quire resistance. Stunned bacteria do. small price to pay for the eradication of hospitals started over ten years ago, Dr. Robert Guthrie, professor of medi­ rheumatic fever. It is true that many one of the items to cut was the budget cine and pharmacology at Ohio State colds are viral and penicillin has no for antibiotics. The approach was to University, reports that under typical role in their treatment. It is true that we give lower doses and less frequently. circumstances the drug concentration now have rapid strep tests, which can Studies were done to show that patients See "Penicillin" page 16

October, 2000 PCMS BULLETIN 15 Penicillin from page 15 drops to subtherapeutic levels in the latter half of the dosage period and that allows the organisms to become resis­ tant The most effective antibiotic treat­ ment and the one least likely to induce resistance consists in short courses of high and frequent doses. That is the opposite of what we have been doing. The only reason to reduce the initial dose of an antibiotic is the concern about a toxic effect, such as a Jarisch- Herxheimer reaction. There is another threat on the ho­ rizon, even more serious than the de­ veloping resistance to antibiotics. It is the looming control on the price of drugs. Price controls will squeeze the pharmaceutical companies and reduce their ability to carry out drug research. That is a bigger problem in the face of Detect osteoporosis emerging bacterial resistance to antibi­ Assess fracture risk otics than anything else. Quantitate bone mineral density changes Bacteria will always try to outwit Monitor therapeutic response j us. That is how Nature operates. How­ 1 1 www.tacomaraa.com ever, we developed the antibiotics we have now, didn t we? We have brains, don't we? We are mapping the bacte­ Allenmore Medical Center Lakewood Office rial genomes, w e are studying their en­ (253) 383-2038 (253) 588-6083 zymes and structural proteins, their systems of communication with one an­ other. We will be able to design drugs specifically directed at the pathogenic bacteria, their toxins and their mecha­ nisms for resistance. We will not be able to do that if we cripple our phar­ nome project, review the public and day of treatment How helpful! maceutical industry. private funding for this program and Private foundations may want to I know, if the pharmaceutical com­ compare the respective results and raise the money and do the job. They panies cannot fund this research, our their usefulness according to the may want to help people in this country government will step in and do that. I money and time spent. and abroad who cannot purchase their will not venture to guess ho w much it I agree. It is not fair that Americans medications. Americans have been will cost and how long it will take just to should pay more for the same drugs generous in the past and they will be do the paperwork on the desirability than Canadians or Europeans. It is not generous in the future. Their private and feasibility of such studies. How fair that our taxpayers should subsidize efforts will be more effective and less much the studies themselves will cost, the treatment of AIDS in Africa, either. expensive in helping others than will how long they will take and what re­ Out of the 300 million dollars our gov­ be government grants. Fairness in in­ sults we will get for the expended ernment plans to spend on this pro­ ternational drugpridng is important, funds is beyond anyone's guess. I gram, the amount that will eventually but there must be a better way to estab­ wonder whether anyone will do an trickle down to the patients with AIDS lish it than through government con­ economic analysis on the human ge- will barely be enough to pay for one trols. ■

16 PCMS BULLETIN October, 2000 Wiwce Q'Uediml dfociety

In My Opinion.... by John Stutterheim, MD

Nostalgia of World War Two

This is the story about little boys in they liked to congregate was in front of a labor camp, named Bangkong, the goedang, the storage area, looking Semarartg, Java, former Dutch East over the vegetables being stored, Indies, during November 1944. In Sep­ while they emphasized the tasty veg­ tember of1944, the Japanese had etables with very wise old faces, nod­ brought together a population of 1,400 ding at each other. As young as they John Stutterheim, MD teenagers, existing mainly of boys, were, some were still ordered to work ages ten through seventeen, and some in the fields. Mr. Vetter, their Hancho, adults. was kind to these kids and never drove their beds. After we had been in Bangkong, them hard. As a result he received During the daytime the nuns in our for about three months one of the many a beating for work not accom­ camp were truly helpful to the little youngest boys, an eleven-year-old, plished. He was in his forties and had ones. They hovered over them and lis­ died. No one knew how to explain this been heavy before the regimen of the tened to their concerns. Especially for to the other little boys, of whom the two camps. He always wore a straw hat and the many sick ones the nuns were a youngest ones were nine years of age. stood in the fields, leaning on a stick, Godsend. It seemed as if they were not really supervising these little ones. They had We older boys had no choice but paying attention; they were always so to pull weeds and while doing that to silently accept these circumstances. I playful. Death was a daily occurrence, work many got sunburned. wondered over and over again why especially among the fifty old men who Skin problems always became less this had to happen. ■ came through camp, but this was the tolerable in the fatigue and hunger of youngest one of our companions to the evenings. At night the little boys felt John Stutterheim, MD is a retired die, and his death affected everyone miserable with their skinbums and had family physician. He was living in deeply. When his little body was car­ nobody to console them. Sometimes at Indonesia with his fam ily prior to ried out in a small coffin, all the little night we could hear them crying and W W II a n d is w riting a book about guys lined up spontaneously to give asking for their mothers as they lay in his war experiences. the last salute, some with trembling lips, butsilentand stalwart nevertheless. The Japanese paid no attention to our attempts at a funeral observance. Medical Placement Service...... They were only concerned that the body be duly removed from camp. At owned and operated by: least some of our middle-aged men, the leaders, such as Mr. Vetter, or Jacob the Jew, a kind man in his thirties, *Permanent Full & Part Time Positions would be present as we paid respects, *Temporary Placements but I never saw the Luxemburger, our so-called chief, who was obviously too cowardly or indifferent to attend even Pierce County’s “medically exclusive ” agency this child's service. Usually some words Employer paid fees were read out of the Bible. The ten-year-olds were achingly brave to manage in this crowded camp 223 Tacoma Ave South 253-572-3709 by themsel ves. During the day they would play some game while sitting be­ tween their mattresses; sometimes they ask for Deborah or Angela were ordered out, to work at the tables cleaning vegetables. One area where

October, 2000 PCMS BULLEI IN 17 B u l l e t i n

Whistler CME set January 24-27, 2001 Condo Reservations/Course Registration Open

Registration is open for the members and other physicians. With Management of Inflammatoiy Bowel College's CME at Whistler/Blackcomb Categoiy I credits, the CME program Disease Advances in Treating Your program. The conference is scheduled features a potpourri of subjects of in­ Geriatric Patient Review of Skin Can­ for January 24-27,2001. terest to all specialties. cer: The Role of the Mohs' Technique The College of Medical Education The program is under the direc­ Recent Advances in Insulin Therapy has selected the Aspens Condos for ac­ tion of Drs. John Jiganti and Rich­ CommonHand Problems "The Plague" commodations because of the very ard Tobin. This year's subjects in­ Advances and Retreats in Infectious competitive rates (compared to hotels clude addresses on: Update on the Diseases Interesting Case Studies ■ and other condos) and quality of the lodging. These negotiated group rates will remain the same as the 2000rates, Whistler Condo Reservations and combined with the Canadian/U.S. exchange rate, result in major savings Deadline December 1 for the conference registrant. A collection of one and two bed­ CME at Whistler participants are College's reserved block of rooms will room luxury condominiums just steps urged to make their condo reserva­ be released after December 1, from the Blackcomb chair and gondola tions early. Reservations for the block 2000. are available. Space is available on a of condos, ALL IN THE ASPENS Reservations can be made by call­ first come first served basis in the As­ AND AT LAST YEAR'S RATES, are ing Aspens on Blackcomb toll free pens. available. To take advantage of these at1-877-408-8899. You must identify The College is offering family va­ savings, you must make your reserva­ yourself as a part of the C.O.M.E. cationing, skiing and the usual quality tions soon, as conference dates are group. For more information call the contmuing medical education to PCMS during the high ski season. The College at 627-7137.«

Blackcomb Mountain

Aspens Condo/Meeting Room

18 PCMS BULLETIN October, 2000 V. Q /H e d k td

Continuing Medical Education COLLEGE Infectious Diseases CME is set for MEDICAL November 20, topics selected Diseases Update CME is set for will speak on Infectious Disease emer­ EDUCATION Friday, November 10,2000 and will be gencies. This year's conference will held at the SheratonTacoma Hotel. feature presentations ore The program, this year directed by David McEniry, MD, will feature Teeth and Terror: Animal Bites; presentations by Infections Limited Antibiotic Associated Colitis; Staph at a Common Office physicians and a national keynoter. Glance; Infectious Diseases This program is designed for phy­ Emergencies: When and How to sicians as an update on common outpa­ React; What to do About the Flu; Problems CME tient and inpatient infections. A brief re­ Advances and Retreats in Infectious view and clinical update will be made Diseases; and Antibiotics 2000: An October 20 on a variety of important topics. This Update. year's keynoter is Steven Mostow, MD The registration brochure will be from the University of Colorado. He mailed in early October. ■ Registration continues for the very popular Common Office Problems CME program. This year's conference Dates Program D ir e c t o r ^ is scheduled for Friday, October 20, Common Office 2000. The conference will be held at St Friday, October 20 Mark Craddock, MD Joseph Medical Center, Rooms 1 A & Problems B. Infectious Diseases The program will offer 6 Category Friday, November 10 David McEniry, MD Update I CME credits and is again directed by Mark Craddock, MD. Medicine & Mental Friday, December 1 David Law, MD The course is designed for the Health primary care clinician and focuses on practical approaches to the most Cardiology for Primary TBA (evening) Gregg Ostergren, DO common dilemmas faced in the daily Care routine of medical practice. Wednesday-Sunday Richard Tobin, MD For more information, please call CME at Whistler the College of Medical Education, 627- January 24-28 John Jiganti, MD 7137between 7:45 and 5:00 p.m. Advances in Women's This year1 s topics include: Friday, February 9 John Lenihan, Jr., MD Medicine ►Appropriate Use of New Antibiotics TBA Pain Management David Paly, MD ►Congestive Heart Failure ►Evaluation of New Onset Seizures in Thursday-Friday Internal Medicine Ulrich Birlenbach, MD Children March 8-9 Review 2001 ►Primary Care Evaluation and Treatment of Irritable Bowel Saturday, April 28 Surgery Update 2001 Glenn Deyo, MD Syndrome Allergy, Asthma & ►Evaluation and Management of Common Knee Problems Friday, May 4 Pulmonology for Alex Mihali, MD ►Hormone Replacement Update Primary Care ►Treatment of Lumbar Rediculopathy Tuesday, May 16 and ►Prostate Cancer: Options for Treatment ■ Tuesday, May 23 Medical Technology TBA (evenings)

October, 2000 PCMS BULLETIN 19 B u l l e t i n

Health from page 11 The Neighborhood Clinic from page 14

avoiding teen suicide). These activities invasive primary care services, except investment for an incredible gift in re­ should help to reduce death rates due obstetrical, are covered. The program turn. Remember, we as physicians to heart disease, lung cancer, stroke, is funded by the Washington State De­ have so much, and these people essen­ motor vehicle injuries (often related to partment of Health and operated tially have nothing. They respect us alcohol misuse), homicide, and suicide. through the Western Washington Area and they need our help." For more information on the Com­ Health Education (WWAHEC) Center "We do the best we can," Dr. munity Health Status Report, go to the and the Washington Statewide Office VanBuskirk added, "and we really do a Health Resources and Services Admin­ of Rural Health. For information or good job at enabling people to help istration webpage: www.community to sign up, interested retired themselves. But, the fact remains that health.hrsa.gov You'll find a number of physicians can contact Trudy the needs out there are huge. And, additional statistics on Pierce County Arnold, WWAHEC, 2203 - 6th they're universal." and other communities on that page. Avenue, Suite #310, Seattle, WA "There is such a need for this facil­ If you have ideas about activities, 98121-2526 or call 206-441-7137; ity," Dr. Hailey noted. "We have a particularly ways Pierce County medi­ FAX 206-441-7158 or email: dedicated board, great support from cal providers and TPCHD can work wwahec@u. wash in gton.edu. the medical community. I think we'll be together to improve the county's "There are such great rewards here a while. As long as there are sick health, contact the Director of Health, working at the clinic," Dr. Hailey people and the volunteers to help Federico Cruz-Uribe, MD, MPH, summed up. "Consider it a very small them, we'll be here. ■ with your suggestions: 253-798-2899. Your ideas are important ■

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20 PCMS BULLETIN October, 2000 VPmts oM edical (Sfodety- Save The Date The Edwin C. Yoder Honor Lectures Friday, November 10, 2000

SPECIAL PRESENTATION by Mary-Claire King, Ph.D. American Cancer Society Research Professor in the Departments of Medicine and Genetics at the University of Washington. Dr. King was the first to prove that breast cancer is inherited in some families and is now investigating how the normal products of these breast cancer genes can reveal pathways critical to the development of breast and ovarian cancer among women generally. Dr. King will explain the technology of gene mapping and discuss the implications fo r clinical medicine. Location: St. Joseph Medical Center

Physician Lectures: This course is accredited fo r 2.0 Category 1 hours

12:30 PM Complimentary Catered Luncheon - Rooms 1/\B

1:00-2:00 PM First Lecture - Rooms 1AB M ary-C /aire King, Ph.D.

2:00 - 3:30 PM Wine and cheese reception with the speaker in the Physicians' Lounge

3:30 - 4:30 PM Second Lecture - Rooms 1AB M ary-C laire King, Ph.D.

Reservations required for lunch and each lecture; - limited seating available Invitations will be mailed in October. For more information, call The FH5 Office of Academic Affairs at (253) 207-6035.

