Chart Notes®

M A R I O N - P O L K C O U N T Y M E D I C A L S O C I E T Y

O C T O B E R 2 0 1 5

Leadership Corner | 3

Looking Back | 4

Interview Dr. Hannig | 6

Wealth Management | 8

Legally Speaking | 10

Risk Management | 18

notes

October marks the 145th anniversary of the Marion-Polk County Medical Society,

and a “Looking Back” article seemed apropos. Unfortunately, Howard Baumann MD, our local medical history expert, was off travelling, so the task fell to me. Let me start by saying I am not a historian. I happily confess avoidance of all history classes since AP US History in high school. A good historian verifies facts from at least two independent sources - don’t expect that from me. I may also have simplified things a bit for the sake of story, but the basic gist is true.

When I began my research, I was surprised at the scarcity of historical data. My initial plan - summarizing the evolution of the local medical community since 1870 - quickly fell by the wayside. A historian could spend an entire career on this topic. However, my historical “poking around” revealed that a surprising number of issues plaguing current medical practice have roots dating back a century or more. Here are a few examples for your consideration.

Continued on page 14

We Owe It All to MedicareAlthough we claim altruistic motives, money definitely inspires health care providers to tolerate the challenges of practice. Every time Medicare threatens our fee schedule, the profession is thrown into panic. It is helpful to remember that physician income on the whole still beats most professions. 2014 income statistics from Oregon show family practice docs with a median income around $175,000/year, ob/gyn $225,000, and orthopedic surgeons $434,000. Nurse practitioners and physician assistants receive $100,000-115,000 a year. Even an intern at OHSU currently receives $52,000 annually. The only other major Oregon profession with a comparable median income is chief executive, at $172,000. Oregon lawyers are down at $115,000. (Notice my intentional avoidance of confounding factors like hours worked, years of education, student loans, etc.)

Yet medicine didn’t start as a high paying career. In 1890, the first house physician at Salem Hospital was paid a

We’ve Seen It

All BeforeBy Sheila Sund, MD

PHOTO BY SHEILA SUND, MD

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Marion-Polk County Medical Society

Chris Edwardson, M.D. President, MPCMS

Chart Notes Editorial Board

Sheila Sund, MD Managing Editor

Board Member, MPCMS

Nancy Boutin, MD

Howard Baumann, MD

Layout and DesignIn House Graphics

Marion-Polk County Medical Society

2995 Ryan Drive S.E., Suite 100Salem, Oregon 97301

(503) 362-9669FAX (503) 362-0109

e-mail: info@mpmedsociety.org website: www.mpmedsociety.org

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PRESIDENT ’S messageWhy celebrate 145 years? I say, “Why not?”By Chris Edwardson, M.D.

I can’t say for certain, but I suspect I am six degrees of separation from the

founding members of the Marion Polk County Medical Society. Maybe fewer.

In 1983, when I finished my Family Medicine training in Saskatchewan, my wife and I wanted to return to the Pacific Northwest – I’m from Vancouver BC and my wife’s hometown is Canby. But this was during a recession with double-digit inflation. I called the recruiter about a job in Dallas and he said, “Oh, you don’t want to go to Oregon. Everybody’s leaving Oregon!”

I didn’t let him dissuade me. Two World War II veterans, Dr. Charles and Dr. Casey, had a very full practice, but they had an old-school, casual approach to running their business. They were in their 60s and had been in town since 1951. They wanted to really revive the practice, have a succession plan, and bring in a young doctor to do OB. I asked them if it would be OK if I changed a few things. They said, “Sure. Go ahead and run the practice.”

During the first year I started OB and rotated call with Keith White and Bob Willey. I also picked up ER shifts here at West Valley. After a few years, Charles and Casey wanted to slow down a bit, go part time. Eventually, they sold me the building and then the practice. They both passed away in 1989. I was very close to them and each had asked me to speak at his funeral. Researching for their eulogies, I learned quite a bit about them. I realized there was a lot of history here, a lot of history.

When I first arrived i n D a l l a s , D r. Bosatti, who later became my patient, called me right away. He had just retired, but he said, “I want you to join the Medical Society. I’ll pick you up.”

He did pick me up – in a little convertible that he drove a bit too fast on the back roads to South Salem. He surprised me – he was in his 80s and very zippy. Driving along, buffeted by the breeze, he talked about medicine. He was quiet-spoken, with a dry sense of humor, but he loved the Society. He really opened my eyes to the culture of medicine, the way it was in a genteel time. You understated facts. And you maintained professional courtesy, no matter how much you might disagree with your fellow physician. His was a valuable mentorship.

He took me several times to the Medical Society – until I joined, of course. He continued going to meetings for a number of years, especially when there was an educational component. He enjoyed reminiscing with the members and even wrote down some of his stories for me.

Dr. Bosatti and his partner, Dr. Page, both lived to be 100. They started their practice in Dallas, and joined the Medical Society, in 1932. They give me a direct link dating back more than half the life of the Society – 83 years. Six degrees of separation doesn’t seem like much of a stretch.

Continued on page 9

Chart Notes i s a b i -month l y publication whose purpose is to pro- vide information of interest to the local medical community. Unless stated otherwise, opinions expressed in any article are solely those of the author and are not necessarily endorsed by the Marion-Polk County Medical Society, its employees, officers or directors. Community members who are inter-ested in writing for this publication are encouraged to contact the editors.

Advertising rates are available from the Medical Society office. Acceptance of advertising in no way constitutes professional approval or endorsement of products or services advertised. The Marion-Polk County Medical Society reserves the right to reject any advertising.

