May 2015 by SMCMA

S a n M at e o C o u n t y

May 2015

in s id e

S a n M at e o C o u n t y M e d ic a l Ass o ci at i o n

Volume 4 Issue 5

Physician Teens and Technology

Taming the “Wild West” of electronic cigarettes

“Screen time” and adolescent sleep disruptions

How my life steered me to the path of medicine

by Robert Jackler, MD

by Deepti SInha, MD

by Gurpreet Kaur Padam, MD

Time to go shopping... ...for a better deal on workers’ compensation.

There has never been a better time to shop the sponsored workers’ compensation plans offered through the San Mateo County Medical Association/CMA. That’s because workers’ compensation insurance rates in California continue to move upward. The Insurance Commissioner recommended an increase of 6.7% in pure premium rates for 2015 compared to the average premiums charged as of July 20141. Your plan may experience a higher or lower rate increase than recommended by the Department of Insurance. Don’t just sit back and accept higher rates! Call Mercer to see if you can get a better deal through the San Mateo County Medical Association/CMA. Working with Mercer as the program administrator, the Association sponsors best-in-class insurance plans at competitive premiums. By becoming involved with the sponsored plans you will receive valuable protection for your practice and employees while supporting the good work of your Association! Take control of your workers’ compensation costs. Call 800-842-3761 now for your free, no-obligation quote. Or visit www.CountyCMAMemberInsurance.com for more information and to download an application or premium indication form.

Sponsored by:

Scan for more info! Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 Copyright 2015 Mercer LLC. All rights reserved. • 777 South Figueroa Street, Los Angeles, CA 90017 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com 800-842-3761 • 71354/71372 (4/15)

1Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/insurance-commissioners-decision-01012015_1.pdf

S a n M at e o C o u n t y

Physician Editorial Committee Russ Granich, MD, Chair Uli Chettipally, MD Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership Vincent Mason, MD, President; Michael Norris, MD, President-Elect; Russ Granich, MD; SecretaryTreasurer; Amita Saxena, MD, Immediate Past President Alexander Ding, MD; Manjul Dixit, MD; Toby Frescholtz, MD; Edward Koo, MD; Alex Lakowsky, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Kristen Willison, MD; Douglas Zuckermann, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org. Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc. © 2015 San Mateo County Medical Association

May 2015 - Volume 4, Issue 5 Columns President’s Message: Adolescent resilience: A period of storm and stress................................. 4 Vincent R. Mason, MD

Feature Articles Chocolate-flavored nicotine: Taming the “Wild West” of electronic cigarettes..................................... 5 Robert Jackler, MD

Technology is good for us…isn’t it? The impact of “screen time” on adolescent sleep . . .................................. 7 Deepti Sinha, MD, FRACP

How my life steered me to the path of medicine.................................... 8 Gurpreet Kaur Padam, MD

Of Interest SMCMA Nominating Committee Report...............................................10 Upcoming SMCMA events. . ....................................................................12 Membership updates, classified ads, index of advertisers. . ................14

President’s Message by Vincent Mason, MD

Adolescent resilience: A period of storm and stress I remember, during the second year of my pediatric residency, wanting nothing more than to become a neonatologist. Fortunately for me, I had a very candid mentor, Dr. Uma Kotagal. Her advice to me was simple: “You don’t have the temperament to be a neonatologist.” Very direct. Very true. I found myself intrigued, instead, by the increasing rate of teen pregnancy in the Cincinnati, Ohio area, as well as across the United States. A crisis occurred in the mid 1980s when a pregnant gingerhaired adolescent girl was placed on the front pages of a prominent magazine

for the entire world to see. This picture (captioned “Children having children”), along with a wonderful group of academic mentors, directed me toward adolescent medicine. Historically the first use of the word “adolescence” appeared in the 15th century. It comes from the Latin word “adolescere,” which means “to grow up or to grow into maturity.” But it wasn’t until 1904 that the first president of the American Psychological Association, G. Stanley Hall, was credited with discovering adolescence (Henig, 2010). During this time period, G. Stanley Hall did a study entitled “Adolescence.” in which he described this new

