ADULTHOOD AND COMING OF AGE IN AN ERA OF MANAGED CARE, 1991-2000
Ralph E. Johnson, M.D. became the Acting Chair of the Department in May 1991, and was appointed the third Chair of the Department in July 1994. He had been at UC Davis since 1987. Dr. Johnson inherited a department with formidable faculty problems. Between 1983 and 1991, there had been a large turnover in physician faculty. When Dr. Lieberman left he took one physiatrist with him to Columbia, and Dr. Fowler retired to Emeritus status. Only three full-time physicians, all at the Assistant Professor level remained, and the Dean had given notice that he was ready to resign in two years.
Gerald S. Lazarus, M.D. succeeded Hibbard E. Williams, M.D. as Dean, School of Medicine in 1993, and Joseph Silva, Jr., M.D. became Dean in 1997. Frank Loge continued as hospital director until 1998, when Martha Marsh succeeded him.
The major challenge in the 1990s was to develop a strategy to cope with the negative impact of managed care on academic medicine. In the early 1990s, 85 percent of the population in Inland Northern California were in managed care programs and 43 percent enrolled in capitated programs. The Medical Center was 97 percent self-supporting and 50 percent of the Medical School's budget was based on clinical earnings and 35 percent on extramural grants. State support for all University of California medical schools had dwindled to 15 percent. At the same time, clinical reimbursements had decreased and the state was in a major recession requiring a significant decrease in the state budget for the entire University.
The challenge was to develop a unified process-focused care management strategy and a geographically distributed health care system to enable competition for substantial market share. By the mid 1990s, a unified UC Davis Health system had become operational, which combined the Medical School with the Medical Center into a single governance structure and budget. A medical group was formed with offices in ten communities. Shortly thereafter, a provider-sponsored organization was developed with Mercy Healthcare of Sacramento; Western Health Advantage. Several areas were identified to be cultivated as "Centers of Excellence," and PM&R was included in two of these areas; Children's Services and a Neuromuscular-Skeletal Center.
During the same time, the Health System continued to expand in facilities including a second inpatient tower; Ambulatory Care, Cancer and Neurosciences Centers, and affiliations with the Sacramento VA Ambulatory Care clinic and the Northern California Shriners Childrens Hospital located next to the Medical Center in Sacramento.
The UCD Health System also started to develop a national reputation in the 1990s. As rated by the U.S. News and World Report, the Medical Center scored among the 40 top hospitals in the country, and the School of Medicine consistently ranked among the nation's Comprehensive Medical Schools.
Managed care and decreased clinical reimbursements, the Ambulatory Care Center, the VA Ambulatory clinic, and Shriners Hospital had a major impact on the Department of PM&R. For the first time, the Department had to aggressively look for sources of clinical revenue outside of the Medical Center Campus, increase its participation in multidisciplinary Medical Center programs, and develop a departmental process-focused care management strategy. By about 1993, the Department had established contractual arrangements with the Sacramento VA Clinic and the California Correctional Medical Facility, Vacaville. When Shriners Hospital opened in 1998, the Pediatric Rehabilitation program rapidly increased in scope and staff. By the end of the decade, Department faculty were participating in the UCD Community Medical Group clinics and the multidisciplinary musculoskeletal and sports medicine group.
Department facilities were significantly improved. The totally inadequate ambulatory clinic was moved from the main hospital to the Professional Building in 1995 and then to the Ambulatory Care Center in 1998, along with an electrodiagnostic laboratory, the academic offices, and the therapy services. For the first time in its history, the Department was no longer in basement quarters! Facilities were spacious, state-of-the-art, and actually had windows.
Section Chiefs during this period were Diane Von Burg and Janet Retke (Physical Therapy), Mary Lou Burke (Occupational Therapy), Robert Buchanan and Peter Santiago (Orthotics), Nancy Borroum and Hilda Mindling (Clinic Nurse Managers), Rick Wanlass (Psychology), and Christine Davis (Speech Pathology). Department Managers included Karen Lehman (School of Medicine), Robert Taylor and Valerie Adame (Hospital).
Clinic patient programs also expanded during the 1990s. In addition to neuromuscular diseases, amputees and spinal cord injury, the Pediatric Rehabilitation Section markedly increased in staff, faculty, and scope. A small inpatient unit was opened on the UC Davis Medical Center Pediatric ward, and inpatient and ambulatory services developed at the new Shriners Hospital. The musculoskeletal service started to move towards a specialty focus including multidisciplinary neck and back pain and sports medicine clinics. The Sports Medicine Group became the team physicians for the UCD Athletic Department, the Sacramento Kings, and the Sacramento Monarchs. New programs included a Dysphagia Evaluation Center with ENT, a Restrictive Lung/Neuromuscular Disease Clinic with Pulmonary Medicine, a Skin Care Clinic, and a Spasticity Treatment Center with Neurosurgery.