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LOOKING BACK in honor of 145 years

During the spring of my surgical internship, a palpable current of unease ran through the faculty.

They warned us, in somber tones, to consider our careers. They told us we had entered the End Times for American Medicine. Medicare had recently announced implementation of Diagnostic Related Groups, and, in so doing, had rent the very fabric of healthcare. Hospitals would fail. Practices would close. No one would want to be a doctor. Henceforth, only C students would apply to medical school.

I decided to go ahead with residency despite their warnings. My husband and I had simple needs. I felt certain that no matter what the future held, we could scrape by on a radiation oncologist’s salary. Yes, we had paid for medical school with loans from First Interstate right there on The Hill, but the total debt equaled the annual pay for a PGY-3, not a private practice neurosurgeon!

I write this on the eve of ICD-10, another threat to the stability of American healthcare, and I know the Republicans are again trying to undo the Affordable Care Act. Despite the dire predictions, I believe the rumors of Medicine’s demise are greatly exaggerated.

My graduate education began at University of Oregon Medical School on a sunny September morning in 1979. The auditorium held 105 students – mostly male, almost all white, generally young, and all anxious to one degree or another. We had so much to learn and a “peripheral brain” meant a pocket full of 3x5 cards, not a smart phone with “Up-to-date” on our favorites list. In those days, a “sim” meant another student let you use them for practice, whether phlebotomy or the evening learn-to-do-a pelvic-exam session.

When I transitioned from Radiation to Palliative Care six years ago, I told the young hospitalists, “Don’t count on me to catch any mistakes. I may have gray hair, but

Rumors of Its DemiseBy Nancy Boutin, MD

the last time I did a medicine rotation, AIDS hadn’t yet been invented.”

We knew in the ’80s that we were in the middle of a knowledge arms race, but I don’t think we could have imagined the changes we would see during our careers. Back then, hours worked was a badge of honor. Surgery residents complained that if they only took call every other night, they would miss half the good cases. Anything under 100 hours a week looked like vacation.

There weren’t many women in the school or in the training programs, so there weren’t many babies—but there were a few. I can’t imagine anyone asking for maternity leave. One

of the OB residents finished a C-section in labor and crawled up on a gurney after an intern wheeled the patient to recovery. During residency, I took my four-day-old to tumor board. Since I scheduled my physics rotation to coincide with my due date, I didn’t have to miss any time at all. After my first baby, a male dermatology resident seemed to take great delight in delaying my lunchtime trips to the peds lactation room. I learned to take a change of clothes whenever we worked together.

Even the women who delayed motherhood faced challenges, especially in surgery. Three of my friends defied the odds and made it through the surgical pyramid at OHSU (the school had changed names twice by that time) and were the first women to do so in the modern era. There

were no female call rooms on surgery wards at the VA because the Chief of Surgery didn’t think there should be women operating at the VA. A few years later, his daughter rotated through and separate call rooms with locking doors magically appeared.

We had no MRIs, and CT scans took forever to run. You could still tell the Hodgkin’s patients by the blue tattoos on the top of their feet from lymphoscintigraphy dye. Older radiologists performed pneumoencephalograms

Continued on page 5

The real – pregnant, cookies, and rockin’ the glasses

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just a few years before I arrived on The Hill. During my first rotation in radiation therapy (the name used between “therapeutic radiology” and “radiation oncology”), workmen removed the Van de Graaff generator (yes, like in high school physics, but much bigger) in favor of a 4 MV linear accelerator.

A visiting surgeon from Salem quietly confided to the students that the lumpectomy fad would only last a few years and then he could get back to real surgery. Extended radical mastectomy, adrenalectomy, and transphenoidal hypophysectomy were all used to combat breast cancer.

By the time I joined the Radiation Oncology faculty in 1987, we had desktop computers in our offices. I could dial up Pub Med, but only because I knew enough DOS commands to do it myself. Otherwise, I had to go to the library where someone else would dial in for me. Colleagues at the Southwest Oncology Group debated getting email addresses, but I couldn’t see how they would be better than the shiny new fax machine we’d installed in the front office.

Medical oncology had only emerged as a subspecialty in the previous decade and had relatively few bullets in the bandolier. At OHSU, we had a separate “Lymphoma Board” and we heard regularly about new acronyms for tumor-busting cocktails. Promace cytabom (pronounced PROMISE SIGHT-A-BOMB) always seemed to offer great lethality, but in the end, CHOP won out. My chairman sent me to a conference in San Francisco to learn about tagged monoclonal antibodies because he could see that immunologic therapies would change oncology. We thought the antibodies would deliver a cytotoxic bomb (radioactive

or poison) to the tumor, and he wanted to make sure radiation therapy didn’t get left behind. We could not see the tsunami of mibs and mabs forming offshore.

Yesterday I heard about IBM’s Watson making cancer diagnoses and formulating personalized treatment plans. I still think human providers will be key to the human delivery of healthcare for the rest of my lifetime. Perhaps technology, which has often taken us away from the bedside, will free us up to return. Maybe we will have enough time to let ethics and compassion catch up with where technology has led us.

So—change. Lots of change. Much good. Often discomforting. But change offers opportunity. Together, I think we are up to the challenge. Nancy Boutin just celebrated her 25th year in the Salem medical community. After 20 years as a radiation oncologist, she is now a palliative care provider and medical director of the Salem Cancer Institute. She is pleased to be back on the pages of Chart Notes. When she’s not taking care of patients or writing, she enjoys quilting and spending time with her grandbabies.