developmental phase that came about due to social changes at the turn of the 20th century. It was during this time, with the influence of Child Labor Laws and universal education, that youth had newfound time in their teenage years when the responsibilities of adulthood were not forced upon them as quickly as in the past. Hall did not have a positive view of this “phase” and felt that society needed to “burn out the vestiges of evil in their nature.” Therefore, adolescence was a time of overcoming one’s beastlike impulses, as one was engulfed in a period of “storm and stress” (Lerner & Israeloff, 2005). He identified three key aspects of this phase: mood disruptions, conflict with parents and risky behavior. In the 21st century, adolescents are still thought of in this way. Multiple studies have been done looking at the teen brain and it’s relationship to behavior, problem solving and decision-making. There are two regions in the brain: The amygdala is responsible for instinctual reaction including fear and aggressive behavior. In teens this region develops early. However, the frontal cortex, the area of the brain that controls reasoning and helps us think before we act, develops later. This part of the brain is still changing and maturing well into adulthood. A changing brain means that adolescents act differently from adults. Adolescents are more likely to act on impulse, misread or misinterpret social cues and emotions, get into accidents of all kind, get involved in fights, and engage in dangerous or risky behavior. And adolescents are less likely to think before they act, less likely to pause to consider the potential consequences of their actions and modify their dangerous or inappropriate behaviors.

4 San Mateo county physician | May 2015

Now, you might wonder why would anyone would want to take care of an adolescent when so much is needed to work with them. I suppose for my personality, dealing with adolescents has and continues to be an amazing journey into their ongoing psychosocial and physical development. The theories of adolescence is multiple and varied, from biological (G. Stanley Hall, Arnold Gesell, James Tanner), to psychological (Sigmund Freud, Anna Freud), to psychosocial (Erik Erikson), to cognitive (Jean Piaget), to ecological (interaction between individual and environment) (Urie Bronfenbrenner), to social cognitive learning (Albert Bandura), to the cultural (Margaret Mead, Carol Gilligan). What I have found over the years is that the more I engage and listen to my adolescent patients, the more I learn about how things have changed from one decade to the next. Teens show me how to maintain the “elasticity” in my aging brain by challenging me to see the world through their eyes and their thoughts and some times their actions. In this issue we will leaning about technology and it’s affects on adolescents and how they sleep. We will hear from a physician and his/her resilience to become a physician after experiencing a terrible event in their life. And also, there is an article discussing the impact/ influence of marketing on adolescents in our society today. Come out of your comfort zone: engage an adolescent today. ■

CHOCOLATE-FLAVORED NICOTINE Taming the “Wild West” of electronic cigarettes

Over the past few years, electronic cigarettes (eCigs) have burst into the American consciousness. They were invented in China in 2004 and were introduced to the U.S. market in 2007. What was formerly confined to a small, youthful subculture is now receiving enormous media attention, including a recent series of front-page New York Times articles. The technology comes in three sizes: eCigs, about the size of typical cigarette; vape pens, which are favorites for delivering marijuana extracts; and the large ehookahs or “hoses.” While still a small fraction of the U.S. combustible cigarette market, at $1.8 billion in 2013, sales are tripling every year and some analysts predict that eCigs may exceed conventional tobacco products within a decade. The eCig market is populated by hundreds of start-up companies, most of whom simply stick their label on one of a mere handful of device types emanating from China. This early entrepreneurial phase is now transitioning to a more mature market in which the major tobacco companies (LorillardBlu, RJ Reynolds-Vuse, and Altria-Mark Ten), with their vast marketing resources and immense distribution systems, are asserting dominance. Rather than smoking, eCigs uses are said to be “vaping.” The devices vaporize a liquid known as “ejuice” or “eliquid,” which contains a mixture of propylene glycol and glycerin together with flavoring and variable concentrations of nicotine (from 0 to 36 mg per ml). Brands compete to create the most impressive plume, with some devices generating impressive clouds several feet in length. Some eCigs strive to emulate the look and feel of a regular cigarette (e.g., NJOY), while others proudly differentiate themselves by distinctive designs (e.g., Blu). All eCigs have three major components: a chamber containing ejuice, a heating coil to atomize it,

by Robert Jackler, MD

and a lithium ion battery. When the user draws vapor, a light illuminates at the tip. Sometimes the tip glows orange to simulate a lit cigarette, while others use fanciful colors. Some eCigs are single-use disposables while others are rechargeable and employ replaceable eliquid cartridges. Technologically sophisticated systems include chargers, USB interfaces, Bluetooth connectivity, and even smartphone apps to record usage and order supplies. The business model is similar to inexpensive computer printers: a cheap device with profit residing in costly refills of proprietary liquid cartridges. As physicians, we would prefer that people not smoke. Studies show that adult smokers try eCigs out of a desire to quit smoking entirely. From a public health perspective, the hope is that eCigs would prove effective as nicotine cessation devices, or at least be a less harmful replacement for combustive cigarettes. As of mid-2014, scientific data is sparse on both accounts. Disappointingly, a recent study from UCSF showed no tobacco cessation effectiveness, while a British study showed that eCigs worked roughly twice as well as patches, but still well under 10 percent efficacy.1,2