"CHI-W/FHS Academic Affairs is accredited by the Washington State Medical Association CME Accreditation Committee to sponsor continuing medical education for physicians. CHI-W/FHS Academic Affairs designates this educational activity for a maximum of 2 hours in Category 1 to satisfy the relicensure requirements of the Washington State Medical Quality Assurance Commission and the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity." October, 2000 pcms bulletin 21

X — ______:- V r a v e lL e r S Health Service A service of Northwest Medical specialties, PILC INTERNATIONAL TRAVEL CAN BE HAZARDOUS TO YOUR HEALTH • PRE-TRAVEL CARE • POST-TRAVEL CARE HOURS CALL EARLY WHEN PLANNING MON-FRI 9-5 253-428-8754 or 253-627-4123 A SER VIC E OF INFECTIONS LIMITED PS 1624 South I Suite 102 (next to St. Joseph’s Hospital)

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Available Suites: S econd Floor: Up to 11,838 SF Third Floor: Up to 16,640 SF

Allenmore Medical Center

2402 South Cedar Slreet

Tacoma, WA 98405 Allenmore Medical Plaza Presented by Kidder Mathews Joining these existing tenants: Building features: & Segner inc m Pacific Northwest Eye Associates, PS Class "A” Building with high quality finishes Contact: David V, Pratt, MD and Troy J, Woodman. I Bill Frame, CCIM Allenmore Ambulatory Surgery Center Located near the Allenmore Hospital Campus 253-383-5693 State-of-the-art Building [email protected] Tenant Improvement Allowance

1'tie information contained herein has been given to us bv Ihe owner or sourccs that v;

22 PCMS BULLETIN October, 2000 Classified Advertising

OFFICE SPACE POSITIONS AVAILABLE GENERAL

Deluxe Office Space. 1700+ sq. Tacoma/Pierce County out­ Drs. W. Jackson & K. Schcrbarth ft., large parking lot. Fircrest. 564-8784. patient general medical care at its best. looking for partners in 47 ft. motorboat Full and part-time positions available in and Mooney airplane. 253-752-6965. Puyallup medical office space Tacoma and vicinity. Very flexible available. 1300 sq. ft. second story, lift schedule. Well suited for career access, 2732 East Main. Build to suit. redefinition forG.P., F.P.. I.M. Contact $1800/mo utilities included. Call Linda Andy Tsoi, MD (253) 752-9669 or Paul Jensen 253-841-0523. Doty (Allen, Nelson, Turner & Assoc.), Clinic M anager (253) 383-4351. Lakewood office space available Directly across from St. Clare Hospital. Plenty of parking and private entrance Ski Bus - No Fuss with Winter Driving Call Carolyn at 253-581 -9313 or 1 -800- For an eight week break from routine, with all the travel handled by others, join 606-9416. us for siding at Crystal Mountain stalling the first Thursday in January and con­ tinuing through February.Bus pickup is in Fircrest at the Recreation Center or at Fred Meyer (Hi-Ho Shopping Center) in Puyallup. Other pickups may be avail­ able. For registration forms or information, call Nikki Crowley at 253-922-7233. The more skiers on the bus, the lower the cost per person. Join us!

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October, 2000 PCMS BULLETIN 23 B u l l e t i n v ------*

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24 PCMS BULLETIN October, 2000 November, 2000 THE PCMS FOUNDATION

Susan Salo, MD, President of the newly formed PCMS Foundation (right) is presented a check by Nikki Crowley, Treaurer. The money was forwarded to the Foundation from the PCMS Alliance to continue the philanthropic work of the medical society

See story, page 3

INSIDE; 3 The PCMS Foundation: The philanthropic arm of the medical society 5 Pierce County Delegates participate in WSMA Annual Meeting 7 “Endings,” by John Last, MD 9 “Trauma,” is subject of November General Membership Meeting 11 Support the Great American Smokeout, November 16th 13 “Will the Kangs Recent Draft Become a Cold,” by David Roskoph, MBA, CFP 15 “Staffing Shortages,” by Andrew Statson, MD \ _____ B u i JLETIN

PCM S O fficers/Trustees: CharlesM . W eatherby,M D ...... P r e s i d e n t PatriceN. Stevenson,M D ...... President Elect S u s a n J. S a l o , M D ...... V ice-President J . J a m e s R o o k s , M D ...... Secretary/Treasurer Lawrence A. Larson, D O ...... PastPresident Sabrina A. Benj am in, M D D r e w H . D e u t s c h , M D K e v i n K . G a n d h i , M D M i c h a e l J . K e l l y , M D D oris A. Page, M D Edw ard I. W alkley, M D Y olandaBruce, PCM S A President

W SM A Representatives: Speaker oftheH ouse: Richard Hawkins, M D Trustees: David Law ,M D ;N icholasRajacich, M D A M A Delegate: Leonard Alenick, M D W AM PAC Chair/6thDistrict: M arkGildenhar, M D W A M P AC 9th D istrict: D on R ussell, DO

Executive D irector: Douglas Jackman

Com m ittee Chairs: Table of Contents Aging, Richard W altman; AIDS, James DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of M edical Education, John Jiganti; Credentials, Susan Salo; Em ergency M edical 3 PCMS Foundation - philanthropic arm of the medical society Standards, Ted W alkley; Ethics/Standards O f 3 Entertainment 2001 Books on sale now Practice, David Lukens; G rievance, Lawrence A. Larson; Labor & Industries, W illiam Ritchie; Legislative, W illiam M arsh; M edical-Legal, M ark 4 In-Home Behavioral Healthcare Services Taylor; M em bership Benefits, Inc., Drew Deutsch; Personal Problem s O f Physicians, Robert Sands; 5 Pierce County Delegates participate in WSMA Annual Meeting Public Health/School H ealth, Sumner Schoenike

The Bulletin is published monthly by PCMS 7 "Endings," by John Last, MD M embership Benefits, Inc. for members ofthe Pierce County M edical Society. Deadlines for submitting 9 Trauma Update scheduled for November General Meeting articles and placing advertisements in The Bulletin are the 15th of the month preceding publication (i.e. October 15 for the Novem ber issue). 10 WSMA sets legislative priorities for 2001

The Bulletin is dedicated to the art, science and 11 TPCHD: Environmental Tobacco Smoke delivery of medicine and the betterment of the health and medical welfare ofthe community. The opinions herein are those of the individual contributors and do 12 Healthy Options moving forward to year2001 not necessarily reflect the official position of the Medical Society. Acceptance of advertising in no 13 "Will the King's recent draft become a cold?" by David Roskoph way constitutes professional approval or endorse­ ment of products or services advertised. The Bulletin and Pierce County M edical Society reserve the right 15 Invisible Hand: "Staffing Shortages" to reject any advertising. 17 Physician Good Samaritan Law E ditors: M BI Board of D irectors; Drew D eutsch, M D, President M anaging Editors: Douglas Jackman/Sue Asher 18 Medical Malpractice Statute of Limitations Editorial Com m ittee: MBI Board of Directors 19 College of Medical Education A dvertising R epresentative: Kristi Brittain Subscriptions: S50peryear, S5 per issue 21 AMA Organized Medical Staff Section2000 Meeting M ake all checks payable to: M BI 223 T acom a A venue South, Tacom a W A 98402 22 It's Time to Vote 253-572-3666, FAX253-572-2470

E-mail address: pcm swa@ pcm swa.org 23 Classified Advertising Hom ePage: http://www.pcmswa.org

2 PCMS BULLETIN November, 2000 Special Feature PC M S Foundation - philanthropic arm of the medical society

The PCMS Board of Trustees bers may forward requests for the Foundation Board of Directors voted at their April, 2000 meeting to donations or request grant applications will explore various avenues of fund formacharitablefoundationadminis- from the Medical Society office. raising. PCMS members will be tered by PCMS. Prompting the decision Previous grant recipients have encouraged to donate to the 501(c)(3) was the disbanding of the Alliance and included, Trinity Neighborhood Foundation via dues statements or the loss of the philanthropic work they Clinic, YWCA Women's Health when a specific request is made or at accomplished. The Alliance contributed Programs, Pierce County AIDS any time a member wants to contrib­ over $20,000 each year to charitable Foundation, American Lung Associa­ ute. Donations are welcome any time. organizations in Pierce County. The tion of W ashington Asthma Camp, PLU Additional fund raising activities Board of Trustees wanted to ensure Wellness Center, Family Renewal will be considered. Entertainment this work would continue. Shelter, Camp Fire Boys and Girls, and 2001 Books are being sold and raffle At their May, 2000 meeting the University Place School District for sales at the December Annual Board named Drs. Susan Salo and Baby Think it Over dolls. Additional Meeting will bring in additional Lawrence A. Larson, former organizations have received funding income. Alliance members Nikki Crowley and in previous years. Recipients must If you have suggestions about Mona Baghdadi and staff member Sue complete an application and submit raising funds or know an organiza­ Asher as first directors of the corpora­ appropriate documentation to be tion that would like to receive tion. Dr. Salo will serve as President, considered by the board as a grant funding from the PCMS Foundation, Dr. Larson as Vice President, Sue recipient. please call Sue at the Society office, Asher, Secretary, Nikki Crowley, The PCMS Board of Trustees and 572-3667.1 Treasurer and Mona Baghdadi, Director. The terms of office are one year or until successors are named. The Foundation's firstproject will Entertainment Books Available be continuation of the Holiday Sharing Card. A popular and successful fund­ The PCMS Foundation is selling Ristorante, E.R. Rogers, Old House raising activity, the Holiday Sharing Entertainment 2001 Books. The books Cafe, Tacoma Bar & Grill, Tides Card allows every contributor to send offer an array of discount coupons and Tavern and many, many more. holiday wishes to colleagues without book sales will raise funds Books cost $35 having to send one card. for the PCMS Foundation to with a portion of each sponsor charitable organiza­ book sold supporting The Foundation Board hopes that tions in Pierce County (see the Foundation. They members will identify with the Founda­ adjacent article). make great holiday gifts, tion as a means of consolidating and Entertainment coupon particularly for staff enhancing the philanthropic outreach books contain hundres of members or people that of the Medical Society as well as 50 % -off and two-for-one are difficult to buy gifts for. directing funds to exactly where the discount offers on fine To order your book need exists. Candidates for funding will dining, family dining, fast call the Medical Society submit an application to the Foundation food, movies, sporting office, 572-3709. We will be detailing the organization's purpose events, activities, special happy to deliver them to and specific needs. To receive attractions and hotels. your office. Books will also be on sale consideration, applicants must have The South Puget Sound / Penin­ at the PCMS Annual Meeting, Tues­ proof of 501(c)(3) status. PCMS mem­ sula edition includes over 650 bargains day, December 12th at the Sheraton/ and offers for, among others Altezzo Tacoma Hotel. ■ B u l l e t in

In-Home Behavioral Healthcare Services

Good Samaritan In-Home Services well as dementias with behavioral The program works primarily with lias a program to provide psychiatric disturbances. Any patient who is patients who meet criteria for Medicare services in the home under the homebound because of a mental Home Health and Hospice, private direction of a primary care physician health or behavioral problem or insurance and managed care contracts. and / or psychiatrist to patients whose who suffers from a physical To make a referral, simply call mental and/ or physical illness makes it disability or medical problem is Good Samaritan Home Health253-841- difficult to receive outpatient mental elig ib le. 5668. Referrals can be made from health services. The primary care physician or doctors, hospitals, other home health The benefits of such a program psychiatrist provides authorization for disciplines, mental health centers and are many and varied: it is known to be the in-home services. Then, based on other community service agencies. a cost-effective adjunct to medical/ need, professionally trained staff will or If you have questions or want surgical patients with stress related may include psychiatric registered more information, call Good Samaritan illness and /or depression secondary to nurses, physical and occupational In-Home Services at253-841-5668 or their diagnosis; it can prevent unneces­ therapists, social workers, speech Good Samaritan Older Adult Services sary hospitalization and/ or re-hospital- pathologists and home health aides. at253-848-5571. ■ ization of homebound patients with serious and persistent mental illness; it provides patients with mental healthcare services in the least restrictive environment; it can provide support, education and assistance to the family or caregiver; it enables patients TACOMA RADIOLOGY to stay within the setting of their choice; it assists patients in being involved in their care and taking responsibility for trea tment; and, it enhances multi­ disciplinary services coordination. The services are for anyone suffering from a form of mental illness-from depression and anxiety following medical events such as stroke to chronic ill­ nesses such as schizophrenia and bipolar affective disorder as & Femur

Medicare covers beneficiaries every 23 months D E X A when the following criteria are met Monilonng < il FDA approved osteoporosis drug therapy may .illovv lor greater frequency of examination

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4 PCMS BULLETIN November, 2000 Pierce County Delegates participate in WSMA Annual Meeting

Pierce County was well represented at the WSMA Annual Meeting in Wenatchee. Participating in this year's decision making process for the state association were Drs. Charles Weatherby, Patrice Stevenson, Lawrence A. Larson, Susan Salo, Sabrina Benjamin, and Doris Page. Drs. Sumner Schoenike, Ron Morris, Steve Konicek, and George Tanbara also served as delegates. Dr. Richard Hawkins presided as Speaker of the House, David Law, MD represents Pierce County on the WSMA Board and Leonard Alenick, MD serves as a Delegate to the AMA. Dr. Don Russell is the 9th District WAMPAC representative. Trustees/delegates Drs. Doris Page (left) and Sabrina Benjamin These are not particularly happy times in the house of enjoyed studying House of Delegate issues medicine and the current health care environment is rife with frustration. While there was not unity on any specific strategy for a solution, there were some common grounds where physicians did come to agreement. The House did vote to not support Initiative 245, the single payer initiative that is now an Initiative to the 2001 legislature. While they voted to not support 1-245, they also voted to not support the opposition of the campaign. The House defeated both requests for support. They redirected their energies to Executive Committee Report N - Restoring Health to Health Care. This report directs the WSMA to promote a policy agenda that supports • Building on the patient-physician relationship as the focus of the healthcare system • Empowering the patient with real freedom of choice • Acknowledgment of the responsibilities and account­ Drs. Don Russell (left) and Nick Rajacich take advantage o f abilities for the various stakeholders in the health care free time to visit. Dr. Russell is a Puyallup pediatrician, Dr. system and to define the overriding concept control­ Rajacich a Tacoma pediatric/adult orthopedist ling allocation of resources • Achievement of real administrative simplification in health insurance • Working with payers, where possible, to solve the problems in the health care system, particularly reduc­ ing variation in the administrative requirements be­ tween health plans • Adequate funding for public and private health care programs • Revisiting the definition of health insurance • Use of information technology to promote efficiencies in the delivery of care and the administration of the health care system • Tort law reform • A limited role for government in promoting viable insurance markets and equalized tax incentives for Drs. Sumner Schoenike and Susan Salo decide on an issue. Dr. health insurance Schoenike is a Lakewood pediatrician, Dr. Salo is a family Continued on page 6 practitioner with Group Health in Tacoma B u l l e t in