Rumors of Its Demise. . . continued from page 4

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“Relaxing” after call

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LOOKING BACK in honor of 145 years

It was 2005 when Salem Health launched a program to provide around the clock

obstetrical care by “ob- hospitalists.” The need was evident. Migrant workers, women with marginal living conditions and others who had little to no prenatal care would show up at Salem Hospital in labor. Prior to that time, when a patient without an obstetrician appeared at the door, labor and delivery nurses would scramble down a call list, hoping for the best.John Hannig was the first of six ob-hospitalists recruited by Salem Health. In addition to deliveries, they are available for obstetricians on staff who need help with C-sections, or to cover for an obstetrician tied up in the emergency department. There are family physicians that have quit delivering babies, but continue to do prenatal care. The ob-hospitalists are there for those patients as well.

John Hannig (JH): I was in a practice with four partners. I was delivering 40 babies a month and had a full load of gyn patients. I was living in San Diego – a place where you needed to be that busy just to cover the cost of malpractice and overhead. The cost of malpractice was raised just prior to 2005, so we were pressured to see even more patients and do more deliveries. My wife Nancy said I was working too hard, but there didn’t seem to be a choice. I looked for a way to slow down in California, but it’s a place where that doesn’t seem possible. You’ve got to be first in line for everything – first at the grocery store, first in the parking lot, and first to leave from home to beat the traffic. When I interviewed in Salem, I said to myself, “This is a place I can be more relaxed and live a slower life.” It’s just what I was looking for. My schedule is seven and a half 24 hour shifts per month. That leaves time for grandchildren, golf and poker – the things that matter to me most. Chart Notes (CN): Tell us about your early life. JH: I was raised in rural southwest Minnesota, the middle child of nine. My dad was a grocer and kids were cheap labor, so we all helped with the produce and served as amateur butchers. At 5 feet, 8 inches, and a strapping 135

Meet John Hannig, MD:Obstetrician, Board Member, and Secret Texas Hold ’Em Aficionado

By Eric Schuman, PA

pounds, I was the quarterback on the high school football team. You can infer from that how small our town was. I completed my undergraduate degree at St. Thomas University in Saint Paul, and it was then I decided I wanted to be a doctor. We didn’t have any medical people in the family. I did lots of volunteer work at the community hospital in the town where I was raised.

It was in college that I met Nancy, whose brother was my roommate at St. Thomas. Nancy typically came to Minnesota during school holidays. She was 19 when we married, so we’ve been together thirty-eight years. She reminds me that if she’d gotten to know me through the usual process of dating, she would never have married me. I consider Nancy to be my lucky break. Our oldest son was born in my second year of med school. CN: How did you end up in the Navy? JH: While I was still an undergraduate, Nancy announced, “I filled out the paperwork for a military scholarship, and you got it.” There were only 4 mid-year scholarships available. Hundreds had applied, and I was lucky enough to get one. Why the Navy instead of the Army or Air Force? Because I didn’t want to live in Texas or North Dakota! I did a 4 year ob/gyn residency at the Oakland Naval Hospital and served another 4 years at the naval hospital in San Diego. I got lucky – I get seasick in deep bathtubs, so I don’t think I would have done too well on a ship.After a brief stint in Issiquah, Washington, we spent 15 more years in San Diego, and then we came here in 2005. It will have been ten years in October. CN: What is Nancy’s background? JH: She was raised in southern California with a brother and three sisters. She studied child development in college and was trained as a singer and actor. She performed in musical theater while I was in residency – Pal Joey, Brigadoon, Gypsy – oh, and don’t forget Fiddler on the Roof. I don’t think I could stand to listen to it one more time. I think I saw nine performances.

PHOTO BY ERIC SCHUMAN PA

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Meet John Hannig, MD . . . continued from page 7

CN: And your children? JH: Samantha is 32, raising 3 children in Gig Harbor, Washington. Jeffrey is 30 and works in advertising in Portland. Ryan is 36 and works as a behavioralist with autistic children from military families in Tacoma. We have five grandchildren, and we travel a lot to help out as much as we can with them.

CN: What are your leisure time activities? JH: I like golf, but was self-taught at a young age by a mediocre instructor. I just recently started taking lessons with a pro who is straightening out my slice. And believe me, at 60 that’s hard to do. I enjoy poker, and I’d like to be able to play well enough to supplement my retirement income rather than drain it.We make our quarterly donation to the State of Nevada when I play Texas Hold ’em in Las Vegas. It’s a game where you take other people’s money instead of a game like blackjack, where the house takes everything. I recently won some small tournaments in the Bahamas.One of my favorite vacations was a $900 per person, 4 night, 5 day trip to New York to see Phantom of the Opera, Les Miserables and Anything Goes. We stayed at the downtown Hilton, had dinner at Sardis, and 5th row center seats for “Phantom” starring Michael Crawford. We got this crazy notion to wait for him at the backstage door in an alley in the rain. He showed up after we’d been waiting about 45 minutes, and believe it or not, he stood

and talked to us for a while. It was a marvelous experience – the perfect theater trip. For our 25th anniversary we had planned a two week Mediterranean Cruise booked for September 17, 2001. Needless to say, after 9/11, the cruise was a no-go. The cruise company gave us a voucher, and the following year we took a 2 week northern European cruise out of London. We love travel. CN: What are your non-clinical professional endeavors? JH: For the past five years I’ve served as the chair of the CME section at Salem Hospital. Only 30% of hospitals are accredited with commendation. I’m proud of our accomplishment at becoming one of those hospitals. We’re teaching med students from OHSU and the osteopathic school in Lebanon. My passion is teaching and my hospital schedule allows for it because of my days off. CN: I understand last year you were quoted in a publication where physicians’ writing rarely appears. JH: I wrote a letter to the editor published in the April, 2014 issue of Natural History magazine. I was horrified by the mass infanticide over seven years of mongoose babies for no apparent reason by people calling themselves scientists. I was surprised when they published it.Dr. Hannig joined the Marion Polk County Medical Society Board of Directors in March, 2014. Eric Schuman volunteers at Salem Free Clinics, where he practices internal medicine and neurology. He was the lead writer for Chart Notes from 2011 through February 2015. His other interests include golden retriever rescue, street photography and canine photography.