Robert K. Jackler, MD, is a Sewall Professor and Chair in the Department of Otolaryngology, Head and Neck Surgery, at Stanford University School of Medicine. He and his wife Laurie Jackler founded the interdisciplinary research group Stanford Research into the Impact of Tobacco Advertising (SRITA). SRITA conducts research on the ways the tobacco industry targets teens, women, and African Americans as well as how recently introduced products such as electronic cigarettes are marketed. References 1. Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern Med. 2014; 174:812-3.

Most experts believe that if a cigarette smoker transitions entirely to eCig use, it is likely to reduce health risk. One reason is that the carcinogenic fraction of cigarettes 2. Bullen C, Howe C, Laugesen derives primarily from the products of leaf M et al. Electronic cigarettes for combustion. While one might speculate that smoking cessation: A randomised eCigs are a safer alternative, they are almost controlled trial. Lancet. 2013; certainly not safe. The effects of inhaled 382(9905):1629-37. nicotine have been extensively studied, but 3. Corey C, Wang B, Johnson SE little is known about the long-term effects et al. Electronic cigarette use of breathing copious amounts of aerosolized among middle and high school propylene glycol and glycerine into alveoli. students—United States, 2011Chronic inhalation of large quantities of 2012. MMWR. 2013; 62:729-730. flavorants made of aldehydes, ketones, and other chemicals is also of concern. Note: This article was originally published in the July/August 2014 issue of San Francisco Medicine, the magazine of the San Francisco Medical Society.

May 2015 | SAN MATEO COUNTY PHYSICIAN 5

Eosinophilic pneumonia from eCigs has been reported and, over the long term, we may recognize a pattern of eCig-caused pulmonary diseases. A big problem with weaning adult smokers from regular cigarettes is the dual-use phenomenon. Discontinuities of nicotine dosing helps smokers quit. Today smoking is widely prohibited in work places, restaurants, bars, public parks, airports, etc. Presently, in most cities (but not San Francisco), vaping is permitted in many places where smoking is not allowed. This enables smokers use eCigs to sustain nicotine levels and thereby discourage cessation.

breathe some aspergillus?), while others have been shown to contain contaminants such as heavy metals and even carcinogens. In April 2014, the FDA proposed rules to address this concern, but the process is so cumbersome that it is likely to be a couple of years before the proposed rule takes effect.