WSM A Annual Meeting highlights and photos

From left, Immediate Past-President Larry Larson, enjoys a The Pierce County delegation applauds House accomplishments, good joke with Drs. George Tanbara (President, 1981) and From left Drs. George Tanbara, Leonard Alenick and Ron Morris, current President Charles Weatherby Drs. Sumner Schoenike and Susan Salo are seated in front

Dr. Richard Hawkins, MultiCare family practitioner, serves as Dr. Leonard Alenick, Lakewood ophthalmologist, addressed Speaker o f the House. He is known as a superb parliamentarian Reference Committee D on the new proposed structure of AMA

The WSMA was also directed to practice environment and the degree are removed form a task force to develop a financ­ to which it makes it impossible for • Seeking reduction in health plan ing reform proposal for submission to physicians to practice medicine administrative requirements that will "Congress, the State Legislature or the Working with patients, Physicians also reduce waste and duplication people of Washington" once it is Insurance, the state hospital associa­ • Advocating for adequate funding ratified by a future House of Del­ tion, medical groups and practices to of state and federal health care egates. conduct this campaign programs. Other organizational priorities * Identifying and publicizing • Reporting back to the 2001 included examples of administrative duplication annual meeting on the progress of its • Educating the public, business and waste that affect the patient/ reform proposal. community, policy makers and health physician relationship and add costs to For more Annual Meeting details plans on the deteriorating medical the transactions so that these burdens go to: www.wsma.org. ■

6 PCMS BULLETIN November, 2000 Special Feature by John Last, MD,FRACP, FRCPC Endings

An old friend is dying, the fifth this happen to those I love. Incurable can­ rible. When I was a medical student I year. Soon there will be more. My wife cer allows time to prepare for depar­ looked after a lad exactly my age. His and I, most of our friends, our siblings, ture, and the unpleasant parts can kidneys had shut down and metabolic are in the decades when the ranks thin mostly be dealt with effectively nowa­ waste products soon would stupefy and out. We are getting used to the notion, days. kill him. But for a day or so his mind and though not morbidly preoccupied, We have gone backwards in deal­ was razor-sharp. We withheld unpleas­ putting our affairs in order, shedding ing with dying. There was once a mix­ ant truths from patients in the 1940s but surplus possessions, handing on others ture of cocaine and heroin, sometimes he had found out he was doomed, and to our children. laced with morphia, for patients with the shouted in rage and terror at being I've discussed with some the fate painful cough of incurable cancer that robbed of a life that until then had been they knew was in store. They had re­ involved the lungs, or advanced tuber­ an exultant and unalloyed delight. jected heroic treatments, seemed well culosis - the Brompton cocktail. You Before dialysis the death of a adjusted, as I hope I will be when my can't get it in this continent of wowsers. youngster from kidney failure may notice arrives. Some used the time left That's too bad, because heroin re­ have been the hardest to watch help­ to realise a cherished wish: visit family lieved the pain as well as the cough, lessly from the sidelines. That fate be­ and friends on the other side of the and that cocktail left the mind un­ fell an occasional pregnant woman. world, travel to exdting places, see the clouded while allowing, perhaps ever- Terminating the pregnancy might save Grand Canyon, New England in the so slightly hastening, a peaceful end of her. When abortion was unthinkable as Fall. Better that than fruitless surgery, life. well as illegal except in such dire cir­ shrivelling radiation, nauseating che­ Our culture botches the inescap­ cumstances, deciding whether or when motherapy. Better than glumly, fear­ able truth that all of us die. Our fore­ to intervene to save the mother's life fully awaiting the Reaper. bears were more matter-of-fact. They was probably our toughest ethical When the newspapers report knew and saw death more often in their problem. someone's death, they often say, "After larger families and far more often felt A mother7s death in pregnancy or along battle with cancer." Why a the pain of having their children cut childbirth has always been a dreadful battle? Many cancers are eminently down before their carefree childhoods tragedy. It still is, for half a million treatable, even curable, but sometimes had ended. Death more often took women every year in the developing the condition can take hold and ad­ young adults too, in the bright blossom countries. 1 think of Mary vance relentlessly. There is no "best" of their lives. Death still takes young Wolfstonecraft as the archetype of way to die, but I hope for cancer as my men and many others, innocent by­ countless victims through the ages. Her terminal illness. It is better than brain standers as well as fighters in the vi­ last three notes to her lover and hus­ failure that banishes you to the land of cious wars that lacerate our quarrel­ band William Godwin were lively, the partly dead; or an affliction of the some species. cheerful, a few hours before she gave nervous system that paralyses limbs, Postponing death has been a birth to her daughter who would be­ causes you to wet and soil the bed. Bet­ growth industry throughout my profes­ come Mary Shelley, and didn't know ter than choking with lungs gone bad sional life. Fifty years ago when I first what lay ahead. I get tears in my eyes after a lifetime of smoking. Above all, began to see people die, w e didn't when I read those final letters. better than instant extinction in a plane have the fancy technology of life sup­ No w, in the rich and peaceful parts crash or a massive heart attack or port systems that decorate a modem in­ of the world anyway, most deaths occur stroke, leaving anuntidymessof unfin­ tensive care unit, and what we had we around or after, often long after, our al­ ished business for grieving families to used sparingly. Not, I fancy, because it lotted three score years and ten. We clear away as best they can, and no cost a lot (it didn't in those days) but be­ have taken postponing of the inevi­ farewells among loved ones. That's a cause we were creatures of older tradi­ table to extremes that can be a tragic selfish way to die. Such sudden exits tions and more wholesome customs. perversion of what the healing profes­ can leave the bereaved feeling angry We didn't fight vainly against the inevi­ sions, medicine and nursing ought to and cheated, with emotional scars that table. be about. Death is put off for many by

are slow to heal. I don't want that to Some of those deaths were hor­ See “Endings,” page 8

November, 2000 PCMS EULLETiN 7 from war zones, a sorrow we all expe­ thanasia. A timely death can be cause for Endings from page 7 rience when those we cherish are rejoicing. A good wake is a celebration taken from us, a sorrow we prefer to of a life well lived, a time for the living to mere weeks. Half or more of all lifetime delay. It is one of the core values of give thanks for all that the dead one did personal medical expenses can occur our culture to believe that every life is with the life that has ended. in that brief period. It's called expendi­ precious to its very end, and so we My father lived a long and active ture on "health care" but it's sick care, delay that end as long as w e can. life, enjoyed it with gusto until his mid­ money that we invest in care of the ter­ Are these culturally driven val­ eighties when things began to fall apart. minally ill. I'mnot suggesting the ues and beliefs immutable? Some val­ His intellect was intact to the end but he money would be better spent on other ues have changed in my lifetime, per­ lost his sight and balance, his supple things, but it ought to be spent with haps in response to changes in family joints and strong muscles, control of his compassion and common sense. I don't structure and function. When I was a bladder and bowel. He didn't lose his think it's compassionate to prolong the boy, my family, like most, was large sense of humour though, and recovered dying process by poking tubes into ev­ and close-knit. We made our own en­ a long-forgotten ability to curse ery bodily orifice, making extra holes tertainment by opening our homes coloufully at his infirmities. He died in a thatnature didn't provide, to pour flu­ and hearts to each other; w e sup­ foreign land where he had come to rest ids into veins and arteries, to force air ported one another in hardship or cri­ a few years before, with no family close into lungs that only want to rest after ses; we took care of our own frail eld­ by, and funeral rites of a religion he had eight, nine or ten decades of breathing erly who mostly died at home in the scorned - he was a sincere and blasphe­ every few seconds. It isn't compassion­ bosom of the family. Divorce was rare mous atheist ate when loving ones can't talk to each and carried a stigma, single mothers It was a bitter cold day for a funeral, other in those final days because the were not welcome in respectable soci­ the first day of a new year with snow to paraphernalia of life support systems ety. Now single motherhood by within a few hundred meters of sea level makes speech impossible. Above all it choice, divorce and remarriage, serial on Sicily across the Mediterranean isn t compassionate when the drawn out monogamy - and depositing elderly whence the penetrating north wind process is painful, as it often is despite relatives in retirement homes — are blew, and we stood shivering while the liberal use of pain-suppressing drugs. everyday events, socially acceptable. priest hurried through the final words of If the drugs deaden the pa in they usu­ As the baby boomers reach their the burial service. There were glitches. ally deaden consciousness too, so seventies, eighties, and beyond, in a Earlier, in the part of the service in the what's the point? I have a " living will," society of fragmented families, many nursing home where he had died, back­ with explicit instructions thatno one of them will lack frequent contact with, ground electronic carol music couldn't shall do these futile things to me. or even easy access to close kin. In­ be turned off, and the priest's solemn re­ Are these so-called heroic mea­ stead of the networks that once united marks were intoned to the tunes of sures a sacrifice on the altar of the fami1 ies in mutual support and affec­ "Jingle bells" and "Rudolph the red­ medical profession's vanity? Is it vanity, tion and occupied much of their lei­ nosed reindeer/' bringing giggles from or stubborn refusal to admit defeat, sure time, they may have only televi­ acquaintances who accompanied me, the which leads physicians to deploy such sion for company. Perhaps they will solitaiy family mourner. There was an­ weaponry to prolong the process of not have the social safety nets we other hitch when time came to place his dying? Some members of the medical have, and they may have few re­ coffin in the carved stone crypt that is profession can't admit that the forces of sources of their own after a lifetime of customary in Malta. The attendants were nature are more powerful than they precarious employment without pen­ busy in a distant part of the cemetery are. We doctors are an arrogant lot, al­ sion plans. Will they have the same and left us standing about for twenty ways so sure we know what's best, yet values we have? Will isolated indigent minutes or more, shuddering with cold. often wrong. My epigraph is from John old people receive food and shelter at See “Endings,” page 12 Donne's sonnet to proud Death, bu t it public expense? Or will values is the doctors, not death, who are full of change with these new realities? The pride nowadays. baby boomers as they grow old, and Perhaps our culture, not the doc­ the generation who come after them, tors, should be blamed. The loving will have to confront and respond to Please visit us at the ones want to cling to the last spark of these questions. They may be less in­ life in the dying, don't want to hear if clined than we are now to postpone PCMS homepage told that it is kinder not to prolong the death, to invest so much effort and suffering. The sorrow of bereavement money in the infirm elderly. More www.pc mswa. org is a universal human quality that we see readily than we, they might entertain often on television screens in pictures the notions of assisted suicide and eu­

8 P f.MS BUI. LE UN N ovem ber. 20 00 ^Pien>c& - Q 4iedical &c-ciety-

7m&

invites you and your spouse/guest to the

November General Membership Meeting

Tuesday, November 14, 2000 Landmark Convention Social Hour: 6:00 pm Center Dinner: 6:45 pm Temple Theatre, Roof Garden Program: 7:45 pm 47 St. Helens Avenue Tacoma Adult Trauma U pdate

Robert Winchell, MD Director, Adult Trauma Services

The Adult Trauma System has been operational in Pierce County since June. Plan to attend the November meeting to hear about the new system, what is working, and what isn’t. And:

Adult Trauma System - Successes, Failures Availability of Surgical Suites Impact on Trauma Call Roster Hospital Rotation • is it working? Funding Outlook

(Registration required by November 10. Return this form to: PCMS, 223 Tacoma Ave S, Tacoma 98402; FAX to 572-2470 or call 572-3667

Please reserve ______dinner(s) at $20 per person (tax and tip included)

Enclosed is my check for $ or my credit card # is ______

QVisa □ Master Card Expiration Date ______S ig n a t u r e ______

I will be bringing my spouse or a guest. Name for name tag :______

S ig n e d : ______

November, 2000 PCMS BULLETIN 9 WSMA sets priorities for 2001 Personal Problems Legislative Session of Physicians With the 2001 Legislative Session coming soon, the WSMA is busy preparing Committee their annual agenda. The agenda is based on organizational priorities and action taken at the annual meeting in September. Priority items include:

• Adequate funding for public health programs and physician Medical problems, drugs, alcohol, practices retirement, emotional, • Opposition to other health care groups’ perennial attempts to or other such difficulties? intrude into the scope of practice of physicians • Supporting the Liability Reform Coalition (LRC) agenda and introducing, if necessary, separate tort legislation germane to the Vour co llea g u es medical profession. w ant to help • Opposing legislatively mandated sharps protections as unneces­ sary due to WISHA workplace regulations • Aggressively fighting efforts to further fraud and abuse legisla­

*Robert Sands, MD, Chair 752-6056 tion in our state Bill Dean, MD 272-4013 • Preserve funds from Tobacco Settlement for tobacco prevention/ Tom Herron, MD 853-3888 control Bill Roes, MD 884-9221 F. Dennis Waldron, MD 265-2584 The agenda will be adjusted as the legislative session nears. The WSMA expects to review over 2,000 pieces of legislation and will be actively engaged in several hundred bills as part of their work to represent physician interests.

Mark your calendar for the WSMA Legislative Summit in Olympia, on Tuesday, January 23rd. More information to follow.! Confidentiality Assured

MultiCare/3 Do you have patients suffering from Lymphedema?

