INTERVIEW: MMS President Jeffrey Stevenson, MD

Steve Osborn

Born into a faculty family in Berkeley in 1953, Dr. Jeffrey Stevenson grew up in that university town and graduated from UC Berkeley with a degree in neurobiology in 1978. After undertaking graduate studies and research in cell biology, he entered medical school at George Washington University, receiving his MD in 1986.

His career since then has been diverse. He served as a brigade surgeon in the Army, worked in various Bay Area emergency departments, and provided occupational medicine services at several hospitals, including Marin General and Novato Community. He opened a solo practice in Novato in 2005, splitting his time between primary care and occupational medicine.

Dr. Stevenson’s major goals for the year of his presidency are improving care delivery and defending legislation that helps maintain access to care and patient privacy.

Dr. Stevenson’s wife, Charmaine, is his office manager. They have two sons: Vincent, 17, and Kirk, 15. In his spare time, Dr. Stevenson enjoys bicycling. In fact, he was a top-class pro-am cyclist until about five years ago. He also likes working on old cars and motorcycles, and he drives a 1966 Alfa Romeo Giulia Super; his brother Conrad is a mechanical engineer who also works on Alfa Romeos.

This interview was conducted in Dr. Stevenson’s office on June 16th.

When did you decide to become a physician?
It was in high school. We had a class where you went up to Alta Bates Hospital for two hours a day, two days a week, and rotated through different departments. My first day I was in the radiology department and got pulled into their special procedures room. I gowned up and watched an angiogram of a patient with acromegaly to look at his pituitary and his brain circulation, and the doctors were treating me like a physician-in-progress. They were expecting me to pick up the knowledge, the science and the anatomy. I remember the radiologist telling me, “Go look up what a carotid artery is.” That was my assignment for that night.

I was doing well in science and was interested in technology, so a lot of things came together. Between that rotation and many others, medicine seemed like a fascinating, challenging and useful career.

Where did you go to medical school?
I went to George Washington University in DC. They pointed out on their interview offer that they were the most expensive medical school in the country and that I needed to take that into account on the front end. The interest rates on the HEAL student loans were roughly 17% per year, with no end in sight. While watching my credit debt mushroom in the second year of medical school, I signed up for the Army HPSP scholarship, where they pay for your medical school and give you a second-lieutenant commission in exchange for military service, which in my case was three years.

What was your job in the Army?
I was called a brigade surgeon, but I was really a general practitioner practicing on a broader level, handling various traumas and things of that nature. Generally it is primary care and orthopedics, but it can be chest tubes, intubations and amputations in a tough situation.

I volunteered for the infantry because it was the best real military experience. I served in Korea, and then in Panama during the Noriega standoff. In the midst of all that, I spent a month in Germany and Belgium racing bicycles with the military’s World Championship Team. Then I went back to Panama and was there for the U.S. invasion with live rounds and face paint.

So you had been racing bicycles all through this period?
Yes. My first bicycle race was in about 1970. I did very well with bicycle racing, because a lot of it is individual training, plus there is a big group factor. Being stocky, I’m not a hill climber by birth, but stockiness lends itself to sprinting, which is a completely different type of riding. As a sprinter, if you can figure out how to survive the rest of the race, you’ve got a shot at winning. You have to read a pack and anticipate movements and have a certain amount of courage to make moves and to get through a pack in a sprint.

Do you continue to race bicycles?
I let my license go about five years ago, after a criterium race in Burlingame. It took all of my concentration just to stay on a wheel, and at one point I realized that I needed to step down a notch and respect my age and experience and better judgment. As a 50-year-old, you just don’t bounce as well as a 20-year-old.

Why did you decide to go into solo practice?
With my skill set, I was better off running my own practice and being able to make workflow and management decisions myself. Marin County is a unique environment where physicians have excellent relations with each other. We have excellent specialists who enjoy seeing patients, and you’re not caught with tough patients that you have to treat beyond your skill level. In addition, the hospitalist service at Marin General and Novato Community provides excellent care for hospitalized patients. All those factors made it easy for me to go into solo practice.

I came to Marin to work in Employee Health with Sutter. Initially I worked at Marin General, then I moved up to Novato Community Hospital Employee Health when the new hospital opened.  We also provided care for local employers with injured employees, including Costco, Marin Sanitary, and local police and fire departments. I moved down to the Sutter Terra Linda Urgent Care with Dr. Kurt Kunzel from the Novato Emergency Department. We handled urgent care patients as well as worker’s compensation patients. Part of the model of urgent care was to see patients on an emergency basis and then refer them out into the community. If physicians were trying to build their practices, we could refer to them, and we would commonly saturate a practice quickly. There was no shortage of referrals for primary care physicians, and there still isn’t.

Is a solo primary care practice still viable?
I think it’s viable. We need to work efficiently and effectively, and we need to have the operational costs of doing business recognized. Across the board, physicians are working on tighter and tighter margins. Primary care simply requires that you work smarter and develop better tools as you go. It’s constantly evolving.

What do you think are the major medical challenges in Marin County?
Access and affordability.

Do you see that in your own practice? Do patients have difficulty accessing you?
Access and affordability are integrated. If you are able to afford private insurance or Kaiser insurance, access isn’t the problem, except on the private side only a small number of physicians are still taking new patients on a regular basis. Kaiser does a good job of handling a lot of patients.

