2012-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2012

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author.

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Medicine 3

PRESIDENT’S MESSAGE “Do you want us to do everything for him?”

David Herbert, MD

EDITOR’S MESSAGE Universal Health Care – Why can’t we all ride at the front of the bus?

The 20 Gram Fat Diet!

Denette Dengler, MD, MS

Capitol Display Shows off our Museum’s Treasures

Bob LaPerriere, MD

Nathan Hitzeman, MD

Joint Effort Brings Health Care To Knights Landing

Help a Deserving Student go to Medical School!

Alexa Calfee, MS II

Aileen Wetzel, Executive Director

Mallard Math

Casting a Wide Blanket – Moving Beyond Safety Nets for Sacramento’s Underserved

John Loofbourow, MD

A Posit on HPV Immunization

A. Jonathan Porteus, PhD

Origins of the Medical Societies

Colorectal Cancer – Improving Access to Screening, Diagnosis and Treatment in Underserved Communities

Board Briefs

Meet the Applicants

Sandra Robinson

An Intersection in Nicaragua

Colonoscopy Prep Countdown

Nathan Hitzeman, MD

Ann Gerhardt, MD

Classified ads

2012 Alliance Grants

Barbara Andras and Gabby Neubuerger

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/magazine.asp Earlier this year our medical museum was approached by the CMA requesting an exhibit at the State Capitol for CMA’s 2012 Legislative Leadership Day. The planned two-week display in April was to be on the second floor rotunda of the Capitol. Entitled California Medicine: From the Frontier to the CuttingEdge, the exhibit chronicled progress made by California physicians from the early days of statehood into the modern age. Ultimately, three display cases housed artifacts, and one was dedicated to a two-dimensional timeline. See full story on page 16. Photo by David Flatter.

July/August 2012

Volume 63/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

Position Available:

2012 Officers & Board of Directors David Herbert, MD President Demetrios Simopoulos, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD, Secretary District 2 Jose Arevalo, MD Ann Gerhardt, MD Lorenzo Rossaro, MD District 3 Bhaskara Reddy, MD, Treasurer District 4 Russell Jacoby, MD

District 5 Paul Akins, MD John Belko, MD Jason Bynum, MD Steven Kelly-Reif, MD Kristen Robinson, MD District 6 J. Dale Smith, MD

mmended By re Doctors.

2012 CMA Delegation Delegates Alternate-Delegates District 1 District 1 Robert Kahle, MD Reinhart Hilzinger, MD District 2 District 2 Lydia Wytrzes, MD Margaret Parsons, MD District 3 District 3 Katherine Gillogley, MD Ruenell Adams, MD District 4 District 4 Earl Washburn, MD Russell Jacoby, MD District 5 District 5 Elisabeth Mathew, MD Anthony Russell, MD District 6 District 6 Marcia Gollober, MD Karen Hopp, MD At-Large At-Large Alicia Abels, MD Jason Bynum, MD Richard Gray, MD Robert Forster, MD David Herbert, MD Maynard Johnston, MD Richard Jones, MD Alexis Lieser, MD Norman Label, MD Robert Madrigal, MD Charles McDonnell, MD Rajan Merchant, MD Janet O’Brien, MD Richard Pan, MD, Kuldip Sandhu, MD Assemblyman Boone Seto, MD Vacant Demetrios Vacant Simopoulos, MD Vacant CMA Trustees 11th District Barbara Arnold, MD Richard Thorp, MD Solo/Small Group Practice Forum Lee Snook, Jr., MD

Urgent care, full-time, partnership We are seeking a board certified FP, IM, or EM trained physician who is interested in long-term stability and partnership. The Doctors Center is an urgent care office in Fair Oaks with extended hours. We are a singlelocation practice and have a close relationship with physicians in our community. We see a wide variety of interesting patients and procedures typical for urgent care. We are almost fully electronic in our charting and billing, and all records are complete by the time the patient leaves our office (no after-hours charting).