In the mid 1990s, the number of residency positions was reduced from 12 to 10. In order to maintain a sufficient critical mass, the PGY1's were decreased to one position and the PGY2's increased to two slots. Therefore, three residents continued to graduate each year.
"The bantering in the resident's office was also a highlight. A more recent memory was the alumni dinner at the annual meetings in Seattle less than two years ago. Sitting in that restaurant with a large group of alumni and faculty, I was confronted with what a blessing it was to have been a part of UCD's Dept. of PM&R. As a group, both faculty and residents, we were and remain a fortunate bunch."…"Well, that's it. That's quite a bit, actually. Thanks for all you have done for me and the rest of us. I can't begin to fully express my gratitude. Professionally, I will forever be indebted to UCD."….W.S. Rosen, 1992
"I have fond memories of my time as a PM&R resident at UCD. What particularly stands out in my mind are not specific events, although my favorites were Dr. Lieberman's annual parties and Dr. Fowler's crab feast, but the general atmosphere of cooperation that permeated the entire department."….S.E.G. Scholey, 1993
"I was always impressed with the availability of all the faculty members, always. Open door policy is the implied rule. I recall dropping in without notice to talk with Drs. Johnson, Kilmer, or Wineinger about career/professional planning. They literally would drop everything and help me explore my options. I feel very fortunate to have had them available for guidance and direction. I still feel comfortable to call upon them when the need arises because I know that they are genuinely interested and trustworthy."….E.I. Dagher, 1998
"I enjoyed our annual program director's pizza party for the residents at his home to discuss the upcoming year curriculum…helping to produce the senior resident's graduation video roast of the attending faculty…every part of my residency and will miss the department's close-knit friendly atmosphere."….A. Bullock, 1999
Twenty-seven residents graduated between 1991 and 2000: John A. Dorsett, Bill S. Rosen, Viviane Ugalde, Deanice F. Beck, Lisa U. Pascual, Susan E.G. Scholey, James Nelson, Thomas Pattison, Alex Franchine, Larry Paulson, Christine Aguilar, Robert Kawasaki, Ross Bogey, Marian TeSelle, David Gater, Mary Njegovan, Carlos Moravek, Wynette Kitajima, Fulton Chen, Edward Dagher, David Vidaurri, Thomas Hecht, Jeffrey Young, Andrew Bullock, Todd Weitzenberg, Jeffrey Rosenbluth, and Vinay Reddy. Two joined the PM&R faculty; V. Ugalde and Larry Paulson.
"One morning when I was an intern while doing a medicine or surgery rotation, I arrived in the parking lot at 0630. When I got out of my car, there was Ross Bogey (a senior). I asked him what he was doing there so early and he said, "welcome to rehab, baby!" (He was studying for the boards)."….T. Hecht, 1999
"I remember the relationship with my colleagues in residency with fondness, particular my classmates Ross Bogey and Dave Gater. They were fun to work with (even at our weekly 6:30-8:00am board review sessions)! Ross and I used to tease Dave about his caffeine consumption since he would always show up with an extra large cup of coffee and had usually already had several cups of coffee by very early in the morning. Only Craig McDonald managed to eclipse Dave's caffeine intake."….M.E. TeSelle, 1996
The 1990s were a period during which research investigations expanded into areas other than muscle physiology and neuromuscular diseases. Most were linked to the development of new patient service activities. Mobility studies of energy utilization and body composition in children with disabilities and investigations of spasticity and functional recovery from traumatic brain injury in children were generated from the Pediatric Rehabilitation Service. Studies of shin splints and other athletic injuries originated from the increased involvement in musculoskeletal diseases and sports medicine. In addition to investigations of animal models of neuromuscular diseases, studies of fatigue, aging and muscle or nerve regeneration were completed. The focus of research in individuals with neuromuscular diseases shifted from studies of impairment to investigations of secondary complications, such as pain, dyspnea and respiratory control, muscle wasting, and nutrition; function as measured by energy expenditure and physical performance; and participation as evaluated by educational mainstreaming, employment opportunities, quality of life, and measures of stress and coping. Research grant support averaged about $762,500 per year, and an average of 11 papers each year were published.