AMERICAN LUNG ASSOCIATION, The Lymphedema Clinic at Tacoma General Hospital offers ofWbohington the latest treatments by the only certified Lymphedema t Therapists in Pierce County. 1-800-LUNG-USA • Compression bandaging • Manual lymphatic drainage Lung Information • Lymphedema exercises Service Line • Skin/Wound care • Custom fit compression sleeves and stockings Providing patient education materials To learn more or to refer a patient to the Lymphedema Clinic, please call 253 403-1040. Federico Cruz-Uribe, MD The Health Status of Pierce County Director of Health

Environmental Tobacco Smoke

On November 16,2000, many TACOMA-PIERCE COUNT V HEALTH Pierce County restaurants will ban DEPART M ENT cigarettes in their facilities for the day. As part of the American Cancer concentrated than that inhaled by a smoker, research has shown that the health risks Society's "Great AmericanSmokeout," from inhaling smoke - even ETS - is significant. Nationally, the National Cancer In­ the Tacoma-Pierce County Health stitute estimates that 3,000 people die from ETS-induced lung cancer annually. In Department staff have invited restau­ 1992, the U.S. Environmental Protection Agency categorized ETS as a Group A car­ rants to go smoke free for one day, to cinogen. try the idea out on clientele and em­ The impact of ETS on children is sobering. Since the 1970s, studies have consis­ ployees. tently shown that children exposed to ETS at home have significantly elevated rates At the heart of the effort to create of respiratory symptoms and infections. For example (from the national Cancer smoke-free restaurants is the negative Institute's webpage at http://cancernet.nci. nih.gov): health impact of tobacco smoke: both on the smoker and on those who ei­ • Each year, 150,000 - 300,000 U.S. children under the age of 18 months, who are ther inhale the secondhand smoke or exposed to ETS (mostly from their parents) experience lower respiratory tract absorb smoke components, such as a infections (pneumonia and bronchitis); 7,500 -15,000 of these cases require fetus. Data on the health effects of us­ hospitalization. ing tobacco have been mounting for years. The latest, from a Danish study • The EP A estimates that ETS worsens the condition of 200,000 to one million published in the Archives of Disease asthmatic children each year. And ETS increases the number of new cases of in Childhood, shows that30-40% of all asthma in children. cases of Sudden Infant Death Syn­ drome (SIDS) could be avoided if all • ETS exposure in utero can affect lung function and structure to predispose pregnant women quit smoking during children to long-term pulmonary risks. pregnancy. Surveying 25,000 preg­ nant women on their smoking habits, researchers found that the SIDS risk What are some things you can do as a physician to change statistics increased with the number of ciga­ on ETS? rettes the mother smoked, regardless • Talk with your patients about their smoking habits and encourage them to quit, of other factors such as alcohol and caffeine intake, maternal height and especially during pregnancy. The Health Department offers an easy-to-Ieam and weight, and the number of prenatal use process for asking people about smoking and encouraging them to stop. For care visits. more information on the 4-A Model, contact Nancy McKindsey at253-798-6461. Environmental Tobacco Smoke (ETS) is a mixture of chemicals given • Use symptoms such as asthma or bronchial infections in children to discuss the off by burning tobacco and exhaled affects of ETS and, again, encourage parents or grandparents to stop smoking. from the lungs of people smoking. Ac­ cording to the National Cancer Insti­ • Encourage patients and employees to take their families out to dinner in a tute, more than4,000 individual com­ restaurant where smoking has been banned. For a lis t of restaurants, see the pounds have been found in tobacco Health Department's webpage: smoke. Of these, approximately 60 compounds have been classified as http://www.healthdept.co.pierce.wa.us/sniokeout.htiin carcinogens, tumor initiators, and tu­ mor promoters. Although ETS is less B u l l e t in

Endings from page 8 Healthy Options moving forward to year 2001 No wake then, but a splendid one a few months later on a sunny day in Los Angeles among the circle of friends who had worked with him in the Department of Anatomy atthe Several major health plans, particularly in Pierce University of California for two decades after he retired from County, will uproot about 135,(XX) Medicaid patients state­ the Royal College of Surgeons in London. Throughout it all, wide (22,000 in Pierce County) from their existing relation­ from thatcold N ew Year's Day in Malta to the eucalyptus-per- ships with medical practices, beginning January 1,2001, at fumed comfort of the UCLA campus, there was relief that my which time many of them will cease participation in the father's travail had ended, and rejoicing at what he had done Healthy Options medicaid program The Medical Assistance with his long and interesting life. Some day I hope my life will Administration (MAA) is proceeding with administration of be as cheerfully recalled and celebrated. ■ contracts for Healthy Options patients for 2001 in spite of the major shake-up. John Last, MD, is on the Faculty o f Medicine, University of MAA is currently assessing the adequacy of the Ottawa, Ottawa, Canada, K1H8M5 practitioner networks that each participating plan must have to fulfill the contractural arrangements. Medical practices may wish to prepare for the change by: (1) Determining if the health plan(s) you currently contract with have been selected for your county in 2001. If to ta l Asset m anagem ent, inc . they have not and you wish to continue in the HO program, Registered Investment Advisory contact the health plan(s) that are listed and open negotia­ fgyb§g^|j COMPLIMENTARY FINANCIAL tions to contract with them. (Primary care physicians with a CHECK-UP f j | > population of HO patients are usually in a strong negotiating fv- position (2) Tell your patients - Physicians are "invited" by MAA WE MAKE HOUSE CALLS ■; % in i'm9■nH- W 9 to "pro-actively notify" their patients as to which health plans wSSSmKk 'W/ y/’U their practice will be participating in next year (to download Call 858 -2 745 D,„1 J. Itoskoph, MBA, CFP a sample letter, approved by MMM, go to www.wsma.org/ www. 4-TAM-RIA cal ;P VQT OUP vtTfj POP. A newsevents/101300.rft cij\oa't.STI'IP INTRODU MAA will be sending material to Medicaid clients 1 advertising the various health plans, which could lure your patients away to other plans with which you have no contract. MAA claims they want to preserve the patient/ ...a multi­ physician relationship where possible. Please note that any iSftii Allenmore disciplinary communications with your patients should be objective in Psychological behavioral health group tone and content, should not disparage any plans, and HM Associates, P.S. llut works should avoid making inflated claims. with physicians In addition, if you will be participating in Healthy , 752-7320 , Options in 2001 but are changing health plan affiliations, your patients must call MAA, 1-800-562-3022 to request a Do you have patients with difficult emotional change in health plan assignment in order to remain your and stress-related problems? Psychiatric and patient psychological consultations are available. If you will not be participating in Healthy Options in Union Avenue Professional Building 2001, your patient must call MAA's Exemption/Disenrollment ______1530 Union Ave. S.. Ste. 16. Tacoma______line 1-800-794-4360 and request a temporary disenrollment for the duration of her pregnancy and two months postpar­ tum. By doing this, the patient can continue with you, and your services will be reimbursed as Medicaid fee-for- service. please send your email address to For a listing of participating plans for2001, you may us at: [email protected] access the MAA webpagehttps://wwZwa.gov/ dshs/maa/ Heal thyOptions/ index.html or call PCMS, 572-3667. ■

12 PCMS BULLETIN November, 2000 In My Opinion, by David Roskoph, MBA, CFP

Will the Kings recent draft become a cold?

Since this "New Era" began I have lated evolution because the rush to be been asking you not to dispense with first-to-market obscured thebottomline David Roskoph, MBA, CFP all those old, tried-and-true, rules that of profitability. In a historical instant, have established financial markets for consumers were freed from centuries the past century. New Eras have been of middlemen and costly intermediar­ heralded before with their attendant ies; catapulted past decades of thumb­ objective and risk parameters. The market exuberance as that change was ing through catalogues or shuttling S&P500 is capitalization weighted and assimilated into the economy. The between malls. Freed from the considered passive because companies economy was not reinvented or encumbrance of such friction buyers are rotated in or out dependent upon fundamentally altered with these plunged, wallet first, into a sea of cheap their capitalization, i.e. the perfor­ innovations but rather, it assimilated buying opportunities. We all love a mance of their stock. Alternatively, an them. So too will the economy adapt to bargain and after all, the internet built actively managed fund is directed by the internet. The internet will change itself as the ultimate price leader. the manage/ s theory of the future the way business is done and over the Consumer confidence remains lofty as performance of a collection of stocks, next few months the ambiguity of that American consumers consume them­ not tied to market capitalization. change will gradually disappear. What selves into a collective deficit. The Tremendous amounts of money have seems clear is that some things will problem for internet commerce is flowed into S&P 500 Index funds remain forever changed, such as unlimited competitionfor virtually the because of their stellar and steady product and information distribution same goods = no pricing power. In performance, 28.69% (before costs) Unclear however, is the degree to addition, the cost of entering the average annual return from1995-1999. which the new technologies will alter competitive fray is minimal; thus the The S&P 500 has ten components or existing consumer patters. Equity perpetual price war is ensured sectors such as utilities, financials and prices are often credited with the longevity. With no time to evolve a technology. Not long ago, technology omniscience to represent the future sound profit strategy, internet distribu­ represented only 3 % of the S&P 500 until it becomes the present. The tion of products, was doomed from its Index; today technology represents market has bought into a lot of future inception. As explored in the last approximately 33%! This happened profit through technology. Popular article (The New Economy Math Just because over the last two years, stock indexes like the Standard & Doesn ’tAdd Up, Aug. 2000), dot.com investors could not put enough money Poors 500 have been greatly affected retail profit margins alone cannot into New Economy companies like by the most recent New Economy. support the cost of maintaining present Yahoo, Palm and Qualcom. As money Due to the violent shift toward technol­ customers let alone acquiring new ones poured in their stock, their capitaliza­ ogy within the S&P500, it is likely to in light of the apparent lack of conven­ tion rose and they were invited into the disappoint investors as the euphoria of tional loyalty. As Amazon is proving- S&P500 family. Each of these compa­ what could be is distilled down to if the biggest and the best can't make it, nies is trading at stratospheric earnings tangible corporate profits. what is supposed to happen to the rest? multiples well into the hundreds, based A distinction must be drawn As the new versus the old upon very questionable growth between, the internet as a source of cataclysm rages, even the venerable projections. The inflows of capital into retail commerce and, the internet as a S&P 500 Index is brought into the fray. these companies and the resultant source of information. As a source of Over the last decade the S&P 500 has 1000% increase in the technology commerce, the internet was built too gained great fame as an investment component of the S&P 500 has clearly quickly to ensure profits. There was vehicle because it has outperformed gotten out of control. Already each has little time for a protracted and calcu­ most mutual funds with the same See “ K ing” page 14

November, 2000 PCMS BULLEI IN Jd u i .l e t i n v _

King from page 13

lost between 65- 75% of its highest market value. As the profit potential of ^ ean ^ir ^or the N ew Era settles in, the S&P 500 is Asthma Prevention Program likely to be overweighted in technol­ ogy to the detriment of overall perfor­ mance. Investors may be disappointed Do you have patients in your practice with asthma? with the returns of the S&P 500 versus many actively managed funds over the The Clean Air for Kids Program provides trained volunteers next five years because the popular rush to technology stocks has cor­ who can assist families and medical providers with rupted the indexing process itself. • a comprehensive home assessment to help identify Presently, the public consid­ environmental triggers of asthma ers the internet the rebirth of capital­ • practical recommendations to reduce asthma triggers and ism. In fact, the prospects of selling improve home air quality information over the internet for a • a written report of the assessment and recommendations profit are real, however, w e are not yet that dependentupon information alone. to the medical provider Each time major innovation occurs, everyone forgets the experiences of Volunteers do not give medical advice, and would welcome the past while they are mesmerized by referrals from medical providers. The service is free. To make the seemingly endless possibilities that a referral, or to get more information about the program, the new technology portends. It seems contact Sarah Curran at (253) 798-2954. that each generation must experience this phenomena for themselves and turn a deaf ear to history. Unfortu­ Clean Air for Kids is a partnership of the American Lung Association of Wash­ ington, Tacoma Public Schools, University of Washington, Puyallup Tribal nately the dead can't communicate with Health Authority, Washington State Department of Health, Mary Bridge the deaf. ■ Children's Health Center, and The Tacoma-Pierce County Health Department which is dedicated to helping people learn more about ways to reduce asthma David Roskoph, MBA, CFP is a and health risks from pollutants in their home. fee-based investment advisor in Gig H arbor,

MEDICAL LICENSURE ISSUES

Mr. Rockwell is available to represent physicians and other health care providers with issues of concern before the State Medical Quality Assurance Organ &jTissue Commission. Mr. Rockwell, appointed by Governor Booth Gardner, served for DONATION 8 years as the Public Board Member of the Medical Disciplinary Board from 1985-1993. Since then, Mr. Rockwell has successfully represented over 60 physicians on charges before the MQAC. Mr. Rockwell’s fees are competitive and the subject of a confidential attomey-client representation agreement. Gregory G. Rockwell Attorney at Law & Arbitrator Share Your Life. 3055 - 112th Avenue SE, Suite 211 Share Your Decision Bellevue, WA 98004 For more information on organ and tissue (425) 822-1962 • FAX (425) 822-3043 donation please call LifeCenter Northwest email: [email protected] • website: “ggrockwe0.wld.com” toll free, 1-877-275-5269

i. 4 F iJvVj B M lLl l 11J Lkivembf-r, >000 f i e r c e %ou/ity Q 'liedical

In My Opinion.... The Invisible Hand by Andrew Statson, MD

Staffing Shortages

"Ask not what your country can do for you. Ask, instead, what it is doing to you. ” With apology to President Kennedy Andrew y.uuson, MD

A recent bulletin from the State to significant reductions of payment for where. Are they going to charge Department of Health reported a their services and to a significant more? Is Medicare going to pay them serious shortage of laboratory techni­ increase in regulations, which have more? Perhaps the nurses will take a cians. There are about 800 open raised their costs. Many small laborato­ cut in pay and work for less because it positions in the clinical laboratories of ries have been taken over by national is their moral obligation to the commu­ this state. Many current technicians are chains. They have used large amounts nity to do so. asked to work overtime and the work of capital to mechanize and to automate The result for the nursing homes load is such that the likelihood of lab their operations, but there is just so will be the same as for the laboratories. errors is increased. The DOH is going much they have been able to do. The There will be a lot of positions open to study the problem and is planning to costs are still there and they cannot and no nurses to fill them. Care will go to the high schools and entice afford to pay their technicians well remain bad and probably will get students into entering this line of work. enough to keep them. For some worse. Some nursing homes may have The weird feeling here is a unknown reason, the technicians want to turn away patients, or even dis­ flashback to WWIL You can see the to be paid better, so they leave and charge some of those they already recruiting stations, the marching bands, find other jobs in other fields. How ha ve, if they cannot get the required the posters saying "Uncle Sam wants socially irresponsible! quota of nurses. At the same time their YOU." Of course, an appeal to patrio­ The situation with the pharmacies charges will go up, so that nursing tism was justified then Our country was is the same. The small ones have home care will be beyond the reach of threatened and we rose to defend it. disappeared. The big chains have most people. The final result will be Today, the situation is different. taken over. They have kept prices that someone in the family will ha ve to When someone does not want to lower, at the cost of impersonal service, quit her job and take care of mother pay you what your work is worth, he high work load for their staff and and father until they die. That is a type makes it sound like it is your patriotic increased opportunity for error. of nursing care Congress probably will duty, your social responsibility, your Several months ago there was a not attempt to regulate. moral obligation to the community, etc., study on the staffing shortages in The situation in our hospitals is to do the job. You may get a plaque or nursing homes. The conclusion was barely better. The number of nurses a medal in recognition of your contri­ that there were not enough RNs and per patient is slightly lower than in the bution and you are expected to LPNs to take care of the patients. past, but not too low. The problem is consider yourself honored for having Congress was going to mandate that different. Most RNs are burdened with been called to serve your fellow men. there should be at least a certain so much paperwork that they have Payment? What payment? Didn't you number of nurses for a certain number very little time for patient care. At the get a medal? of patients. The nursing homes will be same time, the shortened hospital stays The laboratories in this country required to meet these quotas. The have resulted in increased intensity of have been on the receiving end of an unanswered question is how will these care. economic squeeze, together with the nurses be paid. The nursing homes will In the past, as patients got better, rest of us. They have been subjected have to get the money from some­ See "Shortages" page 16 B u l l e t in V