JOANNE BERKOWITZ, M.D. Board certified in Internal Medicine and Emergency Medicine DONALD S. BLYTHE, M.D. Board certified in Emergency Medicine KIMETTE M. MARTA, M.D. Board certified in Family Medicine

We’re Here When You Need Us 4948 San Juan Ave. Fair Oaks, California 95628 916/966-6287

The Doctors Center Medical Group Inc.

Benefits include professional liability insurance, educational allowance, 401(k) plan with employer match, health and dental insurance, vacation, and partnership options. If you are interested or know someone who might be, please contact one of us.

CMA President-Elect Paul Phinney, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair George Meyer, MD Sandra Hand, MD John Ostrich, MD Albert Kahane, MD Robert LaPerriere, MD Gerald Rogan, MD John Loofbourow, MD Gilbert Wright, MD Adam Dougherty, MS II John McCarthy, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2012 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Avenue, Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Avenue, Sacramento, CA 95819-2396.

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President’s Message

“Do you want us to do everything for him?” By David Herbert, MD IT’S A SCENE REPEATED MANY TIMES daily: A patient nearing the end of his life from one or many illnesses deteriorates because of these or perhaps new problems, and presents to an office or emergency room with concerned family. The patient’s deterioration has made him lethargic and confused and his breathing is becoming somewhat labored. Although the patient’s downhill course has been apparent for some time, neither his family nor his physicians have discussed with him how he wants to die. Now this issue is unavoidable. His physician turns to his family for guidance, and asks, “Things don’t look good. Do you want us to do everything for him?” Let’s pause and picture what the physician is thinking: “This patient is clearly dying, and is likely to need life support soon unless the family declines. We need to get this decided so I can get him into the ICU versus medical floor versus home with hospice. The family has known about his metastatic cancer or advanced organ failure for months and surely has been expecting this.” But what is the family hearing and thinking? Since they haven’t discussed this before, they are often surprised and alarmed by hearing that death may be imminent. And what is this talk about giving up? The patient clearly is uncomfortable — are the doctors and nurses just going to ignore him? And there is no time to gather the rest of the family and confer, so of course they want “everything” done. So the patient gets intubated, which requires restraints and sedation. Hours or days later the family may view this result of their decision with alarm and regret. If the patient survives,

perhaps discussions begin about comfort care. And the patient dies, often in the ICU, or soon thereafter, perhaps additionally suffering a stay in a skilled nursing facility which he never wanted. This end result is a failure in all too many ways. The patient goes through considerable discomfort and indignity in his final days. His family suffers as they watch this and wonders what to do. Our community suffers from the enormous expense of end-of-life care, much of which is futile. As physicians, we have the opportunity to profoundly change this scenario. When we see patients with advancing illness in our offices, we can initiate end-of-life discussions instead of hoping that someone else is doing this, just as they are hoping that we are. Instead of denying patients hope, these discussions can empower patients and families to come together in life’s final months to choose a better course. This is more than just having a patient complete a Durable Power of Attorney form. They should be encouraged to discuss their desires with their family, but likely won’t do so without some specific scenarios from us. And especially when our opening scene is played out in front of us, we can rephrase the discussion to offer a gentler path towards inevitable death: “Your father is dying from his progressing illnesses. Let’s do everything we can to ensure that he is comfortable and can spend his final hours or days with his family.” Hippocrates will be proud. dherbert@pol.net

July/August 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Editor’s Message

Universal Health Care Why can’t we all ride at the front of the bus?

By Nathan Hitzeman, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

I RECENTLY ATTENDED AN ETHICS discussion at the McGeorge School of Law. The keynote speaker was T. R. Reid, a Washington Post writer, contributor to PBS, and an expert on global health care delivery systems. His book, “The Healing of America,” relates his experiences, both as a patient and as a journalist, in interviewing health ministers, doctors, politicians, and citizens of countries around the world. His discovery: The U.S. is the only wealthy country in the world without universal health care. We spend about twice as much on health care as the next highest spending country. Yet we do not cover 50 million people, and we have worse overall outcomes. Ironically, the U.S. helped compose and sign the 1948 postwar document, Reclamations of the Rights of Man, which endorsed a universal right to food, housing, and medical care. And while many countries include a right to health care in their constitutions, ours does not. How different the situation would be if our founding fathers had included those words! Perhaps most shocking is that a prisoner in the U.S. can get cancer treatment while a blue collar worker who doesn’t qualify for Medicaid can’t. I sometimes inwardly rejoice when one of my indigent patients gets on dialysis and suddenly qualifies for Medicare. Is that sick, or what? As someone who has seen how the system can work abroad, Mr. Reid believes all people have a right to health care − routine care as well as urgent. Who among us wouldn’t want