The faculty during 1991-2000 included eleven physiatrists: E. Ralph Johnson, David D. Kilmer, Gregory T. Carter, Mark Wineinger, Craig M. McDonald, Viviane Ugalde, Larry Paulson, Dennis Hart, Dukjin Im, Brian Davis and William M. Fowler, Jr., (Emeritus). As one indicator of reaching adulthood and stability, only two faculty left the Department during this period. Dr. Johnson retired October 1999 to Emeritus status.
"Although not humorous at the time, the one event that I now chuckle about the most is the recollection of seeing our new department chair, Dr. Johnson, become diaphoretic when he was informed that three of his residents had failed their board exams. CPR always comes in handy."….S.E.G. Scholey, 1993
"Dr. Johnson always educated the residents about the history of PM&R and medicine. He always recalled "landmark" articles by physicians who made significant differences in the treatment of diseases. We, the residents, always felt it was material only meant to be memorized for the PM&R boards, but I've come to realize that some of the mentioned articles offered significant gains in the management or identification (i.e. diagnoses) of disease processes. Without these gains, medicine would not have made the advances it has over the years. By the time I left residency, I knew all the answers to the typical questions he would ask, but they have also served as memory joggers to this day. His teaching approach acted as sort of a bridge between PM&R of the past and PM&R of the future."….W.Y. Kitajima, 1997
"I thoroughly enjoyed my experiences with Dr. Johnson during my residency years. He was always eager to teach me new information, whether or not we were examining a patient or just talking on the way to a family conference or the Friday journal club meetings. What is so intriguing about Dr. Johnson is his sharp memory and attention to fine details..he would recall, for example, usually in the hallway during morning rounds, a specific experience during his training with not just the specific diagnosis, but also the exact day, year, weather, hospital location, name and age of the patient! I can remember looking at the other residents and just shake our heads in amazement regarding his recollection of the details. Dr. Johnson's personal experiences, as well as his gentle and friendly bedside manner have indeed left a strong impression upon my daily private practice…with his retirement in 1999, he truly will be missed."….A. Bullock, 1999
"I recall the day in early February 1995, when I interviewed for a residency position with Drs. Johnson, Kilmer, McDonald, Ugalde, and Wineinger. I was living in Reno at the time and drove to Sacramento in the dark, rainy, early morning hours for the interviews. During my meetings with Drs. Johnson and Kilmer, I couldn't help but notice a smirk on their faces. Embarrassed, I realized what was going on. Unbeknownst to me, impaired with my ADLs that morning, I dressed myself with one black and one blue sock, and proceeded to the interview! ADL challenged, I guess they figured I would blend well with the rehab patients. So they offered me the job."….E.I. Dagher, 1998
"The junior faculty attending who would announce that he had an important teacher point to make and then would shock the unsuspecting and naïve med student with the instruction on rounds to "pull my finger." And upon having his finger pulled a rather remarkable sounding flatus would undoubtedly follow."….W.S. Rosen, 1992
"During rounds one of the faculty was trying to demonstrate "melodic intonation" on an aphasic patient. However, he began to sing the words to "Mary Had a Little Lamb" with the tune of "Twinkle, Twinkle, Little Star." Although confused, the patient tried to sing along."….M.E. TeSelle, 1996
"There were some very trying transition times. When Bill Fowler retired and Jim Lieberman left, along with Brenda Mallory, there were only three faculty: myself, Dave Kilmer, and Ralph Johnson. I was quite green but somehow we survived. Having Dave Kilmer there, who is also one of my closest personal friends, was a big help. Talk about male bonding, now that was the trenches. Later I established myself in the RTC research labs and had as much fun as a guy is allowed to have at work. Our lab group, which consisted of Ted Abresch, and Sandy Walsh, collaborating with Mark Wineinger, Sylvia Horasek, and Japanese research fellow, Naohisa Kikuchi, produced two papers which won best research paper awards."….G.T. Carter
At the end of the decade, the Department had grown to about 85 hospital and medical school staff, ten grant supported staff, seven full or part time faculty physiatrists, and three Emeritus faculty. Its national reputation expanded to include Pediatric Rehabilitation as well as neuromuscular diseases.
In Inland Northern California (District 4, California Society of PM&R), community physiatrists increased to about 55 individuals, and community hospital PM&R programs to 15 facilities. As in the 1980s, about 40 percent of the community physiatrists were graduates of the UCD residency program or former UCD faculty.