Several years ago I worked with the RotaCare Clinic in San Rafael, which is a free night-time clinic that Rotary provides as a community service. We could only take a certain number of patients into the clinic at night. I had patients that I saw in the morning for a worker’s comp injury, but they also had hypertension or diabetes that really needed control, so I referred them to RotaCare. If I was working at RotaCare that night expecting to see the patient, I commonly couldn’t see them because they weren’t there fast enough to get a number to get in and see me. That’s a good example of an access problem, but it’s tied to patients not having insurance.

A lot of people are working poor and can’t afford medical insurance. Insurance for a family of four may easily cost $25,000 to $30,000 a year. That’s almost the annual salary for a lot of people. Now the Affordable Care Act has come in, and we’re seeing it evolve as an intermediate plan between Medi-Cal and Medicare, as far as reimbursement goes.

Have you been seeing more patients who have coverage through the Affordable Care Act?
We have many patients calling in to ask if we’ll see them, but I haven’t been able to take new patients. Most of my experience is based on current patients who have converted over to Affordable Care Act insurance.

You have been in practice for more than 20 years. How has your ability to treat patients changed during that time? Are there any medical advances that have really improved your capabilities?
In orthopedic surgery, we have seen tremendous improvements in what we’re able to do arthroscopically. We have made improvements arthroscopically with shoulder injuries and knee injuries. We have been able to do some level of cartilage reimplantation, so in some knees we are able to avoid knee replacements for several years. That can make a tremendous difference.

Reconstructing anterior cruciate ligament tears has completely changed. When I was at Ralph K. Davies Hospital in 1988, we were still sorting out some of the details. We had trouble getting the knee straight, and we were figuring out that we had to cut a bigger notch in the femur to get the knee straight. Our head surgeon, Dilworth Cannon, who was pioneering ACL reconstructions, said that if he was 35 years old, he probably wouldn’t get his ACL reconstructed because we didn’t have the data to establish whether a 35-year-old had the resilience to heal. Now we commonly rebuild ACLs in 50-year-olds and beyond.

In Marin County we have health-oriented adults who are active into their 70s and 80s. If I have a 50- or 60-year-old with an unstable knee, I will generally leverage them to get the ACL repaired so they maintain knee function and don’t grind up what cartilage they have left and end up with an early total knee. Being able to save the cartilage translates directly into being able to maintain your cardiovascular conditioning, reducing your cardiac risk factors.

In primary care, if I have a patient with a bad hip or a bad knee, that’s what’s limiting their ability to maintain or develop conditioning and control their weight. Some surgical risk is worth taking in favor of gaining orthopedic function and being able to get out and get conditioned and control your risk factors for high blood sugars, high cholesterol and excess weight.

One of the biggest current challenges for physicians is Proposition 46, the anti-MICRA initiative that will appear on the November ballot. What would be the consequences if Proposition 46 passes? Why should physicians be concerned about it?
First, I think it’s important to note that Prop. 46 is not just a challenge for physicians. It will negatively impact every single Californian.

Prop. 46 is backed by trial lawyers who want to change current law to make it easier and more profitable to file lawsuits against health care providers. Prop 46 will impact everyone in California because we’ll see a rise in health care costs and a decrease in access to medical care. In addition, our personal privacy could be jeopardized. The consequences of the ballot measure are enormous—which is why such a broad coalition of health care providers, business, labor, local governments and community clinics have joined in opposition.

A measure like this will force many practices, like mine, to reduce or eliminate services, and in some cases, close our doors altogether. With millions of newly insured patients in the state, there isn’t a worse possible time to reduce access to care.

Additionally, the state’s legislative analyst predicts that Prop. 46 will cost state and local governments up to hundreds of millions of dollars annually. If the trial lawyers get their way, health care medical lawsuits and payouts will skyrocket and consumers, taxpayers and patients will have to pay.

As a physician, I’m always looking for ways to improve access to care and health care safety—Prop. 46 will do just the opposite.

This measure includes a provision that could significantly jeopardize the privacy of patients’ personal prescription medical information. The initiative forces doctors and pharmacists to use a massive statewide database, called CURES, which is filled with patient’s personal prescription drug information. Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands this ballot measure will place on it.

This ballot measure will force the CURES database to respond to tens of millions of inquiries each year—something the database simply cannot do in its current form or functionality. Prop. 46 contains no provisions and no funding to upgrade the database with increased security standards to protect personal prescription information from government intrusion, hacking, theft or improper access by non-medical professionals. Another problem for patients and their health care providers is that a non-functioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat our patients, or break our oath by refusing needed medications to patients.

(For more information about how to help defeat Prop. 46, visit www.cmanet.org/micra or NoOn46.com.)

Why should physicians join the Marin Medical Society and the California Medical Association?
Our ability as physicians to be a unified voice is important because we need a show of force—not just for MICRA, but also for economic and practice support, and advocating for our patients and community health issues. We need strong support from the physician community.

Physicians have to show leadership in the practice and management of medicine. When I was in medical school in DC, I spent three days on Capitol Hill with an AMA lobbyist. He said that physicians need to show leadership or it’s going to be done for us. His words still ring true today.

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Mr. Osborn edits Marin Medicine.
Email: jeffreystevensonmd@gmail.com