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the same for our families? He marvels that in other countries, people at all levels seem to acknowledge a moral imperative for universal health care, but here we do not. When one audience member asked why that is, Mr. Reid replied, “If more Americans knew how cruel the system was, they would want better.” He noted that President Reagan often dismissed universal health care, stating that people could just go to the ER. As physicians, we know that that is not cost-effective or ideal routine health care, and we all pay more in the end by not having universal care. One wonders how satisfying strictly emergency care would have been for the President and his wife with his decline into Alzheimer’s disease. Neither was Mr. Reid enamored with President Obama, who made his health care reform package more about insurance reform than about universal health care as a moral obligation. Mr. Reid ended with this anecdote: He was on the Mike Rosen show (a conservative talk show), and Mr. Rosen asked him why the health care system needed to be fixed when 85 percent of Americans in one survey said they were satisfied with it. Mr. Reid said that he fumbled with his answer, but then a caller came on the show and said, “Yeah, well, 85 percent of the population used to be able to ride at the front of the bus in Montgomery, Alabama, but we decided that wasn’t good enough!” hitzemn@sutterhealth.org

Executive Director’s Message

Help a Deserving Student go to Medical School! By Aileen Wetzel, Executive Director SINCE 1967, THE SIERRA Sacramento Valley Medical Society (SSVMS) has awarded scholarships to deserving medical students who have graduated from high school in El Dorado, Sacramento, or Yolo Counties. A number of those students have returned to establish medical practices in our area and have become members of our medical society. In 1962, SSVMS members volunteered to supervise administration of the polio vaccine at multiple locations in the Sacramento area. Known as “Sabin Oral Sundays,” recipients paid only 25 cents for their dose. SSVMS used the surplus funds to establish a Medical Student Scholarship Fund to provide scholarships to medical students from our region. In 1987, the scholarship fund was renamed in honor of William E. Dochterman, who served as Executive Director of the society for 27 years. Since the establishment of the scholarship fund, SSVMS has awarded 178 scholarships totaling more than $200,250. In order to meet the needs of local residents pursuing a medical degree, our endowment needs to grow. According to a recent Association of American Medical Colleges report, the cost of medical education at a public school is, at a minimum, $188,000 over a four-year period, not including room and board. We hear time and again from medical students who receive scholarships through our scholarship fund that they benefit from both the financial assistance and the knowledge that their community believes in them enough to subsidize their education. Some students have shared that earning a scholarship was the catalyst for becoming a physician. Some tell us that if it weren’t for scholarships, they

wouldn’t have attended medical school at all. Below are comments received from three recent scholarship recipients: “I am so incredibly, wholeheartedly grateful for this gift. It’s amazing that your organization offers this help to students from Sacramento, and I really do hope to end up in the area when all is said and done, and medical school leads me to residency.” − Kelly Quinley, 2009 recipient. “I am honored to receive this award and am extremely grateful for your generosity in helping me pay for medical school costs. This academic year has been very interesting so far, and I am excited to learn about the mechanisms of human disease. Medical school just seems to get better and better the more I learn!” −Andrea Nos, 2011 recipient. “Education is one of the greatest and most productive investments in the future, and I thank you for investing in mine. The scholarship will go a long way in helping to ease extraneous thoughts about my financial obligations allowing me to concentrate my efforts on my medical education and patient care.” −Kellen T. Galster, 2011 recipient. Please consider supporting the future of medicine with a tax-deductible donation today. Several of our members and their families have made donations to commemorate a colleague or a loved one. Others have included the scholarship fund in their estate bequests. The future of medicine depends on you − our physician members. For more information, contact SSVMS at (916) 452-2671. Donations can be made online at www.ssvms.org or mailed to the William E. Dochterman Scholarship Fund, c/o Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Ste. 101, Sacramento, CA 95819. awetzel@ssvms.org July/August 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 5

Casting a Wide Blanket Moving Beyond Safety Nets for Sacramento’s Underserved

By A. Jonathan Porteus, PhD, CEO of The Effort, Inc.