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By Ron Kelemen, CFP® — The H Group, Inc., Independent Wealth Management Solutions™ Board Member, Medical Foundation of Marion and Polk Counties

Lending Money to Family and Friends

The odds are high that you have been asked by a friend or family member to lend them money. If

not asked yet, you will be. You are not alone. A Federal Reserve survey calculates that loan transactions between friends and relatives in the US total $89 billion every year. Furthermore, a 2013 survey by American Consumer Credit Counseling found that 82% of respondents of all ages would lend money to a family member that has fallen on hard times, and 66% would give money to a needy friend.

Unfortunately these loans don’t always have a happy ending. Unlike a downturn in the stock market, a loan to a family member or friend can be a permanent loss of assets. Maybe worse, these types of loans might strain

family relationships and ruin friendships. As Shakespeare wrote in Hamlet, “Neither a borrower nor a lender be…for loan oft loses both itself and friend.”

How do you prudently lend money to friends and family? Here are seven suggestions.

1. Ask questions as a banker would. What is the purpose of the loan? Why can’t other sources be used? How and when will it be paid back? Be sure to ask yourself about the creditworthiness and dependability of the borrower. Will the loan really make a difference, given the need? Also ask yourself how this loan may affect family relationships and your relationship with the borrower, especially if the loan isn’t repaid. How will you deal with late payments and defaults?

2. Be prepared to say no. At least allow yourself time to think about it and assess your own financial situation. Perhaps the amount requested consists of money you have earmarked for emergencies or other important goals, such as upcoming home repairs or retirement plan contributions. Quite often young adult children see their parents living comfortably and just assume that “mom and dad can afford it.” Little do they know what it takes to retire and stay retired. Sometimes the best way to help someone who always seems to be in a bad state of financial health is to simply say “no.”

3. Never lend more than you can afford to lose. Even the most well-meaning borrower might fall on hard times and default. This means that you must be prepared to lose that money, treating it more like a gift than a loan.

4. Lend cash only. Never open a credit card in their name or co-sign. If you do, you are put into a position where someone else’s actions could affect your credit score if payments are missed.

5. Put it in writing. Spell out the details, then have it signed and notarized, even if it is for your mom or best friend. You can find sample promissory note forms online or in business supply stores. A written agreement

WEALTH management

Continued on page 9

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Wealth Management . . . continued from page 8.

helps avoid misunderstandings later on and family disagreements after death. A debtor-child may “forget” that the received amounts were loans and not gifts. A written agreement will allow the beneficiaries to equalize the inheritance by offsetting the amount due and owning against the debtor-child’s share.

6. Charge interest. This makes it feel more like a loan than a gift, and it keeps you in good graces with the IRS. The Applicable Federal Rate (AFR) set each month by the IRS is a good benchmark. Actually, at today’s low interest rates, it is probably too low. You can charge more, and your borrower will still get a better deal than if he or she could have qualified for a bank loan. A good example of this would be to help a child refinance 8% student loan debts by paying you 3% interest over 10 years. Both of you win if your child pays you back on schedule.

7. Distance yourself from the loan. Try to keep your relationship as it was before the loan. Don’t micromanage that person’s spending, because the money that you lent is no longer in your control. If you must worry about it, focus instead on repayment, not how it is spent.

Lending to family members or friends may not be the best financial decision you can ever make; however, sometimes relationships trump traditional money sense. If you must make a loan, do so with your head, not just your heart. Relationships need not trump common sense. Ron Kelemen is an independent CERTIFIED FINANCIAL PLANNER™ with 34 years of experience, and the author of The Confident Retirement Journey—Your Personal and Financial Roadmap. His team offers fee-only investment management and wealth management advice through The H Group, Inc., one of the largest independent registered investment advisory firms in the Northwest. You can follow his regular commentary at his blog post, located at the “Our Blog” tab of his website: www.TheHGroup-Salem.com and at www.ConfidentRetirementJourney.com | Water Place Building | 500 Liberty Street SE, #310 | Salem, OR 97301 | 800-285-6240.

President’s Message . . . continued from page 3

When I think about everything Dr. Bosatti taught me, I realize this is also a good time for reflection. I believe we are in one of the most transitional times in American medical history. The independent practice of medicine existed, essentially unchanged, for about 100 years. After that, solo general practice gave way to a more specialty-driven world with the increase in knowledge and an increase in technology. Over the last 30 years, we have been experimenting, trying to find a more affordable and outcome-oriented model of medicine. We are transitioning further, with the Affordable Care Act and Accountable Care Organizations likely the model of the future. We are certainly changing the way clinicians are paid and looking towards redefining the practice of medicine. It is important for us, as a Medical Society, to come together and realize what we have in common – because in this time of change, we could become distracted from the sanctity of the provider-patient relationship, the heart of what we do.

We may not be the oldest county medical society in America, but there are very few societies west of the Mississippi any older. That’s something to celebrate. And – I think we should celebrate anytime a group of independent practitioners agree on anything! 145 years of it is nothing short of phenomenal.

Here’s to our future!