To make someone a physician in name, and on the quality of medical care the Shortages from page 15 it takes at least eight years. To make people are going to receive will be someone a physician at heart, it takes such, that neither the physicians nor much more than years. the country can come out of it without they required less and less nursing In 1998, Germany enacted strict major bruises. N o nation can punish its care. N ow they go home early, so they controls on the budget for health physicians in such a manner and need rather intensive care up to the services. One of these controls had to expect that its people will receive good day of discharge. Yet the nurses still do with prescriptions for drugs. If the medical care when they get ill. are assigned about the same number of general practitioners in a region If they can, some physicians will patients. So if two of their patients overspent their budget on medications, retire, find other jobs or leave the should develop some problem at the they all could be fined up to 15,000 DM country. Those that are left will have same time, as it happens more and more (about 7,000 dollars) per practice. The lost their desire to perform. They will frequently now, the nurses can only fines were waived for 1998, but in 1999, go through the motions all right, but take care of one of them and may not ten of the 23 German Lander had their heart will not be in their work. even be aware that another one needs exceeded their budget for drugs and The health care system will limp along, their attention. now the government wants to collect. A while for most patients a free market The nurses aides are asked to health ministry official has said, "If we alternative, in Germany, Switzerland, give more and more care, which they offer an amnesty again, w e might as or some other country, will be the only are not able to do well, because they well give up on the budget." w ay to get good medical care. When a are not properly trained. Even worse, As a rule, the Germans are a country spits on its physicians, it will get they are not able to detect the early disciplined people, respectful of for physicians the sort of people who warning signs of problems the patients authority. Yet the association of don't mind being so treated. The kind may show before they get very sick. general practitioners plans to oppose of medical care they will give, such a By the time they realize something is the fines. This is a confrontation in country will fully deserve. You can happening, a patient may be in serious which there can be no winner. The only get what you pay for, and fre­ trouble. The hospital pharmacies are effect on the morale of the physicians quently not even that much. ■ also understaffed, so that on busy nights the patients may have to wait for hours to get their medications. The recent poll of physicians by Merritt, Hawkins and Associates, reported in the PCMS F AX New s is another example. Among physicians 50

years old or older, 38 % plan to retire Nationally Accredited within three years and 12% plan to Residential Treatment for seek jobs in nonmedical settings. Chemical Dependency Intention does not necessarily translate B e g i n s into action, but that means 50% of the physicians in that age group are deeply Inpatient Treatment dissatisfied with the practice of medi­ cine. Probably most of them love their Recovery House profession and their work and entered O utpatient the medical field with great enthusiasm. To have reached the point of Family Education wanting to get out in such massive and Support numbers is a sad reflection on the Relapse Prevention current condition of our profession. The people who are going to replace State Certified them will have neither their experi­ Diagnostic Assessment ence, nor the incentive to work hard. It will take more new people to replace those that will leave. When the quality A llv eS t 8021 230th SW, Edmonds of medical care has dropped enough to H o ilS e www.allvesthouse.com be noticed by the authorities, it may take a long time to repair the damage. North 4 2 5 - 7 1 2 - 0 5 0 5

16 PCMS BULLETIN November, 2000 ^kvce 'ipw tihj. Q 'iledkal Society

Physician Good Samaritan Law Directory changes

May a physician be held liable for services voluntarily rendered at Please make note o f the following the scene of an emergency? changes to your 2000 PCMS Directory. Generally, no. Under the "good Samaritan law," a physician who renders emergency care at the scene of an emergency, without compensation or the Esuabana, Asuquo, MD expectation of compensation, is not subject to civil liability for any act or omission in 3418 McKinley Ave E, Tacoma 98404 the rendering of such emergency care, unless the physician's acts or omissions Phone: 404-0914, FAX 552-2441 constitute gross negligence or wilful or wanton misconduct. If, however, the physician renders emergency care in the course of regular Lee, David E., MD employment and receives or expects to receive compensation for such care, the Change address to 1901 South Union, "good Samaritan law" does not apply and the physician may be held liable for his or Suite B6007, Tacoma 98405 her negligent acts or omissions. Moore, Jane, MD May a physician be held liable for failing to obtain consent to the 6002 North Westgate Blvd, #160 rendering of emergency medical or surgical or health services? Tacoma 98406; Phone: 759-9902 Generally, no. A physician is not subject to civil liability for failure to obtain consent in rendering medical or surgical services where the patient is unable to give Sullivan, Rebecca, MD, CEO consent for any reason and no other person legally authorized to provide consent is Puyallup Valley Healthcare reasonably available, so long as the physician acted in good faith and without 1317 East Main, Puyallup 98372 knowledge of facts negating consent. ■ Phone:435-8171 ■

From: Washington Physicians' Guide to Health Law

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November, 2000 PCMS BULLETIN 17 v B u l l e t in

Medical Malpractice Statute of Limitations

What is a statute of limitation? omission, unless the patient is a minor • For one year following a written, good faith request for mediation before It is a time limit beyond which a or is incompetent. For purposes of a claim of continu­ filing a lawsuit person may not bring a lawsuit. ing negligent medical treatment, the Does the medical malpractice What is the medical malpractice statute of limitations begins to run on statute of limitations apply to statute of limitations in the date of the last act or omission every medical malpractice action Washington? alleged to have caused the harm. against a physician? A medical malpractice action in When is the medical malpractice No. The medical malpractice Washingtonmustbebroughtwi thin the statute of limitations tolled? statute of limitations does not apply in a later of: The medical malpractice statute of civil action based on intentional • Three years of the act or conduct brought against a physician for omission alleged to have caused limitations is tolled (does not run) in the recovery of damages for injury as a the injury or condition following circumstances: result of childhood sexual abuse. • One year of the time they patient • Upon proof of fraud It also does not apply to an action or his representative discovered • Upon proof of intentional for wrongful death against a physician. or reasonably should have concealment The patient's personal representative discovered that the injury or • Upon proof of the presence of a has three years from the date of the condition wascausedby the foreign body not intended to patient's death to bring a wrongful action or omission. have a therapeutic or diagnostic death/ medical malpractice action. ■ A medical malpractice action, purpose or effect however, may not be commenced • During the minority of a patient more tan eight years sifter the act or • During the incompetency of a From: Washington Physicians ’ Guide patient to Health Law

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18 PCMS BULLETIN November, 2000 V W’iemoe, Q-Meckcal (^octety

Continuing Medical Education COLLEGE Medicine and Mental Health MEDICAL Conference offered December 1 A continuing medical education • Depressive Disorder in Children and EDUCATION focusing on the diagnosis and Adolescents management of mental heal th • The Many Faces of Addiction complaints faced in the primary care • Update on Insomnia: Diagnosis and and internal medicine practice is set for Management Friday, December 1. • Double Trouble: Anxiety and ID Conference The complimentary program, directed by Drs. David Law and Mark Depression is set for Craddock, offers 6 Category I CME • Recent Development in the November 10 credits. Topics include: Diagnosis/Treatment of ALzheimers • Diagnosis and Treatment of Chronic The program is scheduled for the Registration remains open for the Depression Lagerquist Conference Center of St. Infectious Diseases Update CME set • Optimal Management of Psychosis JosephHospitalMedical Center. Call for Friday, November 10,2000. The and Agitation in the Elderly 627-7137for registration information. ■ program will be held at the Sheraton Tacoma Hotel.This year the course is directed by David McEniry, MD and will feature presentations on: Dates Program Director^ Infectious Diseases • Teeth and Terror: Animal Bites Friday, November 10 David McEniry, MD • Antibiotic Associated Colitis Update • Allergy to Antibiotics Medicine & Mental Friday, December 1 David Law, MD • Infectious Diseases Emergencies: Health When and How to React Tuesdays, January 9 Cardiology for Primary • What to do About the Flu Gregg Ostergren, DO • Advances and Retreats in Infectious and 16 (evenings) Care Diseases Wednesday-Sunday Richard Tobin, MD • Antibiotics2000: An Update CME at Whistler January 24-28 John Jiganti, MD Call 627-7137for registration and more information ■ Advances in Women's Friday, February 9 John Lenihan, Jr., MD Medicine Condo reservation TBA Pain Management David Paly, MD Thursday-Friday Internal Medicine deadline for Whistler Ulrich Birlenbach, MD is December 1 March 8-9 Review 2001 Reservations for the College's Saturday, April 28 Surgery Update 2001 Glenn Deyo, MD block of condos in the Aspens at Allergy, Asthma & Whistler are available. Call toll free 1- 877-408-8899 and identify yourself as Friday, May 4 Pulmonology for Alex Mihali, MD part of the College of Medical Educa­ Primary Care tion to receive the negotiated reduced Tuesdays, May 16 and rates. ROOMS WILL BE RELEASED Medical Technology TBA AFTER DECEMBER 1,2000. ■ 23 (evenings)

November, 2000 PCMS BULLETIN b u l l e t i n

Did You Pierce County Medical Society Medical Placement Service

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2 0 PCMS BULLETIN November, 2000 VPiwce ^otmby, oM edieal (Stocieiy

For the first time ever, the American Medical Association Your opportunity to act. Organized Medical Staff Section will open its door at TheAMA will open the door. It’s up to you to step the Interim Meeting to all physicians — regardless of through. And because your participation is so practicc affiliation or m embership status — at a important, there’s no fee. Just sign up and attend For unique‘Open House" gathering in Orlando. Florida, more information, call 800 262-3211, or visit us online November 30 through December 4, 2000. at www.ama-assn.org/omss

Your advocate for positive change. ThcAMA wants to help you overcome the incredible Register today challenges you face. Reduce onerous regulations AMA Organized Medical Staff Section (0MSS) and managed care demands. Protect your autonomy 2000 "Open House" Meeting and patient relationships. Ensure appropriate November 50-December 4. 2000 reimbursement. .Vlake sure no one treats physicians The Hilton in the Walt Disney World Resort like commodities. Orlando, Florida Your place to speak up. To help unify theAMA and the nation's front-line physicians, this one-of-a-kind meeting offers you a direct avenue for raising your issues and concerns and proposing solutions. American Medical Association Ph ysicians (Ird ic a k -il l<» Lluj heall li o f A m e rica

November, 2000 PCMS BULLETIN 21 B u l l e t in

Its Time to Vote

It is time to elect a world leader and your vote counts. Here's the scoop on the three leading candidates: Candidate A: associates with faith E R ^ c S E healers and consults with astrologjsts. He's had two mistresses. He chain THAT TATTOO smokes and drinks 8 to 10 martinis a WORRIED ABOUT WHAT YOUR SPOUSE, day. YOUR FRIENDS OR EVEN YOUR BOSS Candidate B: w as kicked out of THINKS ABOUT YOUR TATTOO? office twice, sleeps until noon, used OR ARE YOU JUST TIRED OF opium in college, and drinks a quart of LOOKING AT IT? brandy every evening. Today’s newest Alexandrite laser, Candidate C: is a decorated war will remove your tattoo hero. He's a vegetarian, doesn't smoke, with minimal discomfort & drinks an occasional beer and hasn't less than 1% risk of scarring. had any illicit affairs. ('.dll Uxiuy for more intoi niacioti Which of these candidates is your PIERCE COUNTY choice? LASER CLINIC Who are the candidates? Director I'utcr K. Marsh M.l), Candidate A isFraMinD. Roosevelt; Bis WnTston (253)573-0047 Chovhili and C isAdolphHitler

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November, 2000 PCMS BULLETIN 23 z: x B u l l e t in

Concerns Come First

“I appreciated the fact that Physicians Insurance was really looking out for my interest and not just their own.”