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

DIEGO INCHED OUT ONTO THE LEDGE. The heat was unbearable: he had to jump. Below him a voice, maybe two voices, called up from the dark. “Jump. Jump. It’s your only chance. We are holding a net!” The flames appeared from nowhere and he’d watched them grow, helpless. Panicked reflection, a wish to blink and have it all go away. Now his only chance was to fall into the unknown hoping the safety net would hold him. He jumped. For those of us in the caring professions, each day brings examples of health issues that have spun out of control. Often these issues are graver than they were to begin with, and our treatment options become more assertive and costly. A casual peek on any given night in a local emergency department shows us the abundance of undocumented, uninsured, poor, and working poor, who — like Diego above — walk the ledge until it is time to jump for help. And often they are not sure how much to trust the net below. The time has come for us to move beyond these “safety nets.” According to a March 2012 Suttercommissioned Valley Vision study, Sacramento County alone has a treatment capacity shortfall of primary care services leaving 82,000 persons with Medi-Cal without access to health care. Our current safety net consists of multiple organizations, most with a clinical specialty or cultural niche focus, that have traditionally functioned in relative isolation. In recent months, the Sierra Health Foundation has convened a “Healthy Sacramento Coalition” bringing this diverse group together. This is timely as a January market analysis by their team of consultants predicts a tsunami of 220,000 persons in the Sacramento region who will convert from uninsured to Medi-

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Cal with the advent of health care reform. We must act quickly to secure facilities and ensure a workforce to provide medical homes in a relatively short time. I am encouraged by the community-wide conversation, as well as programs like the county’s Low Income Health Program that will increase coverage for up to 8,000 currently medically indigent people. Here at The Effort, we are stepping up our role in the community. The Effort is the largest local Federally Qualified Health Center (FQHC) with four full-scope Health Centers serving core medically underserved areas in Sacramento on a North-South axis from North Highlands to Midtown, to Oak Park, and South Sacramento. Using recent Geographic Information Systems (GIS) data to map each nexus of need for health access, a fifth Health Center opened in Roseville in March and will be followed in short order by Health Centers in Folsom, Rancho Cordova, downtown Sacramento, and Citrus Heights. A detailed map of The Effort’s current locations can be found at http://www.theeffort.org/loc_map_ and_service_guide.htm.

Dental Clinics None Too Soon Our Health Centers provide pediatric and adult primary care, women’s health services, and prenatal services (most notably our “centering pregnancy” model and Comprehensive Perinatal Services Program). In addition, the third of four First 5-funded state-of-the-art children’s dental clinics will be completed this July, and the fourth should start serving the eastern part of Sacramento County by mid-2013. The dental clinics came not a moment too soon, given the miserable state of the local MediCal-funded children’s dental network.1 Assemblyman Dr. Richard Pan and State Senator Darrell Steinberg

have been very supportive of our cause. The Effort is also a well-known regional behavioral health provider. Poor access to mental health services is a major driver of health care costs and ED visits. Our Health Centers use an Integrated Behavioral Health model to extend the capacity of a generalist practice. The model also addresses the fact that the average life expectancy for a person with a mental illness is 25 years shorter than for a person without one, largely due to silos of care. Many of our Health Center locations offer synergistic access to other services, including: County-contracted child, adolescent, and family counseling services; behavioral health counseling and psychiatry; evidence-based home visitation and family resource center services through our role as a founding partner in the Birth and Beyond network; 2 and Youth Development programs including street outreach and gang prevention.3 Innovation is at the core of many Effort programs. For example, The Effort’s partnership with Sutter Health led to the acclaimed T3 model (Triage — Transport — Treat), successfully supporting frequent non-urgent ED visitors into “whole person” coordinated care in a Health Center medical home and providing assertive case management to meet other needs (e.g. benefits acquisition, housing for the homeless, etc). The result: a 65 percent reduction in ED utilization. Targeting coordinated care to these daily ED patrons makes sense on all levels from giving humanistic care to saving health care dollars and promoting sustainable preventive and primary care services. Our results are comparable to ED reductions seen in a recentlypublished study of a North Carolina program where high risk, uninsured patients were assigned to a primary care interdisciplinary team.4 Their study also references many other studies showing how proactive outreach can curtail costs and utilization. Dr. Aytul Gawande drives home the point in his New Yorker article, “The Hot-Spotters.”5 Our service to homeless members of this cohort led us to build satellite FQHC clinics