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Strategies for Maximizing Social Security BenefitsPart III – File and SuspendBy Eden Rose Brown, JD, Attorney and Counsellor at Law Past Board Member of theMarion-Polk County Medical Society Foundation

Social Security was designed at a time when most men worked full-time jobs and their wives stayed home and

raised the children. Though that is not the norm today, the benefit structure has not changed. Therefore, when one spouse has made significantly less over the years, Social Security ensures that the lower-earning spouse will not be left without income if the earning spouse dies earlier.When to claim and how to maximize Social Security benefits has become one of the most important decisions to be made as retirement age approaches, yet few dedicate the time necessary to analyze the best strategies for maximizing their benefits.

The last few columns have explored some of the strategies available to Baby Boomers as that generational cohort enters retirement age. This final column in the series highlights the File and Suspend strategy.

Age at Full RetirementAccording to the Social Security Administration, if you were born between 1943 and 1954, you can collect your full benefits at age 66. If you were born in 1955, you can collect at 66 and two months; in 1956, at 66 and four months; in 1957, at 66 and six months; in 1958, at 66 and eight months, and in 1959, at 66 and 10 months. However, if you are 62, you are eligible to claim an “early retirement.”

Claiming Early Claiming an early retirement benefit at age 62 will reduce your payments for the rest of your life. If you claim Social Security at 62, then you get just 75% of what you would receive each month if you waited to claim until you were 66, or 67 for younger boomers.

People who claim Social Security early get smaller payments over more months versus more money per month. Generally, you would receive substantially more money if you claimed later and lived longer. Of course, no one knows how long they will live, but you can get a pretty good idea by considering your current health, how long your parents lived, and their cause of death.

LEGALLY speaking

Maximization Strategy: File and SuspendIf you are married and/or have dependent minor children, you might be able to boost your household income immediately and provide for a larger survivor benefit later by using the “File and Suspend” strategy.

The File and Suspend rule was added to Social Security in 2000 as part of the Senior Citizens Freedom to Work Act to help couples plan their retirements. It did not attract much attention until a few years ago when it became a media darling.

This strategy is available for those who have reached full retirement age and have not claimed their benefits early.

If you have reached full retirement age, you file for your retirement benefits so your spouse or dependent children can collect their benefits based on your earning record. Then you immediately suspend your own benefits and delay claiming them until they are worth more at an older age.

Once you file for benefits, Social Security rules provide that a spouse, whether the person ever worked, is entitled to a benefit equal to up to one-half of the other spouse’s retirement benefits, so your spouse can claim and begin receiving spousal benefits. At age 70, you can begin getting benefits, but at a higher rate than if you had never suspended them.

ExampleTom Payne, a local physician’s assistant, and his wife Jill, are both 66, which is their full retirement age. Jill is retired, and Tom plans to keep working until he is 70. At 66, Tom, who had a bigger income than Jill over the course of his career, files for his full retirement benefits of $2,000/month, but immediately suspends payment. By doing that, he will begin accruing delayed retirement credits: For each year that he keeps his payments in suspension, they’ll be 8% higher when he does take them. The credits top out at age 70. Since Tom’s basic retirement benefit at 66 was $2,000, his new payment if he waits to age 70 to collect will be about $2,600, plus any cost-of-living increases.

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When Tom filed for his benefits, he automatically activated Jill’s ability to apply for a spousal benefit. Social Security rules provide that a spouse, regardless if that spouse worked outside the home or not, is entitled to a benefit equal to up to one-half of the other spouse’s retirement benefits. So Jill can collect $1,000/month. But something else will also be happening: because Jill has reached her own full retirement age but is not taking her own retirement benefit, she will begin accruing delayed retirement credits that will boost her own benefit when she applies for it in the future.(Note that if Jill would have been at less than full retirement age but 62 or older, she still could have begun a spousal benefit based on Tom’s move to file and suspend, assuming that the benefit would be larger than what she was due on her own work record. However, the spousal payment would have been less than the full 50%. And Jill would be locking in a discounted rate forever, whether for the spouse benefit or her own work record benefits.)If you are over 60, married, healthy, and have not yet filed for your Social Security benefits, before deciding on which option is best suited for your particular circumstances and preferences, carefully consider and analyze the File and Suspend strategy along with the other available options with your professional advisory team and/or the helpful folks at the Social Security Administration (800-772-1213). If you take the time to analyze and focus upon which strategy is best for you, you can make a difference in maximizing your Social Security benefits well into the future. Attorney Eden Rose Brown is dedicated to providing comprehensive, highly personalized, counsel in wealth preservation strategies, family legacy design, and estate, tax and charitable planning. Honored by her peers as an Oregon Super Lawyer and named one of the Top 100 Attorneys in the United States, Eden’s innovative planning strategies maximize client control and family harmony, while minimizing taxes and preserving a family’s legacy for generations. The Law Office of Eden Rose Brown has offices in Salem, Eugene, Portland and Bend. (503) 581-1800; Office@EdenRoseBrown.com. www.EdenRoseBrown.com.

This information was prepared by Law Office of Eden Rose Brown and is intended only to provide general information. It is neither offered nor intended for use as legal advice, nor is it a substitute for a consultation with an attorney.

Legally Speaking . . . continued from page 10.

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12

Thank ou In honor of the 145th Anniversary of the Marion Polk County Medical Society,

we’d like to acknowledge the wonderful people, businesses, and non-profit

organizations that have supported the Society and Chart Notes since 2010.