W hether it's a claim, a lawsuit, or a risk management issue, Physicians Insurance keeps customer concerns at the forefront. Claims representatives work closely with insured defendants and experienced attorneys to secure the best possible outcome for our policyholders. Equally as dedicated, our risk manage­ ment representatives conduct interactive seminars and respond to questions in person, by phone, and by mail. Our goal, now and in the future, is to help physicians, clinics, and hospitals remain successful. Physicians Insurance Western Washington 1-800-962-1 j>99 a Mutual Company Eastern Washington 1-8Q0-962-1398 Created Jtrui sponsored b\ the Wii.^luri^inti smu- ML-dn.,il A.vsoci.iUi'jn Ore eon 1 "800" 5 6 5-1 892 S cjille, W A © Physicians Insurance IQyO

Pierce County Medical Society PRESORTED 223 Tacoma Avenue South STANDARD Tacoma, WA 98402 US POSTAGE PAID TACOMA, WA PERMIT NO 605 Return service requested

24 PCMS BULLETIN November, 2000 INSIDE: President’s Page: “Reflections” Medicaid Reminder: Monitor Healthy Options Plan Affiliations PCMS Annual Meeting will feature Allen A.M.E. Gospel Choir Be Aware of New “Managed Care” Developments Clean Air For Kids: A Partnership to Fight the Crisis of Astlniu The Emergence of Antimicrobial Resistance “Purchasing Power,” by Andrew Statson, MD V B U L ! ,ETIN

PCM S Officers/Trustees: Charles M. W eatherby, M D ...... P r e s id e n t Patrice N. Stevenson, M D ...... President Elect Susan J. Salo. M D ...... Vice-President J. James Rooks, M D ...... Secretary /Treasurer Lawrence A. Larson, DO ...... Past President Sabrina A. Benjamin. MD Drew H. Deutsch. MD Kevin K. Gandhi, MD Michael J. Kelly, MD Doris A. Page, MD Edward I. W alkley, MD Yolanda Bruce. PCM SA President

W SMA Representatives: Speaker of the House: Richard Hawkins. MD Trustees: David Law. MD; Nicholas Rajacich. MD AMA Delegate: Leonard Alcnick, MD W AM PAC Chair/6lh District: M ark GUdenhar, MD W AM PAC 9th District: Don Russell. DO

Executive D irector: Douglas Jackman

Committee Chairs: Aging, Richard W altman; AIDS, Janies DeMaio; Bylaws, Richard Hawkins; Budget/Finance, James Rooks; College of M edical Education, John Jiganti; Credentials, Susan Salo; Em ergency M edical Standards, Ted Walkley; Ethics/Standards Of Practice, David Lukcns; G rievance, Lawrence A. Larson; Labor & Industries, W illiam Ritchie; Table of Contents Legislative, W illiam Marsh: M edical-Legal, Mark Taylor: M em bership Benefits, Inc., Drew Deutsch; Personal Problem s O f Physicians, Robert Sands; Public Health/School H ealth, Sumner Schoenike 3 President's Page: “Reflections"

The Bulletin is published monthly by PCMS 4 Medicaid Reminder: Monitor Healthy Options Affiliations M embership Benefits. Inc. for members of the Pierce New Drunken Driving Standard County M edical Society- Deadlines for submitting articles and placing advertisements in The Bulletin More Doctors Advising Patients to Quit Smoking are the 15th ofthe month preceding publication (i.e. October 15 for the November issue). 5 PCMS Annual Meeting: Fun and Entertaining

The Bulletin is dedicated to the art, science and delivery of medicine and the betterment of the health 6 WSMA Legislative Priorities for 2001 and medical welfare of the community. The opinions herein are those of the individual contributors and do 7 Be Aware of new “Managed Care” Developments noi necessarily reflect the official position of the Medical Society. Acceptance of advertising in no way constitutes professional approval or endorse­ 8 Fees for Duplicating and Searching Medical Records ment ot products or services advertised. The Bulletin and Pierce County Medical Society reserve the right 9 Clean Air For Kids: Partnership fights Asthma to reject any advertising.

10 PCMS New Members M anaging Editors: Douglas Jackman/Sue Asher 10 Directory Changes Editorial Com m ittee: MB! Board of Directors 11 TPCHD: Antimicrobial Resistance A dvertising Representative: Kristi Brittain Subscriptions: $50 per year, $5 per issue 13 The Invisible Hand: “Purchasing Power” M ake all checks payable to: M BI 223 Tacoma Avenue South, Tacoma WA 98402 15 College of Medical Education 253-572-3666, FAX 253-572-2470

E-mail address: pcmswa@ pcmswa.org 16 Antibiotic Prescribing for Children is on the Decline Home Page: http://www.pcmswa.org 19 Classified Advertising

2 PCMS BULLETIN December, 2000 President’s Page by Charles Weatherby, M.D.

Reflections

As my Presidency comes lo an The mergers of the various end, I would like to reflect on som e of insurance plans are creating concerns the things that have transpired. A for many of us. Our own Regence trauma system has returned to Pierce Blue Shield is one such plan. It is County. Several of my predecessors because of this concern that members (luirh's Wctilhrrlrv. MD

were deeply involved in negotiations of your Board of Trustees met with PCMS l‘r< s hinu with getting the trauma system reestab­ Regence representatives several lished. I’m the fortunate one to have times. M ost recently, we met w ith the seen the system come to fruition during new' physician liaison representative. services continues to fall. These are my term of office. I w ould like to thank Dr. Larry Donahue. He is the “physi­ some of the issues that require our all of those responsible. As w ith any cian ombudsman.” He seems to be support of organized medicine. new system, there will be some kinks very willing to listen lo our concerns Your Pierce County Medical and growing pains. There are probably and assist us. However, he also Society support staff led by Doug still some who oppose the system. Let informed us that he will be retiring Jackman, has kept Pierce Comity at the us all support Dr. W inchell and his shortly. forefront of organized medicine, trauma team. Hopefully, next year we At the state level, W SM A is especially at the state level. At the time will be celebrating a successful First continuing to support legislation that of the printing of this Bulletin, our anniversary. improves access to care and remains executive director, Doug Jackman will While medical societies in general concerned about physician reimburse­ be just several weeks from a well are demonstrating decreasing numbers ment and medical practice viability. In deserved retirement. I am very of members, our Pierce County prioritizing legislation for the upcom­ honored to have been the last presi­ Medical Society has maintained its ing session next year, the list includes: dent to have served with Mr. Jackman. membership numbers. I would like to adequate funding for public health On behalf of the PCM S. I w ould like to thank you for renewing your member­ programs and physician practices, wish Doug and his lovely wife. Connie, ship and continuing to support orga­ opposition to other health care group's a glorious and wonderful retirement. nized medicine, at least at the county intrusion into the scope of physician May God continue to bless them and and state levels. Also, at one of our practices, and preserving funding from their family. When you see them at the recent general membership meetings, the tobacco settlement for tobacco Annual Meeting just give them an extra we had one of the largest crowds in prevention and control. hug. Also, at the time of this Bulletin, some time. I would like to also thank A recent survey indicated that your PCMS Search Committee, chaired you for attending. funding for state health programs, i.e. by President-elect, Patrice PCMS remains concerned about Healthy Options and Basic Health, Stevenson, will have selected a new issues extremely important to patient remains inadequate to meet the executive director. Let us all warmly care and viability of medical practices. programs' demand. Medicaid payments welcome the new director to the While trying to prepare ourselves for for health services remain at one-half PCMS. So. I’ll conclude by saying the future, we met some of the major of the private insurance carriers. thank you to all of you for your support “players” in the area. These included Medicare payments in Washington of me. the top executives of Good Samaritan, state rank 45th nationally. Meanwh i le, Happy Holidays. Merry Christmas. Puget Sound, The Franciscans, and as premiums for commercial health Happy Hanukkah. Happy Kwanzaa. Multicare. We were given some of insurance continue to climb, payment Doug, we’re all going to miss you. their goals and plans for the millennium. to those who actually provide the —CMW

December, 2000 PCMS BULLETIN 3 B u l l e t in

New national drunken Medicaid Reminder: driving standard set Monitor Healthy Options President Clinton signed legislation last month setting the Plan Affiliations national blood-alcohol level — the standard for drunken driving — at .08. This step is consistent with AMA policy, which calls for an even lower national BAC level. It’s important to check the Medical Assistance Administra­ At 0.08% BAC, a 170-pound man could consume four tion (MAA) W eb site to confirm their health plan affiliations. drinks in one hour before reaching the limit, while a 137- Health plans are required to have adequate networks of pound woman could have three drinks. Currently, 31 states practitioners, so it’s important to ensure those networks are set the drunken driving limit a t. 10. The remaining 19 states represented accurately. To check your affiliations: and the District of Columbia, already have the 0.08% BAC on the books. Based on the new law, the 3 1 states without the .08 1) Go to the state’s “Internet Provider Director” at https:// laws will lose a significant amount of federal highway funds if ww2.wa.gov/dshs/maa/ipndweb/ - there is a “How to Use” they fail to implement the new standard by 2003. Supporters of section for guidance the new standard say it will save an estimated 500 lives a year 2) The simplest approach: search “By Provider Name,” and prevent thousands of injuries. by entering the physician's name Washington State’s drunk driving limit is .08% .® 3 ) Enter a "Program” section. For Medicaid, select Reprinted from AMNews, 11/20/00 “Healthy Options” (you may also review' other state programs if you wish) 4) IM PORTANT: If the search results display a plan or More doctors advising plans that you DO NOT participate in, NOTIFY THAT PLAN IMMEDIATELY advising them to remove your patients to quit smoking name from their roster! s)! Doctors may be doing better when it comes to advising their patients to quit smoking, according to data published in Also, please notify both M A A , using the “contact us” the September 8 Centers for Disease Control and Prevention reference at the bottom of that w'eb page, and the WSMA by MMWR Weekly Report. sending an email to our general email address, The HCFA and the CDC examined information gathered www.wsma.org. The W SMA is monitoring these problems and from the 1998 Health Outcomes Survey in order to character­ will present that evidence to MAA. ize smoking and the frequency of doctors’ cessation advice to WSMA is working to prevent any misrepresentation of Medicare managed care patients. About 13% of enrollees the physician networks of the health plans in Medicaid reported that they were current smokers. Among those who Healthy Options. For questions, contact Bob Perna at the visited a p hysician in the past year, approxim ately 71 % WSMA office, [email protected]. ■ reported receiving smoking cessation advice. This figure Reprinted from WSMA Membership Memo, represents a significant increase over statistics from the early N ovem ber 10, 2000 1990s. Overall, the advice to quit increased with the number of doctors' visits." Reprinted from AMNews, 11/20/00

Allenmore Go Online for AMA dues discount

Psychological If you haven't already renewed your AMA mem­ ■ (B Associates, P. S. bership, you can now do so online - and receive reduced rates in the process. Members who renew their 752-7320 membership through the AMA Web site will receive a 10 Do you have patients with difficult emotional percent discount on their membership dues. The offer and stress-related problems? Psychiatric and also is good for first-time members, so now is the perfect psychological consultations are available. time to encourage your colleagues to join. Go to: www.ama-assn.org/mem-data/mem-main/liow.htm Union Avenue Professional Building for more information. ______1530 Union Ave, S.. Ste. 16. Tacoma______

4 PCMS BULLETIN December, 2000 C Pierce G oun/y (JlC ed ica[< S ociefy

inuiles you and your spouse or (jue.sl to ffie

2 0 0 0 A N N A ETTNC

Tuesday, December 12, 2000 Social Hour: 6:30 p.m. Sheraton Tacoma Hotel, Ballroom Dinner: 7:00 p.m. 1320 Broadway Plaza, Tacoma Program: 8 :1 5 p.m.

featuring ALLEN AJVLE. GOSPEL CHOIR

Williard Loggins az Victoria Woodards, Choir Directors

♦Introduction ofthe 2001 Officers ►Please bring an unwrapped toy (child) and/or a wrapped gift (woman) for YWCA Shelter residents

Please return before Friday, December 8 to: PCMS, 223 Tacoma Avenue South, Tacoma, WA 98402 You may fax to S72-2470 or call 572-3667 for more information

Please reserve dinner(s) at $40 per person. Enclosed is my check for $______

Or, charge my credit card # ______Expiration date:______

□ Visa □ Master Card Signature:

My name for name tag: (please print or stamp):_

My spouse/guest name for name tag:______

Please join us!

December, 2000 PCMS BULLETIN 5 B u l l e t in

WSMA sets priorities for 2001 Personal Problems Legislative Session of Physicians Committee With the 2001 Legislative Session coming soon, the WSMA is busy preparing their annual agenda. The agenda is based on organizational priorities and action taken at the annual meeting in September. Priority items include:

• Adequate funding for public health programs and physician Medical problems, drugs, alcohol, practices retirement, emotional, or other such difficulties? • Opposition to other health care groups’ perennial attempts to intrude into the scope of practice of physicians • Supporting the Liability Reform Coalition (LRC) agenda and introducing, if necessary, separate tort legislation germane to the Your colleagues medical profession. w ant to help • Opposing legislatively mandated sharps protections as unneces­ sary due to WISHA workplace regulations • Aggressively fighting efforts to further fraud and abuse legisla­ *Robert Sands, MD, Chair 752-6056 tion in our state Bill Dean, MD 272-4013 • Preserve funds from Tobacco Settlement for tobacco prevention/ Tom Herron, MD 853-3888 control Bill Roes, MD 884-9221 F. Dennis Waldron, MD 265-2584 The agenda will be adjusted as the legislative session nears. The WSMA expects to review over 2,000 pieces of legislation and will be actively engaged in several hundred bills as part of their work to represent physician interests.