Advertising of eCigs has been characterized by many as a “Wild West” with an attitude that anything goes. Immune from stringent cigarette regulations, eCig marketers have recapitulated every long-banned advertising device used by tobacco companies and, in many cases, exceeded them in outrageousness. How else could you get six companies touting pink breast cancer-prevention eCigs? Eversmoke uses A major concern is the upsurge of eCig use among teens. the colorful slogan: “Save a life, save a lung, save a boob.” Smoking typically starts as an act of teen rebellion and, once My research group’s website contains more than 4,000 eCig hooked by nicotine addiction, adults cannot break free even advertising images and hundreds of promotional videos though surveys show that some 90 percent wish they could. As (tobacco. stanford.edu). These includes images of doctors teen starters account for almost all adult smokers, the highest and nurses, pictures of healthy pink vaper’s lungs contrasted priority should be to discourage teens from becoming nicotine with blackened smokers lungs, and brand names such as addicted. Evidence is accumulating that eCigs are a gateway Lung Buddy, O2 Easy, e-Health Cigarette, and SafeCig. Some to nicotine addiction. A recent CDC report found a doubling even go so far as touting medicinal effects such as nutritional of eCig use among students value (VitaminSmoke) and weight-loss between 2011 and 2012, with an effect (NutriCigs). Famous endorsers estimated 1.78 million students include rock stars (e.g., Courtney Rather than target committed having tried eCigs.3 The 2014 Love), movie stars (e.g. Stephen Dorff), rate is undoubtedly substantially adult smokers, as the industry and famous athletes (e.g., NASCAR’s higher. Especially troubling is Sorenson). They use cartoons, professes in its correspondence Reed that many middle schoolers who event sponsorships (e.g., Oscars, Go use eCigs have never used regular with Congress, their advertising Daddy Bowl), brand merchandise (e.g., tobacco products. Studies also have t-shirts), and outdoor advertising, unmistakably targets youth. identified a high rate of dual use and they give away free samples at among teens. street fairs—all methods banned for cigarettes. Remarkably, eCigs are now Rather than target committed adult advertised on television and radio, smokers, as the industry professes including the last two Super Bowls, in its correspondence with Congress, their advertising marking the first appearance of a smoker’s product in more unmistakably targets youth. Advertising features young than forty years. Most eCig advertising involves new media models engaged in patently adolescent behavior, including channels such as websites, online video, blogs, wikis, and a overtly sexual themes. With slogans such as “Rewrite the heavy presence on social media (Facebook, Tumblr, Twitter, rules” and “Inhale the freedom,” eCig advertising appeals to etc.). teen rebelliousness. A patently obvious device used by eCig companies to attract teens is youth-oriented flavors. In its My personal view is that I would not want eCigs to be banned, flavored product lines, eCig makers have greatly exceeded as they are likely less harmful that combustible tobacco anything that the tobacco industry was willing to do. It appears products. I do feel that regulation is urgently needed. Both as though they went through flavorant-company catalogs advertising and place-of-use policies need to be aligned and created ejuice varieties in every conceivable flavor that with those for cigarettes. Because flavors entice youthful might appeal to young people. Use of flavored tobacco is well starters, the combination of flavor and nicotine should not recognized as a gateway to nicotine addiction. Flavored ejuice be permitted. As teens have limited discretionary income, types include candy (e.g., bubble gum, gummy bear, cotton taxation of eCigs is important so that they do not remain a candy, chocolate), ice cream (e.g., mint chocolate chip, banana cheaper source of nicotine. Unless these measures are adopted, split), pastry (e.g., cinnamon bun, maple pancake), fruit (e.g., any possible public health gain from conversion of current peach, pineapple), alcoholic beverage (e.g., beer, mojito), smokers will be offset by youth initiation and dual use. pepperoni pizza, and many others. Poison centers report a rash Regrettably, the FDA process currently underway is lethargic of poisoning among toddlers who imbibe sweetened ejuice, including a number of fatal cases. and the initial proposed regulations are tepid. It would seem logical that any vapor intended to be inhaled deeply into the As of mid-2014, eCig production and advertising is completely unregulated. No government agency evaluates the purity of C ontinued on P age 10 eliquids. Some are produced in unsterile facilities (care to 6 San Mateo county physician | May 2015

Technology is good for us…isn’t it? The impact of “screen time” on adolescent sleep Living in the 21st century, we depend on technology. It enables us to communicate with our friends and family anywhere in the world in real time with the touch of a button, get information on any topic we desire with a click of the mouse, and play video games almost anywhere. The convenience makes for more efficient use of our time, but what are the side effects? In schools, more assignments are being done on computers. Teenagers typically have their own cell phones, tablets and other devices they use day and night. Having easy access to these technologies is convenient, but it can affect sleep and daytime performance. For example, A.P. is a sophomore in high school. She wakes up at 6:30 on Wednesday morning and has a normal day at school. After school she has a snack and goes to ballet practice from 3:45 to 6: 45 p.m., as she does four days a week. She comes home, eats dinner and starts her homework. She has an assignment due tomorrow, so she will stay up late to finish it, typing on her laptop on her bed. She finally finishes at 1:00 a.m., turns off her laptop, and tries to go to sleep. She can’t. She finally falls asleep at 2:00 a.m. and is up again at 6:30 the next day. Thursday night, she is tired after ballet and is ready for bed by 10:00 p.m. Just as she is getting into her bed, she gets a text from her best friend telling her that she won’t be able to go to the movies with her on Friday night. Suddenly she is no longer sleepy, but is worried about Friday night. She and her friend exchange text messages for the next hour. She finally falls asleep at midnight and is up again for school at 6:30 the next morning. She wants to sleep in on Saturday but knows she has to get up for her softball game...and so it goes. Along with technology and efficiency have come expectations that our adolescents can fit more into each day. Most technology use occurs later in the day, which can affect how much sleep the teen gets. Reasons technology affects teenagers’ sleep: •

Screen light delays melatonin production/circadian rhythm.