We apologize if we missed anyone – it wasn’t intentional, and we thank you

anyway! It’s quite apparent that it takes a village…

MEDICAL SOCIETY PRESIDENTS

Chris Edwardson, MDMark Fischl, MDMark Gilbert, MDBrooke Renard, MDScott Stice, MD

MEDICAL SOCIETY BOARD OF DIRECTORS

Peter Bernardo, MDSarah DuVal, MN, PMHNPJohn Hannig, MDLawrence Holley, MDErin Hurley, MDPaul Huun, MDRonald Jaecks, MDCaroline King-Widdall, MDKeith Neaman, MDWilliam “Bud” Pierce, PhD, MDWilliam Purnell, Jr., MDEric Schuman, PASheila Sund, MDKeith White, MD

CHART NOTES WRITERS

Howard Baumann, MDNancy Boutin, MDMark Fischl, MDMark Gilbert, MDBeverly JeffsSteele, D.OMichael Rohwer, MDEric Schuman, PAScott Stice, MDSheila Sund, MDBarbara HalseyRon Kelemen, CFPEden Rose Brown, JDDouglas Parham, CPASaalfield Griggs, PC

CHART NOTES GUEST WRITERSFrancis Biagioli, M.D.Douglas Carney, MDSatya Chandragiri, MDMaurice Collada, MDJay Jamieson, MDKaren Landers, MDIan Loewen-Thomas, M.D.Laura Metzger, MDPrasanna Pati, MDWilliam “Bud” Pierce, MDPeter Ronai, MDKeith White, MDAudrey AndersonPhyllis FeatherstoneBeth Jackson, EdMKathy Kirk, RNLace LaTulippeMelissa LuLacy LyonsRyan Orr, JDJeanine Stice, MPHSharon TolandLisa WalligMany of our sponsors!!

MEDICAL SOCIETY EMPLOYEESDean LarsenShaney StarrJodilou BerryElizabeth MontiMichelle PatstonLinda Safina-MasseyMelissa ThomasCarol Yoder

calendarEVENTS

NOVEMBER 6, 2015New Provider DinnerFriday | 6 pm Mission Mill Dye House

New healthcare providers to our community and new members of the Medical Society are invited to dinner with the Medical Society Board of Directors. A great chance to get acquainted and make connections!

DECEMBER 6, 2015Holiday at the Riverfront CarouselSunday | 6 - 8 pm Salem Riverfront Carousel

Bring the kids in your life, or the kid in you, to this exclusive holiday event for Medical Society members and families. Enjoy treats and drinks, and (sssh!) a visit from Santa.

APRIL 8, 2016An Evening with Emmitt Smith Annual Benefit, Medical Foundation of Marion Polk CountiesFriday | Salem’s Historic Elsinore Theater

Don’t miss this chance to hear the former Dallas Cowboys football champion and Dancing with the Stars winner!

Contact the Medical Society at info@mpmedsociety.org or 503-362-9669 for more information.

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MEDICAL SOCIETY SPONSORS

(Events, Chart Notes content, other support)Thank ou

Abiqua AcademyAtrio Health PlansBBSIBen Bednarz, SMI Commercial Real EstateBenny Won, CFM, Merrill LynchCamp Attitude (Keith White, MD)C&R RemodelingCapitol Surgery CenterCapstone Wealth AdvisorsCD Redding ConstructionCenter of Outpatient MedicineCNAColumbia Bank Devault TravelDiagnostic Imaging of SalemTerry Frohnmayer & Jeff Corner, First Commercial Real Estate ServicesFitness TogetherGreen Acres LandscapeKaufman HomesMarian EstatesMedical Protective Company

Mission Medical ImagingNorcal Mutual InsurancePain Management NorthwestJ Brooks Peacock, Wells Fargo AdvisorsJeff Thomas, New York LifePioneer Trust BankProf-U-Source Business SystemsRich Duncan ConstructionRise ServicesSalem Cardiovascular AssociatesSalem Chamber Orchestra Salem HealthSalem Gastroenterology Consultants?Salem Radiology ConsultantsSalem Spine CenterSalvation Army Salem (Kroc Center)Sanfords Property ManagementStephen G. Tandy, Coldwell Banker Mountain WestTerry Hancock, Prudential Commercial Services

The Doctors CompanyThe H Group, Inc.Valley Credit UnionVan Natta Public RelationsVirgil T. Golden Funeral ServiceWillamette Ear Nose Throat and Facial Plastic SurgeryWillamette Health PartnersWillamette Valley Community HealthWVP Health Authority

i i i i i i i i i i

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i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i

AAA TravelAtrio Health PlansBarrett Business ServiceBBSICapitol Auto GroupCascade CardiologyCatholic Community ServicesColumbia BankDiagnostic Imaging of SalemDoris Perry, The Salem Real Estate GroupFirst Call Home Health CareHeltzel, Williams, Yandell, Roth, Smith & Peterson, P.C.Liberty HouseMarion County Public HealthMarion-Polk Food Share

Mary Lou Zeek GalleryMission Medical ImagingNorCal Mutual Insurance CompanyPain Management NorthwestPacific Pathology AssociatesDrs. Bud and Selma PierceRAM Restaurant & BreweryRich Duncan ConstructionSaalfeld Griggs, PCSalem Audiology ClinicSalem Cancer InstituteSalem Cardiovascular AssociatesSalem HealthSalem Keizer Education FoundationSalem Radiology ConsultantsSantiam Memorial Hospital

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whopping $20 a year, plus room and board. Adjusted for inflation, that’s equivalent to $542 today. Admittedly, he was only a lowly medical student, but for $20, he took call 24/7/365.

After World War I, the reputation (and skill) of physicians had improved. Most physicians were solidly middle class (average income of $3,800 in 1929, or $53,000 in 2015 dollars). Occasional famous specialists in big cities earned over $17,000 a year (equivalent to current 2015 income when adjusted for inflation!), thanks to a “cult of personality” creating national celebrity status. Then as

We’ve Seen It All Before . . . continued from page 1

physician incomes have now stalled or even declined, there is no doubt that insurance plans and Medicare played a major role in making us a highly paid profession.