Mark your calendar for the WSMA Legislative Summit in Olympia, on Tuesday, January 23rd. (See page 7) ■ Confidentiality Assured

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6 PCMS BULLETIN December, 2000 fPie-rce '~y{ier!t<'al

Be aware of new “Managed Care” developments

of Health Insurers A new strategy for carriers to save There is such concern in the ► Fraud & Abuse Enforcement money is being coined “the new man­ medical community regarding this and What it Means for You aged care.” issue that Andy Dolan, JD. will be ► White Collar Crime Enforce­ Health insurers now know that the presenting at seminars statewide to ment old managed care, with insurers’ educate physicians and their staff ► Sequelae of health Insurers' heavy-handed controls on care deci­ members. Mr. Dolan, an attorney in Decisions about Physicians sion is no longer acceptable. Yet, there private practice, specializing in ► Strategies for Physicians- are strong indications that a new form health care law, represents physician Prevention, Defense, Of­ of managed care is being implemented, practices throughout Washington. fense which is potentially worse than its pre­ He has worked closely with orga­ ► Disassociating Your Practice decessor. nized medicine for many years. from Health Insurers For example, insurers can conduct The seminar, “Health Insurers’ audits of your practice, through which "Fraud and Abuse” Enforcement: For registration information, you they have broad discretion to scruti­ The New' Managed Care?” is spon­ may call PCMS and we will fax a reg­ nize and pronounce your medical sored by WSMA and will be held on istration form to you or you may call records to be "inadequate.'' judge your Friday. D ecem ber 15 in Tacom a at Becky Harrington, 1-800-552-0612 at selection of CPT codes to be guilty of the Sheraton Tacoma Hotel, 12:30 to the W SM A office. ■ “upcoding" and allege that your billing 4:30 p.m. practices are “fraudulent” and "abu­ Topics include: sive,” in whatever manner the insurers Excerpted from WSMA Membership choose to define those terms. Such al­ ► Cost Containment Strategies Memo, November 10, 2000 legations can result in huge demands for refunds from your practice, termi­ nation of your agreement with an in­ surer with or without cause, and filing a report with a national data bank for performing fraudulent or abusive bill­ WSMA Legislative Summit ing activities. These accusations can easily Tuesday, January 23 in Olympia cause you to incur considerable ex­ pense, in defending your professional The annual WSMA Legislative Afternoon activities will include reputation and your continued ability Summit will be held on Tuesday, physicians meeting with their own to practice. Under practice agreements January 23 at the West Coast Olympia legislators as well as the following with insurers, physicians may not have Hotel in Olym pia. sessions: any effective remedies. The m orning’s ♦House Health Care activities include Committee Hearing (as well continental breakfast as other hearings) Organ S^Tissue and presentations by ♦"New to the Process,” A legislative speakers learning experience about DONA T I O N such as the Speaker the Legislature of the House, ♦Guided Tour of the Com mittee Chairs, Legislative Campus Executive Branch ♦Meetings with Executive Leaders,etc. Branch leaders During the lunch Share Your Life. session, W SM A will There is no charge for present their legislative priorities for WSMA members to attend the Legisla­ Share Your Decision.™ the session, as well as offer talking tive Summit. Please call PCMS, 572- points and tips on how best to influence 3667 for a registration form or you may For more information on organ and tissue call Patti Smith at the WSMA 1-800-552- donation please call LifeCenter Northwest your own senators and representatives. toll free, 1-877-275-5269 0612 for more information.*

December, 2000 PCMS BULLETIN 7 Fees for searching and duplicating medical records

As of July 1, 1999. fees that WAC 246-08-400 allows medical providers to charge for searching and duplicating medical records increased. The WAC allows lor Statutory Authority RCW 70.02.010 and states the following:

RCW 70.02.010( 12) allows medical providers to charge fees for searching and duplicating medical records. The fees a provider may charge cannot exceed the fees listed below:

(1) Copying charge per page: (a) No more than seventy-nine cents per page for the first thirty pages: (b) No more than sixty cents per page for all other pages.

(2) Additional charges: (a) The provider can charge an eighteen dollar clerical fee for searching and handling records; (b) If the provider personally edits confidential information from the record, as required by statute, the provider can change the usual fee for a basic office visit.

(3) This section is effective July 1. 1999 through June 30. 2001."

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8 PCMS BULLETIN December, 2000 Clean Air For Kids™: by Ms A Partnership to Fight the Crisis of Asthma

I arrived early in the office in May and is based on the American Lung As­ team approach. Genevieve worked with to prepare for a meeting. The phone sociation of Washington's Master the landlord to relocate the family rang at 7:00 am and when I answered I Home Environmentalist™ program and while the problems were being miti­ heard a sigh and then, "thank you so the Asthma Outreach Project that is gated. In the meanwhile, Genevieve much for being there I need your conducted by James W. Stout, MD, scheduled multiple visits with the family help.” After I sat down in my chair, I MPH and LaTonya Rogers at the which allowed her to assess not only the heard a story about a woman and her Odessa Brown Children's Clinic in environmental factors contributing to son that is becoming far too common. Seattle, WA. Jake’s ongoing asthma symptoms, but Penny, the woman who called, was The first step in our process to to determine the economic and social a middle aged mom, recently divorced help Penny was to send her to the issues facing the family. Here’s what and scraping for every dollar by piec­ Tacoma-Pierce County Health Depart­ she found: ing together part-time jobs, while try­ ment to speak with Frank Dibiase, ing to care for her son, 3 and ° year old Community Environmental Health “Jake and Penny were not enrolled in Jake. Jake had been diagnosed a year Specialist, who recommended that he Basic Health Plan of Washington earlier with moderate persistent asthma come out to her house with a volunteer °Jake had not seen a doctor for his but had changed homes so much during to conduct an environmental assess­ asthma in the last 4 months the separation and ultimate divorce of ment of the home. °Jake had very little medication left in this parents, that his care was sporadic Home environmental assessments the house at best. are free to any resident of Pierce County °Jake did not have consistent medical Jake’s asthma was originally who is affected by allergies or asthma. care treated with Cromolyn but when the A trained volunteer from the Master °No asthma management plan was medication and prescription ran out, he Home Environmentalist™ (MHE) present for Jake only had a small supply o f albuterol re­ program* is assigned to a family upon "Mother smoked in the house and maining. their initial inquiry. The volunteer then around Jake Penny had moved with her son goes to the home and conducts an as­ °Dog slept in Jake’s bedroom into an apartment, and was finally feel­ sessment ofthe environment, focusing °No dust control plans existed ing that her life was settling down. on things that can trigger allergies or Only two days after moving in, how­ asthma episodes. The volunteer is Here’s what the Clean Air Kids™ ever, Jake’s coughing at night was so trained to offer low or no-cost solutions program did for Penny and Jake. The bad that Penny had to call someone. for improvement of the home environ­ team: She did not feel she could call the pri­ ment, and then does a follow-up phone mary care provider because her ex-hus­ call two weeks later to see if the family 1) Supervised the mitigation of the band still had not paid an outstanding needs additional assistance. A copy of apartment and ensured that all bill and she could not afford it. So, she the home action plan is left with the improvements were sound and called the American Lung Association family and a second copy is sent to the relatively permanent. of Washington and asked us, one early physician, with the family's permission. 2) Provided an application for the morning, for help. And help for Penny, The most significant problems for Basic Health Plan of Washington Jake and others like them is what we Jake were two fold: there were large 3) Worked with the primary care intended to provide. amounts of mold growth in the home provider to handle the overdue pay­ Through a grant from the National and on-going water damage; and, the ments and clear the way for Penny to Heart, Lung and Blood Institute, the mother smoked in the house. The im­ schedule a medical appointment for Tacoma-Pierce County Health Depart­ mediate need and recommendation was Jake. ment and the American Lung A ssocia­ to have the exposure to mold problem 4)Made sure Jake received, posted and tion of Washington have initiated an fixed. adhered to the asthma management plan asthma prevention partnership to alle­ Frank called the American Lung through follow-ups with the family. viate the impact of asthma on children Association of Washington and we in­ °5) Recommended the mother quit and families in Pierce County. The pro­ troduced our Asthma Outreach smoking and provided information on gram is called Clean Air For Kids™ Worker, Genevieve Schmidt, into the See “Clean Air" page 12

December, 2000 PCMS BULLETIN 9 New Members Directory changes

BAKER, JAMES, MD GE, ZHENG, MD, PH.D Please make note of the following Family Practice Nephrology changes to your 2000 PCMS Directory. Practicing at Gig Harbor Medical 1802 S Yakima, #208, Tacoma 98405; Deyo, Glen, MD Clinic, 6401 Kimball Drive, Gig Harbor Phone: 627-5755; FAX 627-5755 Change Zip Code to 98418 98335 Medical School: Shanghai Medical Phone: 474-5530; FAX 475-1185 Phone: 858-9195, FAX 858-4348 U niversity Physicians only: 474-4861 Medical School: State University ol' Internship: Mt. Sinai Medical Center New York at Buffalo Residency: Mt. Sinai Medical Center Etzkorn, Eugene, MD Internship: Providence Hospital. Seattle Fellowship: Stanford Medical Center 3611 South D Street. #21, Tacoma 98408 Residency: San Bernardino County Phone:474-4667; FAX: 476-1437 General Hospital NERKAR, MANISH S., MD Internal Medicine Knight, Ronald W., MD DOBBINS, JILL, MD 1708 S Yakima, Tacoma 98405 1802 S Yakima, #102, Tacoma 98405 Radiology' Phone: 627-9151, FAX 593-8418 Phone: 272-7777 Practing with Diagnostic Imaging NW. Medical School: Indira Gandhi Physicians only: 383-4564 222 15lh Ave SE. Puyallup 98372 Medical School FAX: 383-9109; UPIN#A08776 Phone: 841-4353 Internship: Thanis Jefferson Univ Medical School: Univerity of Residency: Thomas Jefferson Univ Washington Medical School Sullivan, Rebecca, MD, CEO Internship: Maine Medical Center YOUNG, CHRISTOPHER, MD Puyallup Valley Healthcare Residency: Maine Medical Center Family Practice 1317 East Main, Puyallup 98372 Phone:435-7181 South Hill Family Medicine, 3908 - FAHMY, JANA L., MD 10th Street SE, #200, Puyallup Radiology Medical School: Univ of Washington Practicing with Pacific Nephrology Internship: Valley Medical Center Assoc. Phone: 383-1099. FAX 383-3919 Residency: Valley Medial Center Medical School: Loma Linda University School of M edicine Internship: Loma Linda University Medical Center Residency: Loma Linda University Medical Center MEDICAL LICENSURE ISSUES Fellowship: Childrens Hospital of LA Mr. Rockwell is available to represent physicians and other health care providers with issues of concern before the State Medical Quality Assurance Commission. Mr. Rockwell, appointed by Governor Booth Gardner, served for 8 years as the Public Board Member of the Medical Disciplinary Board from TACOMA/PIERCE COUNTY 1985-1993. Since then, Mr. Rockwell has successfully represented over 60 physicians on charges before the MQAC. Mr. Rockwell’s fees are competitive Outpatient General Medical Care. and the subject of a confidential attomey-client representation agreement. Full and part-tim e positions available in Tacoma and vicinity. Gregory G. Rockwell Very flexible schedule. W ell suited Attorney at Law & Arbitrator lor career redefinition for 3055 - 112th Avenue SE, Suite 211 GP, FP, IM. Bellevue, WA 98004

Contact Andy Tsoi, M D (253) 752-9669 (425)822-1962 • FAX (425) 822-3043 or Paul Doty' (Allen, Nelson, Turner email: [email protected] • website: “ggrockwell.wld.com” Assoc.), Clinic Manager (253) 383-4351

10 PCMS BULLETIN December, 2000 Federico Cruz-Uribe, MD The Health Status of Pierce County D irector o f Health

The Emergence of Antimicrobial Resistance

Few physicians alive today know pact of environmental residues is not what it was like to treat patients in the known, we do know that chronic low- pre-antibiotic era. The rapid develop­ dose exposure to antibiotics selects for ment of antimicrobial agents in the resistant strains of bacteria. HEALTH 1940s and 1950s revolutionized m edical Antimicrobial resistance is a rapidly DEPARTMENT and surgical care, leading some to pre­ growing problem in Pierce County. dict that infectious diseases would one Between 1995 and 1999 the percent of •Making accurate diagnoses by day be eliminated. Today, with newly S. aureus isolates resistant to methicillin using culture and sensitivity testing emerging, reemerging, and drug-resis­ (MRSA) doubled in Pierce County, whenever possible, so that treatment tant pathogens threatening to reverse growing from 10% to over 20%. MRSA can be well-targeted at the offending the gains of the last half century, we is usually multi-resistant, and we are m icrobe are humbled by the realization that seeing decreased sensitivity in S. •Revising empiric treatment based evolution is perhaps one of the stron­ aureus to almost every available drug. on lab results, if neccssary gest forces in nature. Only 84% of E. Coli isolates were sen­ •Using narrow spectrum agents By engaging in an arms race with sitive to trimethoprim/sulfamethoxazole whenever possible, in order to pre­ microorganisms, the ammunition we in 1999. National data on streptococcus serve broad spectrum agents for seri­ previously relied on is no longer ef­ pneumoniae resistance to penicillin, ous infections fective. We m ust continuously find which rose from 0.2% in 1989 to 18/7% •Reminding patients who are new, stronger weapons. But is this an in 1996-1997, has prompted consider­ given an antibiotic to finish the entire arms race we can win? Only one new ation of doubling the dose of course class of antimicrobial agent has been amoxicillin for acute otitis media. •Not giving in to patient demands developed in the last 30 years. We are The problem of antimicrobial resis­ for a prescription or for a specific drug running out of novel ways to kill patho­ tance has many causes. Because of this, is such treatment is not indicated gens. And if we do not judiciously use the solutions will involve almost every •Following guidelines for treat­ new drugs, every new agent will have sector of society, from industry to ment o f com m on infections a short useful life because resistance health care to private citizens. The •Avoiding the use of antibiotics to will inevitably develop. Tacoma-Pierce County Health Depart­ treat infections likely to be viral, such At the present time antimicrobial ment is bringing together people from a as the common cold agents are used fairly indiscriminately variety of disciplines to collaborate on •Practicing rigorous infection con­ in the United States. The CDC esti­ finding and implementing strategies to trol in every aspect or practice mates that 50% of antibiotic prescrip­ this growing health threat. This task •Keeping patients' immunizations tions written by physicians are unnec­ force will work on factors that impact up-to-date essary. A recent study o f W ashington antimicrobial resistance in inpatient and •Educating patients about antimi­ state hospitals found that 39% of vanco­ long-term care setting, outpatient and crobial resistance mycin orders were inappropriate. Anti­ community settings, and agricultural •Educating resident physicians biotics are sometimes used to treat non- and veterinary settings. about antimicrobial resistance infectious conditions such as de­ Because physicians have a great creased gastric motility. Many veteri­ deal of control over the use of antimi­ And, if you are interested, you can nary antibiotics can be purchased with­ crobial agents, they will play a signifi­ participate in the Interdisciplinary Task out a prescription. Livestock are fed cant role in stemming the tide of resis­ Force on Antimicrobial Resistance. For antibiotics in subtherapeutic amounts to tance. And ensuring that effective inform ation about antim icrobial resis­ promote growth, and whole-herd-dos­ agents are available to treat serious in­ tance or to join the Task Force, contact ing for prophylaxis or therapy is com ­ fections in the future is in everyone’s Monica Raymond, Epidemiologist. Anti­ mon. Antibiotics are also used in fish­ interest. As a physician, you can do a microbial Resistance Program, farming, bee-keeping, and are sprayed great deal to promote judicious antimi- Tacoma-Pierce County Health Depart­ on fruit trees to treat or prevent infec­ robial use and reduce resistance, such ment at 253-798-2873 or tions. Antimicrobials have been found as: [email protected]/ in sewage effluents. Although the im­ See “Antimicrobial” page 17

December, 2000 PCMS BULLETIN 11 B l 11.1,1- I IN

Clean Air from page 9

smoking cessation classes. Until then, educated the mother on the necessity to smoke outside and wear a smoking jacket that should slay outside as well. What problem And, again, followed up with home visits to determine if smoking was really occurring outside. can we solve 6) Provided dust covers for the bed mattress and pillow. Talked about cleaning techniques for .lake's for you today? bedroom and sheets. 7) And. became an advocate for the family to help them get to the fresh start they were longing to achieve. As an advocate, the outreach worker will assist primary care providers by working with the families to make sure the asthm a m anagem ent plan is 1 ^ Computer Networking understood and being used appropriately. The outreach worker can f t General Computer Support also provide valuable feedback to providers as she spends time with the family and gets to know them in their ^ Security and Virus Protection every day environment. The services of the Clean Air for @ Custom Development K idsIM program can be accessed in a variety of ways. The family can con­ tact the program directly, the physician Internet Connectivity can initiate contact, or a school nurse or childcare provider can call with a referral. Contact Prank DiBiase at 798- 7674 or Cicnevievc Schmidt at 272- 8777. Please keep this initiative in mind when you see your next motivated family who could use some help!