•

Content is emotionally/physiologically stimulating.

•

Technology time directly replaces sleep time.

•

Technology interrupts sleep—e.g., texts after the teen has fallen asleep.

•

Creates poor sleep “hygiene”—e.g., using technology while on the bed can eventually lead to insomnia.

D eepti S inha , MD, FRACP

Adequate sleep is required for optimal functioning, both physical and mental. Over time, the lack of sleep accumulates (sleep debt) and can have adverse effects on the adolescent, such as: •

Difficulties with focus/concentration and decline in grades

•

Tiredness or hyperactivity

•

Slowed reaction times while playing sports

•

Mood issues/irritability/social isolation

•

Poor short term memory

•

Fatigue-related accidents, such as a motor vehicle accident

•

Weight gain due to poor food choices and lack of energy to exercise

While we can’t remove technology from the environment, some things can be done to help improve the ability for teens to fall asleep more quickly. Tips to help sleep promotion: •

Limit screen time two hours before bed. This includes texting and phone use, as well as television and recreational computer and video game use.

•

Do not use media on the bed. Homework should be done off the bed and ideally out of the bedroom.

•

Create a sleep promoting environment—a dark, quiet, cool room with no media.

•

Create a schedule with homework and other stimulating activities to be completed by early evening if possible.

•

Create a family media pledge. This is an agreement between teenager, parents and the rest of the family regarding content and timing of media use. Specifics regarding end time of use can be added to this. www.healthychildren.org/English/family-life/Media/ Pages/Media-Time-Family-Pledge.aspx

•

Talk to the wireless provider. Some providers can allow restriction of timing of text and internet use. ■

About the author Deepti Sinha, MD, FRACP completed her Sleep Medicine fellowship at Stanford University for adult and pediatric sleep disorders. Prior to this, she completed her Pediatric residency at University of Illinois at Chicago (U.I.C.). She is a native of Australia and received her medical degree from the University of Melbourne. She has also completed a fellowship in General Pediatrics in Australia and has been a research fellow for Children’s Memorial Hospital in Chicago with a focus on childhood obesity. May 2015 | SAN MATEO COUNTY PHYSICIAN 7

how my life steered me to the path of medicine by

G urpreet K aur P adam , MD

The most difficult question anyone has ever asked me is “Why did you become a doctor?” A new patient recently asked me that and I was dumbfounded. Like a movie on a projector, my pre-teen years flashed before my eyes. I held back my tears and responded, “let us talk about it another time.” She respected my wishes and agreed that we would defer the discussion. I wish the answer were as simple as, “My father bought me a Red Riding Hood doll when I was little, and instead of playing dress up, I gave her injections and tried to heal her imaginary ailments.” I knew I wanted to be a physician; in fifth grade my conviction was reaffirmed. A dark haze lowers over my memories when I think about October 31st, 1984. We were let out of school early, around noon, and it was announced that the Indian Prime Minister had been assassinated by her Sikh bodyguards. When I reached home, my mother hurried us to the market to stock up on food, as a curfew was anticipated. While mom was picking out essentials, the shopkeepers hastily pulled down the shutters. Thud, thud, thud, and the shops were locked up. The shop keepers folded their hands in request that we leave the plaza right away, for our own safety, as things were about to get ugly. My father was away on business in Gurgaon, a town near New Delhi. He was in the process of relocating his business, which has been in our family for several generations. We lived in an industrial area without any other homes on the block. Workers, helpers at home, the gardener and the cleaning lady were all let out early, and there was an eerie quiet in the middle of the day as people retreated to their homes. Within hours, news traveled that there organized mobs, supported by police and government, armed with iron rods and kerosene oil, on a mission to finish off the Sikhs. They had access to the voters’ lists, and Sikh homes were being targeted and marked by an “X” for easy identification. The Sikh Code of Conduct mandates that all initiated Sikhs wear each of the articles of faith known as the 5 K’s. (Sikhs who are not initiated may carry some or all of the articles of faith). The five articles are the Kara (an iron bracelet), the Kanga (a small comb), Kachera (a special, longer type of underpants), Kirpan (a small sword) and Kesh (uncut hair). Sikh men and some women wear a turban with uncut hair. The visible K’s—the Kara and the turban with uncut hair—make it easy to identify a Sikh. On the main street a little further from the inroads of our home, any visible Sikhs on the street were pulled 8 San Mateo county physician | May 2015