The Death of Marcus WelbyThe primary care shortage has been discussed as long as I’ve lived in Salem, but when I can’t find a doc for my own family member, it really hits home.

In 2015, 3006 students were matched into United States family practice residencies, and only 42% were US medical school seniors. Many entering medical students profess a goal of primary care, but by the time of graduation, only 8% choose family practice. Pediatrics and internal medicine match larger numbers, but

now, primary care income lagged, particularly in smaller towns and rural areas where generalists frequently took home under $2,000 a year –less than firemen and locomotive engineers. So how did physicians jump to the upper income brackets? Ironically, we can thank our major stressors of today – health insurance and Medicare. In the “olden” days of fee for service, most patients could not pay in full. Sliding scales, barter, and charity care were common. Many people avoided medical care entirely. Physician income correlated directly with patient income. However, when World War II prompted a national wage freeze, large numbers of employers started adding health insurance benefits instead of salary increases. For the first time, medical care became affordable for many – assuming you were employed. The elderly joined the patient pool with the creation of Medicare in 1965. Once someone else was paying the bill, the population seeking medical care grew rapidly.More importantly, in order to entice physician participation in these new insurance programs, they were allowed to continue billing “normal and customary charges.”. With payment coming directly from insurers or Medicare, collection rates jumped to over 95%. Between 1940 and 1970, mean physician income increased from $50,000 to $250,000 (in 2010 dollars), elevating us solidly into top earners. Obviously, this system was unsustainable and led to the current environment of limited re imbursement and excess ive regulation. However, even though

Amputation – the standard for compound fractures

John St. John Long – 19th century artist turned physician. A media celebrity, his “public” adored him, despite being found guilty of manslaughter twice. Personality pays! IMAGE CREDIT: WELLCOME LIBRARY, LONDON

15

Continued on page 16

more than 2/3 specialize after residency. After all, who wants to acquire the same student loan debt (currently averaging $180,000) just to earn half the income in a field with excessive demands, poor prestige, and limits to the provision of good care? NP and PA colleagues help the shortage, but can’t solve the problem.Once upon a t ime , a l l physicians were primary care – a combination of physician, surgeon, and apothecary – but the debate about specialist versus general practice has been present since the American Revolution. John Morgan, the “father of American medicine,” argued in 1776 that all physicians should be educated specialists. He likened a physician’s expertise to an army general’s knowledge of war and the battlefield, whereas surgeons and apothecaries were lowly soldiers fighting in the trenches. Ironically, Morgan became penniless for lack of patients, until he broke down and agreed to “push pills.”On the other side, we have Webster Cathell, who in the late 1800s established the concept of medical professionalism that still persists today. He believed strongly in the general physician, stating: “Never turn your cases over to specialists. You will lessen your own scope.” Despite his advice, the growth of specialists paralleled the increasing role of science in medicine. As the president of the AMA said in 1886, “by devoting themselves to one branch instead of working up a general practice, [specialists] could often do more good, earn more money, and have less arduous work to perform.”

1901 advertisement – doctor as Big Pharma, drug rep, and prescriber rolled into one

In the first half of the 1900s, 70% of physicians still chose office-based general practice after one year of internship, opting for independence and quicker income. In contrast, specialists of this era required hospitals and access to new technology, including X-rays, electrocardiograms, and blood transfusions. Shared interests resulted in hospital evolution from dingy, dark ward environments to clean and shiny examples of modern progress. Of course, this specialist/hospital marriage drew more patients, allowing both to profit. Even then, procedures paid more!Today, American physicians are 70% specialist and 30% primary care – a complete switch, thanks primarily to government involvement. Beginning in World War II, advanced medical training (i.e. specialist certification) was rewarded with higher military rank. The United States Government invested in medical research for the first time, which paid off with rapid advances during and after the war, and helped establish America as a world leader in modern medicine.

Similar investment in hospital growth and physician education led to the birth of the academic medical center. Without a role in research or education, general practitioners were displaced from academic centers to community hospitals. With most specialists remaining at the universities, primary care actually “ruled” the local medical communities for several decades (the Marcus Welby era).However, when academic medical centers are staffed primarily by specialists, they train primarily specialists. As specialty residency positions exploded from 5,000 in 1940 to 65,000 in 1970, the young trainees in turn spilled out from academic centers to community hospitals and local clinics, where an admiring American public quickly adopted the concept that certification meant better. In a belated attempt at “if you can’t beat them, join them”, the remaining generalists rebranded themselves as the specialty of Family Practice, officially recognized in 1969. Although this finally allowed primary

16

care residency programs, family practice was already less desirable. 1996 caps on government support for residency positions ensured the discrepancy would persist.

The Blame GameMedical liability has been around as long as doctors. The Babylonian Code of Hammurabi (circa 1750 BCE) specified: “If a surgeon performs a major operation on a [nobleman], with a bronze lancet and caused the death of this man, they shall cut off his hands”. The multimillion-dollar jury awards of today versus losing your hands – which would you choose?Physician/patient communication has long been a source of litigation. Henri de Mondeville , a 14th century French surgeon, recommended that doctors “promise a cure to every patient” hoping that a good prognosis would inspire a good outcome to treatment. The courts apparently disagreed, finding numerous physicians guilty of “breach of contract” for failing to heal the patient as promised. The concept of expert witness testimony started with Emperor Charles V’s requirement in 1532 that “medical men” be formally consulted for every case of violent death. In 1767 England, a man with a poorly healed leg fracture sought wound care from a second physician, who instead chose to re-fracture the leg and set it in “a heavy steel thing that had teeth to stretch it”. His subsequent lawsuit included testimony by other physicians that the treatment was contrary to standard medical practice. In addition, the court stated that “a radical experiment could itself be considered malpractice, at least in the absence of the patient’s

We’ve Seen It All Before . . . continued from page 15

President Lyndon B. Johnson signs Medicare into existence in 1965, permanently increasing both physician income

and headaches. MAGE CREDIT: HARRY S. TRUMAN LIBRARY

both our legal system and the minds of the American public.