within affordable housing settings (providing immediate and preventive care). We figured that medical homes work best when coupled with real homes. A full scope Health Center is built into the new multi-story affordable housing complex going up in downtown Sacramento at 7th and H Streets. Another partnership program of ours, the Interim Care Program (ICP), serves all four regional health systems by providing safe hospital discharge for persons who are homeless. Patients are discharged to The Effort’s FQHC satellite within the Salvation Army where they receive health access and assertive case management. Over 800 ICP discharges have yielded over 20,000 bed days in this successful and cost-effective program, and copies of it have sprung up elsewhere. We have a YouTube video explaining the process to discharge planners.6

The Name Says It All All of these services emerge from our “Health Access and Case Management” division. The name says it all. Kaiser CEO, George Halvorson, describes the need for “connectors” in his 2009 book, “Health Care Will Not Reform Itself,” and these programs exemplify his vision. So in another program, we have partnered with Sutter to create a Navigator program serving Sutter General and Memorial EDs. Seven days a week, we approach all users of the ED (not just the non-urgent, frequent users targeted in the T3 model) to ensure that they have access to health care, benefits, and any other ancillary services in the community.7 The growth of The Effort has been nurtured by partnership, the generosity and support of the health systems, and programs such as SPIRIT through the Sierra Sacramento Valley Medical Society. As our Health Center network expands, there are also increased opportunities for volunteerism and pedagogical relationships. Providing a community-level opportunity to serve, as well as to learn, is vital for our next generation of physicians. The Effort’s collaboratives with UC Davis exemplify this pedagogical synergy and workforce development, be it through the Pediatric

July/August 2012

Providing a communitylevel opportunity to serve, as well as to learn, is vital for our next generation of physicians.

Residency partnership, community fellowship, or the two student-run clinics hosted in our facilities on Saturdays (Clinica Tepati and Imani Clinic). An expansion of these partnerships provides crucial settings for training, the groundwork for a Teaching Health Center, and exposure to this very meaningful workplace for an emerging primary care workforce. Of note, The Effort is a National Health Service Corps provider, and therefore, able to accelerate loan repayment while paying a competitive salary. An exciting future looms, one promising to relieve some of the burden of health access for low-income patients, with critical interrelationships between systems of care, with opportunities for enhancing quality, and with opportunities for workforce incubation. Feel free to contact me if you would like to participate in our mission, or learn more about us at www. theeffort.org. Through our shared hard work and investment, I envision that our proverbial