from their vehicle and beaten, doused in Kerosene and burned alive. I was not meant to hear this, but it couldn’t be helped. At night, mom said we had to turn down the lights and not make any noise. No one should know that we live here. I remember sitting curled up in a corner of our veranda, where I had decided to be on watch. A myriad of emotions took over me. I didn’t know at the time, but what I was feeling was sorrow, pain and anger. Naively, I was not afraid. I felt helpless for the victims and wanted to do something. I couldn’t expose myself and go to the streets, defenseless. In the sleepless night, my ears were perked for any rustling footsteps or noise indicating that the mob was headed our way. The next morning, I saw plumes of smoke at a distance. Did I imagine it, or was it the smell of human corpses burning? Two very large trucks stopped in front of our house. Two turbaned men stepped out and stood by our iron gate, seeking shelter. I could see apprehension in my mother’s eyes, as there was the risk of 19-22 foot long commercial trucks being followed to our home. My grandfather, an eco-enthusiast, had planted around 200 eucalyptus trees in the back of the house. The trees were now tall and lush. Mom allowed the trucks to be hidden in back and the trees made for an ideal camouflage. For the few days the truckers were given shelter, food and water in our home, news of crimes against Sikhs was pouring in from New Delhi and many other cities in India where Sikhs were being targeted by organized mobs. Days went by and we didn’t have any news of my dad’s whereabouts. We had heard about villages where women had been raped and tortured and left with the bones and ashes of their sons, husbands and fathers. In one such town in Delhi, Tilak Vihar, the entire population of Sikh males were murdered. It is now known as “Widow Colony.” For who escaped being burnt alive were beaten to a pulp. I wept alone as I didn’t want mother to see me like this. In my corner, every night, I thought about what I would do if the mob came to our home. We had a shotgun, which was my only solace. A week went by and there was no news of Dad. When people were visible on the streets again, we went to visit my history teacher, who had been forced to jump from her balcony when the mob approached her home. As a result, she fractured both

her legs and pelvis. She was in bed, a full cast up to her waist, lying in bed when she shared her experience. A friend of my mother’s from Canada, visiting her family in India at the time, had also perished. My blind music teacher, a deeply spiritual man, was also murdered amongst all the other Sikhs who were being targeted on trains traveling from Amritsar to Delhi. The accounts of pain were too numerous to count. I stopped listening at some point. I knew I couldn’t do anything to help. It was too late. Thousands of homes and businesses were plundered, people perished and my father was missing. We feared the worst. About a week after the October genocide was instigated, a car pulled up in the driveway with four or five men in it. Mom approached them and they accompanied her into the house and sat in the living room, speaking quietly for several hours. Once they left, one man remained behind. He approached me with his outstretched arms and said, “It’s Dad.” His eyes were swollen and his face was puffy. He didn’t have his visible K’s anymore. My eyes searched for the long flowing beard or the soft mustache. He didn’t have his turban or his hair underneath. I refused to believe that this man was my father; I looked at him in disbelief. I didn’t see the usual spark in his eyes, heavy under the weight of his tears.

Opposite page: Dr. Padam and her daughter, Arzoe. This page, from top: Dr. Padam as a toddler with her father Dr. Padam’s parents, Harinder and Rabinder Padam, at their 50th wedding anniversary Dr. Padam’s husband, Dickey Singh, and their twins Aekash and Arzoe. All photos courtesy of Gurpreet Kaur Padam, MD.

He told us that when the mob lit the factory on fire, he was trapped between the choice of burning to death inside or at the hands of the bloodthirsty mob waiting outside. He didn’t have anything to fight back with and he didn’t want to die in vain. Sikhs trapped in the burning factory decided to remove their Ks and were able to escape. They travelled in the night and made the several-day journey home. Dad started to tell my siblings and me about his eyewitness accounts but then he stopped. He could not bring himself to speak further. My charming, marathon-running father, my hero, the gentlest soul I have ever known, who has never raised his hand or his words against me, faded away to retreat from the world in the quite crevices of his mind. He became a reserved and a more observant man. His view of the world