Lawsuits remained a fairly minor practice issue until 1970-75, when, in five years, four times as many claims were filed than in the previous 35 years. Since then, unwarranted litigation, excessive awards, liability coverage shortages, increased premiums, and decreased profitability for both insurers and physicians have become the order of the day, while drastically altering the practice of medicine. Somehow, I doubt that’s what Hammurabi had in mind.

I hope you’ve enjoyed this non-historian’s view of medical history. Had I the space, time, and energy (and desire!), other topics could have included documentation, medical education, certification, patient communication, and more. However, the real message is we’ve seen it all before, even if not during your years of practice. Relax and remember the reason we chose to go into medicine – our patients need us! Sheila Sund is a hospice and palliative care physician, and a speaker on disaster preparedness. She writes frequently for Chart Notes, and volunteered to become Managing Editor in September 2015. In her spare time, she can usually be found with her camera and dog.

consent”. Not only was the patient awarded $100,000 in today’s dollars, but the case became famous f o r c o d i f y i n g b o t h professional standards and informed consent.

In America, lawsuits were uncommon until the mid-1800s when the number jumped 950% over 20 years . 70% involved orthopedic injury with imperfect results. Ironically, lawsuits were against highly trained physicians (with deeper pockets), who were using new techniques to repair compound fractures without amputation. Not surprisingly, juries were sympathetic to deformed limbs, and frequently returned guilty verdicts with large awards for pain and suffering. If a physician just amputated the limb, they were safe from lawsuit, as amputation was considered standard practice, performed regularly by poorly trained doctors everywhere. So much for medical innovation! On a positive note, this deluge of malpractice cases led to the formation of the AMA and eventually laws on licensure and training, which in turn standardized the safe and effective practice of medicine.

Liability insurance became a reality by the beginning of the 20th century, relieving doctors of the threat of personal bankruptcy. In exchange, it made all physicians vulnerable to suit (not just the rich ones). Some experts feel insurance also removed incentives for the medical community to fight for a better way of handling malpractice claims before the practice became entrenched in

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ON ALERT: What All Doctors Need to Know About Alzheimer’s DiseaseBy Cynthia Morrison, RN, ARM, CPHRM, Patient Safety Risk Manager, The Doctors Company

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Alzheimer’s disease is the sixth leading cause of death in the United States and is the only disease in the list of

top 10 diseases that cannot be prevented, slowed, or cured.1

Early diagnosis of dementia, requiring the expertise of a neuropsychiatric physician who specializes in it, is essential to allow for maximum quality of life.2,3 Physicians of all specialties should become familiar with the early signs of this disease in order to refer patients with symptoms to a specialist for further testing.

The early signs of Alzheimer’s are:• Memory loss that disrupts daily life (e.g., forgetting

important dates or events).• Difficulty completing familiar tasks at home, work,

or leisure (e.g., trouble driving to a familiar location or remembering the rules of a favorite game).

• Confusion with time or place. • New problems with words in speaking or writing. • Decreased or poor judgment.• Changes in mood and personality.

Only 45 percent of people with Alzheimer’s disease or their caregivers report being told of the diagnosis, whereas 90 percent of people with the most common types of cancer have been told of their diagnosis.1 The benefits of clearly explaining the Alzheimer’s diagnosis include:• Improved decision making. When patients are fully

aware of their diagnosis in the early stages of the disease, they are more likely to be competent to understand options and provide informed consent for current and future treatment options. When patients

are actively involved in decision making about their care, they are more likely to be compliant.

• Access to services. Knowing the diagnosis allows caregivers to obtain information about support services and plan ahead.

• Safety. Awareness of the diagnosis allows caregivers to take steps to ensure the patient is in a safe environment and identify certain activities that may need to be curtailed, such as driving.

• Social support. Knowing the diagnosis helps affected people focus on spending quality time with loved ones.

Once a patient has learned of his or her illness, physicians should:• Educate caregivers and patients on ways to promote

activity. As the disease progresses and cognitive and functional abilities decline, patients have difficulty moving and, therefore, are more vulnerable to infection. Pneumonia is often a contributing factor to the death of patients with Alzheimer’s disease.

• Facilitate consults and have a system in place to track and recall patients to ensure there is appropriate follow-up.

• Consider referring patients to a mental health professional. Depression occurs in 40 percent of Alzheimer’s patients and a mental health professional can help provide treatment. Other team members may include home healthcare workers, social workers, and psychologists.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety or contact your local representative Sarah White at (971) 223-6323.

REFERENCES 1. Alzheimer’s News: New Alzheimer’s Association report finds less than half of people with Alzheimer’s disease say they were told the diagnosis. Alzheimer’s Association website. http://www.alz.org/news_and_events_facts_figs_told_diagnosis.asp. Published March 24, 2015. Accessed June 8, 2015.

2. Dementia Advocacy and Support Network. http://www.dasninternational.org. Accessed June 11, 2015.

3. 2015 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association. http://www.alz.org/facts/downloads/facts_figures_2015.pdf. April 2015. Accessed June 10, 2015.

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