“safety net” will morph into something more substantial — perhaps a “safety blanket.” Who wouldn’t want a blanket? Diego smelled burning. Flames had appeared from nowhere. He quickly threw a fire blanket over them, thinking “good thing everyone has one of these.” He called maintenance and then set to work cleaning up and figuring out what had caused the fire and how to prevent another one. jporteus@theeffort.org 1 The Sacramento Bee 2/14/12 (Editorial: Dental plan for poor kids is a mess, http://www.sacbee.com/2012/02/14/4261500/dentalplan-for-poor-kids-is-a.html#storylink=misearch) 2 The Sacramento Bee 2/28/12. Science-based parenting classes help moms and dads deal with discipline, http://www.sacbee. com/2012/02/28/4295448/science-based-parenting-classes. html#storylink=misearch 3 The Sacramento Bee 7/17/11 and Capital Public Radio 4/4/12. East Bay gunshot victim a success story for Sacramento intervention program, http://www.sacbee.com/2011/07/17/3774589/ east-bay-gunshot-victim-a-success.html#storylink=misearch, ER becomes turning point for young victims http://www.capradio. org/articles/2012/04/04/er-becomes-turning-point-for-youngvictims. 4 Crane S et al. Reducing utilization by uninsured frequent users of the emergency department. J Am Board Fam Med. 2012;25(2):184-191. 5 http://www.newyorker.com/ reporting/2011/01/24/110124fa_fact_gawande. 6 Type “ICP Referral” in YouTube and you can see The Effort team explaining the program to discharge planners. 7 See the 3/23/12 feature in The Sacramento Bee for a deeper description. Sutter “navigators” steer routine patients out of emergency rooms. http:// www.sacbee.com/2012/03/23/4359992/sutternavigators-steer-routine.html#storylink=misearch.

Remember When?

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Colorectal Cancer Improving Access to Screening, Diagnosis and Treatment in Underserved Communities

By Sandra Robinson, Vice President of Programs, CMA Foundation The author, Sandra Robinson, is the former Statewide Director for the American Cancer Society, and in addition to being the current Vice President of Programs for CMAF, she is also the Board Vice President of the California Colorectal Cancer Coalition (C4).

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

MAJOR HEALTH CARE GROUPS in the Greater Sacramento Region have come together to make colon cancer screening a reality for the underserved! The California Colorectal Cancer Coalition (C4) has taken on this challenge and facilitated the cooperation of the Sacramento County and Community Clinics, California Department of Public Health, Sierra Sacramento Valley Medical Society (SSVMS), SSVMS’ Sacramento Physicians Initiative to Reach out, Innovate, and Teach (SPIRIT) program, the California Colorectal Cancer Coalition (C4), and the American Cancer Society (ACS) to make it happen. By bringing this much-needed service to the medically-underserved community, we will potentially save many lives and prevent unneeded suffering from a later-stage diagnosis of colorectal cancer. The uninsured face many challenges; dealing with colorectal cancer should not be one of them. Colorectal cancer is the second leading cause of cancer death, and the third most common cancer, among both men and women in the United States. More than 5,000 Californians die of colorectal cancer every year. Moreover, a disproportionate number of advanced cancers are found in the uninsured and underserved populations. Survival of colorectal cancer is nearly 91 percent when found before it has extended

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beyond the intestinal wall. Yet only about 44 percent of cases are found at early stage, compared to 70 percent for breast cancer and 77 percent for prostate cancer.1 Getting tested can help detect early-stage colorectal cancer and even prevent it. And yet too many people do not get the life-saving tests. The uninsured are particularly vulnerable. According to the 2009 California Health Interview Survey,2 published by the UCLA Center for Health Policy Research, CRC screening rates are at unsatisfactory low levels, particularly for the uninsured. Of uninsured California residents age 50 and older: • 53.9 percent have never been screened for CRC (nearly triple the rate of insured residents). • 66.7 percent are non-compliant with screening recommendations (twice the rate of insured residents). The most commonly-cited reasons for not getting screened include lack of insurance, inability to pay, lack of awareness, and cultural or linguistic barriers. We know that health care reform will not insure everyone and that the public health care safety net is often times strained by the demand of the uninsured community. We also know there are practices for providing clinics with a mechanism to ensure that every eligible patient gets a recommendation for screening, that non-profit hospitals have community benefit obligations to meet, and that many licensed medical professionals are willing to volunteer their time to address this critical need. It is very important that communities address this need in a coordinated effort to avoid continued on page 13