changed forever. Our lives were spared, while thousands of others were not. How could I live with this? My heart ached for those who died a painful death. I wanted to reach out to the victims and I wanted to help make things better. At 12 years of age, my childhood dream to become a doctor became my calling. For months that followed, I was taunted at school and students made fun of my long hair. My brother, a visible Sikh, was no longer safe on the streets. My parents decided that it was time for us to move to a place where we could live without fear of persecution. My family packed up their entire legacy, a handful of pictures, clothes and those belongings that would fit in a suitcase, and $50 in their pockets, and we migrated to the United States. As a middle school student in metropolitan Illinois, I struggled to forget my past and assimilate in the culture of my new homeland. I found a friend in The Diary of Anne Frank. I drew comfort from her strength. My parents worked many jobs to provide for the three of us and put us through college. As teenagers, when my sister and I would deter from a goal, my father would remind us that money and riches are transient and fluid, but education and skills will stay with us forever. He wanted us to be self-sufficient. My father’s constant reminders kept me aligned with my vision of my future as a healer, and before I knew it, I graduated from medical school and was starting Residency in Family Medicine. In my third year of residency, I felt drawn to the field of hospice, which led me to Stanford/VA Palo Alto Hospice and Palliative Medicine Fellowship. I thought the volume of dying patients, which surrounded me, would scare me. However, when I arrived at the VA hospital for my first day and I took my first step out of the elevator, I felt a certain calm. Serving the veterans, who had survived torture and war, many of them Purple Heart recipients, instilled humility and resolution. I had found my niche and I finally felt redeemed. I was home.

continued on next page

May 2015 | SAN MATEO COUNTY PHYSICIAN 9

How my life steered me to the path of medicine continued from previous page

San Mateo County Medical Association 2015 Nominating Committee Report

I now believe in the possibility of a good death. My current practice is a balance of Adult Medicine and Hospice. Visiting patients in their place of residence remains the most gratifying part of my work. I would be lying if I said that I practice medicine solely to help others. My patients have come from all walks of life and I like to get to know about their lives. I like to see the family pictures hanging on the wall and I like to listen to their stories.

The 2015 SMCMA Nominating Committee has proposed the following candidates to officer, board, and delegation positions. Nominations may also be made by members of the Association. These nominations are to be in writing, signed by 10 active members, and delivered in person to the association headquarters or by registered mail no later than June 19, 2015.

I was once visiting a 90-year-old patient with severe dementia in a nursing home. I had seen her many times before; however, during this visit, I noticed a large black and white poster of a beautiful young dancer above her hospital bed. I asked one of the nurses the significance of the poster and I was pleasantly surprised to learn that she was a concentration camp survivor and a professional ballerina in her younger years. Honored by the opportunity to get to know her, I cupped her hand and told her how beautiful she looked in that poster. She gently squeezed my fingers with hers. In that moment, the noticeable odor of this nursing home was juxtaposed by the life affirming memories of people living there.

Officers

Acknowledging a person’s past dignifies and humanizes them. Compassion and connection can be healing. Selfishly, it helps me become a better person and helps me provide better care to my frail patients. I am grateful that 30 years later, in April 2015, California became the first state to recognize the anti-Sikh holocausts. (http:// asmdc.org/members/a09/news-room/press-releases/californiabecomes-first-state-to-recognize-the-anti-sikh-pogroms). When Asian American for Community Involvement (AACI) in Santa Clara requested participation in a video for the New Refugee Service Program, it was eye-opening experience. I learned that while my family immigrated to the United Stated, numerous others sought refuge and asylums and continue to do so, till this day. As a physician, I recognize the cultural and linguistic barriers to delivery of health care and access to resources. The videos in English and Punjabi were created in hope that refugees from India would have more information about social and medical resources available to help them acclimate. http://cst.aaci.org/ learning-resource-center/videos/.

continued on page 14

Taming the “Wild West” of electronic cigarettes lungs on a daily basis ought to be carefully evaluated for safety before it could be introduced into the mass market. That the burden of proof in the federal regulatory process requires scientific proof that eCig vapors are unsafe is a serious failing of its responsibility to protect the public. We are now engaged in a large-scale experiment in which our youth are principal participants. Congress has the 10 San Mateo county physician | May 2015

Russ Granich, MD President-Elect Alexander Ding, MD Secretary-Treasurer Vincent Mason, MD Immediate Past-President The office of the President will be filled by Michael Norris, MD

Board of Directors Susan Pertsch, MD Michael Ren, MD Board members continuing terms: Toby Frescholtz, MD Alex Lakowksy, MD Michael O’Holleran, MD Douglas Zuckermann, MD