* MHli volunteers have passed a We can help you. Washington State Patrol criminal history check and serve under the Managing technology is no easy task. supervision of the Tacoma-Pieree County Health Department. They have IT Source can help you solve computer also completed a 30-hour training that covers basic information on asthma, problems so you can get on with more landlord tenant issues, cultural sensitivity, biological hazards, dust, important things...like your business. toxicology, behavior change theory and an overview of common indoor air quality problems. Volunteers backgrounds range anywhere from physician assistants and nurses to college students and real estate agents 253.835.1200 and people who have a general www.itsource.com concern about the environment IT s o u rc e overall. Many of the volunteers have 2000 IT Sourco, A Continuum Company asthma and allergies themselves. ■

12 PCMS BULLETIN December, 2000 In My Opinion.... The Invisible Hand by A ndrew Statson, M D

Purchasing Power

“Plurality which is not reduced to unity is confusion; unity which does not depend on plurality is tyranny. ” Blaise Pascal (1662) \ndrc'.\ .V/ivrv,)//. MD

The cost of prescription drugs has sketchy and there are no details of how lives, however, was picked up by some created quite a stir lately. When pa­ that distribution system worked. In any enterprising managers, who started tients paid for their prescriptions out of event, sensible management of gov­ commercial ventures. Perhaps the most pocket, they were the only ones to ernment programs, such as buying in successful of these is Costco. It is a complain and were all too often ig­ times of plenty, when prices are low, commercial organization with a mem­ nored. As various insurance companies and selling in times of scarcity, when bership fee. This fee has both an eco­ and government programs started cov­ prices are high, is rare. nomic and a psychologic effect. It as­ ering prescription costs, they felt the There are records of the Roman sures the company a certain minimum pinch as well. At the same time, partly Republic from the second century' BC, income. At the same time, the members because of prescription drug cover­ which show that in times of shortages are encouraged to shop there, be­ age, but also because many new and the state purchased grain at the market cause, after all, they paid for the privi­ better drugs appeared on the market, price and sold rations to the citizenry at lege. The prices are low, because the the spending on pharm aceuticals rose lower prices, at the expense of the Ro­ stores concentrate on high volume faster than that on medical services and man Treasury. I think this program items in large packages. The choice is became a much larger part of total started with the populist laws of the limited to the most popular products, health care expenditures. Gracchus brothers, enacted when they frequently sold in only one size. A number of options are being were tribunes, and continued through Costco has been successful because it considered to remedy this situation. For most of the years of the Roman Empire, has used its purchasing power where it instance, Governor Locke recently as illustrated by the slogan “bread and could do the most good. suggested the formation of a purchas­ circuses.” How can the state emulate that? ing group for senior citizens, a pre­ During the inflation of the 1970s, The difference in cost between whole­ scription drugs buyers club, which will many people got together to buy gro­ sale and retail is due to the work of the have a membership fee and will be ceries on the wholesale market, trying retail stores. They provide a useful connected with the state Uniform Medi­ to save money. The results were rather service, or they would not be around. cal Plan. By using the purchasing disappointing and these purchasing The people who work in the distribu­ power of the state, he hopes to reduce groups slowly faded away. They could tion channel expect to be paid for what the cost of medications for this popula­ not compete W'ith the grocery stores on they do. If the need for their services tion. fresh produce. There was too much can be reduced or eliminated, the cost Purchasing cooperatives have ap­ work and too much spoilage during the of the product will drop. For instance, peared periodically on the scene, usu­ distribution process to make it worth­ the state of Oregon requires that gas ally at turbulent economic times, to help while. The system worked reasonably station attendants pump the gas. They people through a crisis. Some of them well for dry goods, mostly because the have no self-service stations. This re­ have been private; some, public. The people who did the buying and the dis­ quirement certainly is not based on latter are more likely to have been re­ tributing worked at no pay. Eventually, economics and, as a result, Oregon mo­ corded. The biblical story of the seven the system broke down. It required too torists pay about 20 cents more per gal­ fat years and the seven lean years is much effort to justify the benefit. lon than we do in Washington, where one example. The information given is The idea of purchasing coopera- See “Purchasing” page 14

December, 2000 PCMS BULLETIN 1 B u l l e t in

Purchasing from page 13

While this discussion is going on If our goal is to reduce govern­ we hardly have any contact with an at­ in this country, some border towns in ment, as Mr. Bush proposes, or to rein­ tendant. Canada are setting up clinics for vent it, as Mr. Gore suggests, allowing A bottom of 100 Tylenol tablets in American patients where, for a nomi­ unrestricted access to the international the drugstore costs about the same as nal fee, we can get a brief examina­ market would be a step in the right di­ one tablet to a hospital patient, in spite tion and a prescription, so that we can rection. The argument that such im­ of the purchasing power of the hospi­ buy our drugs there, at lower prices. ported drugs may not be pure or safe tals. In the drugstore the patient walks It seems the main reason for the dif­ enough for our use is a spurious one. through the aisle, picks up the bottle ference in drug prices is the restric­ We have not heard that Canadians or and pays at the checkstand. The tion on the importation of medications Europeans are having problems with people involved in this service are a to this country. If our pharmacies the purity or safety of their drugs. We Stocker and a checker. In the hospital, could buy their drugs from interna­ also import large amounts of foodstuffs the physician has to write the order on tional suppliers on the open market, from other countries and so far we the chart; the nurse has to check the the cost of medications may drop by have not suffered from any significant time of the last dose, request the next 50%. The end result would be the food poisonings. We have had more dose from the pharmacy, take it to the same as if the federal government problems with our domestic products. I patient and wait to make sure he took it, had paid for half the prescription am afraid such a solution is much too then go back to the chart and record costs, as it has proposed to do for simple to be adopted, but we can al­ the event; the pharmacist has to dis­ Medicare patients. ways hope.* pense the medication and make an en­ try in his own record. Somewhere along the line billing clerks, insurance companies and accounting department get involved. No wonder it costs so much. To save money on prescriptions, i- j 1 / \ 'jW \'3 X A '$ the patients should be able to buy them in bottles of a hundreds, three hun­ J J _/ \_y~A_i dred, or perhaps even a thousand. Kings Silvers Halibut Lingcod When a pharmacist has to open a bottle of a hundred and count out thirty or This Summer, fish . ninety tablets, because that is what the where you’ll feeljlf insurance company requires that he like family! dispense, he has to be paid for this ser­ Our business is built Ofli vice. The final cost frequently is more repeat clients, therefore: than to just hand out a bottle of a hun­ we strive to provide ths dred tablets. Even though the state may finest service in Sitka.) When you book with u| pay for a large amount of rescription your package will drugs, the cost of distribution will not include everything" be reduced if they have to be dis­ you’ll need from pensed in bottles of thirty. The people fish processing in the distribution channel will still have to lodging and to be paid. dinners at Sitka’s finest restaurants.There are The state could establish drug­ no hidden extra costs. We only cater to a maximum stores, where people could buy their of 4 per trip so you can be assured the medications. If the example of the li­ utmost in personal service. quor stores means anything, it is not go­ Call us. Let’s plan your memories today. ing to be cheaper. In spite of the pur­ chasing power of the state, liquor is enny’s Guide Service more expensive here than in states like 1-888-847-3659 California, where it is retailed by pri­ www.sitkafishcharters.com [email protected] vate stores.

14 PCMS BULLETIN December, 2000 COLLEGE Continuing Medical Education Cardiology CME scheduled for MEDICAL consecutive Tuesday evenings This year's Cardiology for Pri­ from their daytime office hours. EDUCATION mary Care CME program will be of­ The College's sixth annual pro­ fered on two consecutive Tuesday gram featuring subjects on cardiology evenings in January, instead of the tra­ for the primary care physician will be ditional 6 hour program on a Friday, held at St. Joseph Hospital, Laqerquist This year's program is scheduled for Conference Center Rooms 1A and B. Whistler CME Tuesday, January 9th and Tuesday, The course director is Gregg January 16th from 6:00 p.m. to 9:00 p.m. Qstergren, DO. January 24-27, on both nights. Topics include Genetics & The program will begin with Hyperlipedemia; ACE/ ARB Combina­ condos full speakers on the 9th - three hours of tion?; Are Beta Blockers Underutil­ CME and end with three additional ized?; New Strategy in Treating Hy­ hours of CME on the 16th. The change pertension: Optimizing in Patient Out­ The CME at Whistler program is is in response to expressed interest by comes; Women's Cardiology: Evalua­ most popular this year. The College's physicians from the College's recent tion, Diagnosis and Management and reserved block of condos at Black- CME survey. Many physicians are Lipid Intervention for Primary and comb's Aspen Lodge have all been finding it more difficult to take time Secondary Prevention oif CAC. ■ reserved. The usual block and additional Aspen condos were booked prior to the December 1 deadline. At press time, four Chateau Dates Program Directors) Whistler Hotel rooms (part of a block often) were available. Those inter­ Tuesdays, January 9 Cardiology for Primary ested should inquire on availability and Gregg Ostergren, DO call1-800-606-8244 and mention the and 16 (evenings) Care College. Those still interested in other Wednesday-Sunday Richard Tobin, MD possible lodging should call individual CME at Whistler facilities or a central toll free number, January 24-28 John Jiganti, MD 1-800-WHISTLER. This year's program is under the Advances in Women's Friday, February 9 John Lenihan, Jr., MD direction of Drs. John Jiganti and Medicine Richard Tobin. Program topics include: TBA Pain Management David Paly, MD • Management of Inflammatory Bowel Thursday-Friday Internal Medicine Disease Ulrich Birlenbach, MD • Advances in Treating Your Geriatric March 8-9 Review 2001 Patient • Review of Skin Cancer: The Role of Saturday, April 28 Surgery Update 2001 Glenn Deyo, MD the Mohns' Technique Allergy, Asthma & • Recent Advances in Insulin Therapy • CommonHand Problems Friday, May 4 Pulmonology for Alex Mihali, MD •"The Plague" Primary Care • Advances and Retreats in Infectious Tuesdays, May 16 and Diseases Medical Technology TBA • Interesting Case Studies 23 (evenings)

December, 2000 PCMS BULLETIN 15 Antimicrobial from page 11 pierce, wa.us Just as it was naive to believe in the 1950s that infectious diseases would be eliminated, it is naive for us to believe today that we will always develop a new drug to kill resistant organisms. Even without restrictions on funding and lengthy approval pro­ cesses, this is an unrealistic goal. Our technology simply cannot outcompete the evolutionary prowess of single-celled organisms. If we wish to avoid returning to the pre-antibiotic era when we were virtually powerless against infectious diseases, we must learn to view antibiotics as they truly are: precious, life-saving agents.

RESOURCES:

General information about antimicrobial resistance: Alliance for the Prudent Use of Antibiotics: http://www.healthsci.tufts.edu/apua/

Detailed treatment guidelines for the judicious use of antimicrobial agents in upper respiratory tract infections, otitis media. pharyngitis, acute sinusitus. cough illness/bronchitis, and the common cold: http://www.cdc.gov/ncidod/dbmd/antibioticresistance/other.htm

Brief treatment guidelines (Academic Detailing Sheets) for otitis media, rhinitis/sinusitis, pharyngitis, cough illness/bronchitis: http://www.cdc.gov/ncidod/dbmd/antibioticresistance/materials.htm

Guidelines for the prudent use of vancomycin: Recommendations for Preventing the Spread of Vancomycin Resistance: http://aepo-xdv-www.epo.cdc.gov/wonder/prevguid/m0039349/m0039349.htm

Recommendations on prophylaxis for traveler’s diarrhea: http://www.heatlhsci.tufts.edu/apua/Newsletter/Borbach.html

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December, 2000 PCMS BULLETIN 17 V .

B u l l e t i n

Antibiotic prescribing for children is on the decline

Physicians are prescribing respond to antibiotics and are there­ upper respiratory infections including antibiotics less frequently to treat fore not appropriate indications for the common cold, bronchitis and cMdren with respiratory illnesses, antibiotic use. sinusitis; and sore throats decreased by according to results of a Centers for The study demonstrated a steady 34% between 1989 and 1998. In 1989 Disease Control and Prevention decline. For example, the annual rate and 1990, approximately 669 prescrip­ survey presented at last month's at which office-based physicians tions were written for every 1,000 meeting of the Infectious Diseases prescribed antibiotics in cases where children. Between 1997 and 1998, the Society of America. the patient was younger than age 15 rate was 439 per 1,000 children. ■ "Our survey suggests that physi­ and diagnosed with infectious respira­ cians are getting the message that the tory diseases; middle-ear infections; Reprinted from AMNews, 11/20/00 overuse of antibiotics can be harmful," said Linda F. McCaig, MPH, a survey statistician at the CDCNational Centers for Health Statistics, in a statement issued by IDSA. please send your According to the CDC, about half of all antibiotics prescribed during email address to us at: office visits are for colds, coughs and other viral infections that do not [email protected]

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20 PCMS BULLETIN December, 2000