Delegation Alexander Ding, MD Mark Levsky, MD Delegates continuing terms: Dirk Baumann, MD; John Hoff, MD; Leslie Kim, MD; Steve Kmucha, MD; Michael Norris, MD; Amita Saxena, MD; William Tatomer, MD

Alternate Delegates Alternative Delegates continuing terms: Gordon A. Brody, MD; Julie O’Callahan, MD

continued from page 6 ability to accelerate the regulatory process, and I applaud Bay Area Congresswoman Jackie Speier for her efforts in this regard. Should it takes years to reign in the eCig industry’s targeting of our young, an entire generation of America’s youth, attracted by the irresistible lure of chocolate-flavored eCigs, will be at risk of suffering lifelong nicotine addiction. ■

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Thursday, June 18, 2015 6:30-9:30 p . m .

San Mateo County Medical Association

2015 ANNUAL MEETING

Please join us as we welcome the 2015 SMCMA Board of Directors and honor the recipient of our Distinguished Service Award, James Missett, M.D. Dr. Missett is a board-certified psychiatrist in Menlo Park and an Emeritus Adjunct Clinical Associate Professor at Stanford University School of Medicine. He has also served as a consultant with the U.S. Secret Service on the West Coast and performed forensic psychiatry for the State of California Office of the Attorney General. The celebration will include a cocktail reception followed by dinner. Our venue this year is the Candy Store, a one-of-a-kind classic car museum in the heart of Burlingame. Learn more at www.candystoreclub.com. Tickets are just $65 per person for members and their guests, $95 for all others. Tickets can be purchased by calling (650) 312-1663 or online at www.smcma.org/annualmeeting2015.

SMCMA ICD-10-CM Two-Day coding Workshop Tuesday-Wednesday, July 21-22, 2015 8:00 a.m. - 5:00 p.m.

With the October 2015 transition to ICD-10, current code sets will under-go a significant restructuring as well as increasing from 14,000 to approximately 69,000 codes. This change will require providers, coders and billing staff to learn new codes and coding concepts. To help your practice prepare, the SMCMA is holding a special two-day code set training with the American Association of Professional Coders (AAPC). This training is designed to give attendees a comprehensive understanding of guidelines and conventions of ICD-10, as well as fundamental knowledge of how to decipher, understand, and accurately apply codes in ICD-10. Specifically, the training will focus on: • • • • •

Overview of the code set ICD-10 format and structure Complete and in-depth ICD-10 guidelines Nuances found in the new coding system with coding tips Coding case studies and exercises

This training is conducted in a classroom style format and will be conducted over two (2) days that includes sixteen (16) hours of intensive general ICD-10 code set training. Each attendee will re ceive the AAPC ICD-10 Work Book, an ICD-10 codebook, and a certificate to take the AAPC Online ICD-10-CM Proficiency Assessment Exam. Lunch will also be included. This onsite training course is approved for 16 CEU’s through AAPC.

Fee: $399 per person* *This is a group discount price; individual AAPC course is $695 online. Register online at www.smcma.org/ICD10-Training or contact us at (650) 312-1663. 12 San Mateo county physician | May 2015

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How my life steered me to the path of medicine continued from page 10

Yu-Ming Chang, M.D. *Gastroenterology Redwood City

Kristin Gershfield, M.D. *Internal Medicine Redwood City

I aspire to master both the science and the art of medicine. In the process, I have found healing, joy of serving others and gratification which are welcomed side effects of my profession. At the end of the day, when my children ask me “How was work?” I feel pride in telling them that it was a busy and a gratifying day. I am humbled to have this opportunity to be of service. ■

About the author

Lisa Lam, M.D. *Family Medicine San Carlos

Deborah Myers, M.D. *Emergency Medicine S. San Francisco

Maureen Park, M.D. *Obstetrics & Gynecology S. San Francisco

Pei Tsai, M.D. *Thoracic Surgery San Carlos The following SMCMA members have recently retired from practice:

Jeffrey Javerbaum, M.D. Derrick Taylor, M.D.

Gurpreet Kaur Padam, MD, practices adult medicine and hospice with the Permanente Medical Group. She is fellowshiptrained and board-certified in hospice and palliative medicine, board-certified in family medicine, and completed a minifellowship in ethno-geriatrics. She is a founding boardmember of the Sikh Family Center, which promotes healthy families in the Sikh American community by closing current gaps in access to resources and increasing community awareness and activism.

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