Colonoscopy Prep Countdown By Ann Gerhardt, MD T minus 22 hours: Shopping list: Chicken and beef bullion cubes Jello Clear juice Tea Flavored waters and sodas Soap Toilet paper Zinc oxide ointment Non-fiber Ensure (Pssst! Don’t tell anyone, but it has no residue, so it’s an unclear, clear liquid − but don’t tell your gastroenterologist that!) T minus 20 hours: Ate some meat, crackers and a carrot and said good-bye to food. Lime or strawberry Jello? Made the strawberry. T minus 16 hours: Dulcolax, surely a sado-masochist pharmacologic invention. Mixed up Gavilyte-C Solution ZZ, with lemon flavor. Yum. I wonder what ZZ stands for – sleep? Surely not. Drank four cups before I realized that at least half was not dissolved. Damn! More water, more volume. This is going to get old. T minus 15½ hours: Bloating and gurgling commence. Still, I am hungry for broth. T minus 14½ hours: Something better happen soon or I’m going to explode. T minus 14 hours: Something happened. T minus 12½ hours: Bloating, gurgling, spouting, wiping, zinc oxide, try to stand up. Repeat. Again … This

is so bad, I’ll do my taxes at the same time to complete the misery! T minus 11 hours: If I drink tons of fluids, I’ll run clear that much sooner, and can forego some ZZ poison. Kiwi-strawberry Clear Choice – must be a clear liquid, it says so. Giving into cravings for Licorice tea – Hmmm. Whoops! Licorice lowers serum potassium levels. Along with diarrheal potassium losses. Here come the cramps. And slow motility from low potassium. Oh, no! A poor prep which will surely be blamed on Ensure. I’m in trouble! Now I have to drink clear juices for more potassium. Am I over-analyzing this? T minus 10½ hours: What about low phosphate? That can slow motility, too. But starvation raises phosphate levels, and I’m certainly starving. Well, sort of … not really. The clear, fake sodas give me some phosphate. Now I can worry about something else. Filtered pear and cherry and prune juice will give me sorbitol, another laxative. Do I really need that? I’m feeling like a chemistry experiment. T minus 9½ hours: I’m trying to reproduce on the piano the chords and harmony of my mid-section. Am I losing it? Or does Wynton Marsalis have some real competition? T minus 9 hours: Beer’s a clear liquid, right? What about Guinness? I wonder what filtered Guinness tastes like. If there is fiber in Guinness, is it soluble or insoluble? If it’s soluble, filtering won’t work. Now I know I’m losing it. continued on next page July/August 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

2012 Alliance Grants By Barbara Andras and Gabby Neubuerger THE SIERRA SACRAMENTO VALLEY Medical Society Alliance (SSVMSA) is pleased to announce the recipients of this year’s Community Grants. SSVMSA awards grants to non-profit organizations which promote the health and welfare of individuals and families in our community. A Touch of Understanding − $3,450 to provide educational materials for 5,000 students in the Sacramento area attending workshops promoting a safer, non-bullying, and friendlier school environment for all students, especially those with disabilities. (www.touchofunderstanding.org) Community Against Sexual Harm (CASH) − $676 to develop and distribute brochures in the Oak Park region as part of the Health Education and Healthcare Access program for victims of sexual exploitation. (www.cashsac.org) Fiesta Educativa − $2,100 to provide a workshop to train professionals and caregivers serving low-income, Spanish-speaking families who have loved ones with disabilities. (www. fiestaeducativa.org/html/SacramentoReg.htm) Music Partners in Healthcare − $1,620 for a start-up program to provide live, therapeutic music at bedside in a skilled nursing facility. (www.mpih.org)

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Colonoscopy

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Roseville Home Start − $2,080 for “Healthy Jump Start,” a program that provides education on nutrition and healthy families for adults and children. (www.rosevillehomestart.org) Sacramento City Unified School District − $7,292 for the “Let’s Eat Right Now” program, which provides low-income families with education on nutrition and healthy cooking. (www.scusd.edu) St. John’s Shelter − $5,000 to build a permanent play structure at the shelter, which provides services to homeless women and their children. (www.stjohnsshelter.org) Stanford Settlement − $1,940 to purchase a new blood pressure monitor, first aid kits, and to provide free health screenings for seniors at an annual health fair. (stanfordsettlement.org) Wellspring Women’s Center − $3,992 for the “Cotton Club” program, which provides education and feminine hygiene products for women in need of assistance. (www. wellspringwomen.org) For more information about the SSVMSA, please see our website at www.ssvmsa.org. bandras@surewest.net gabby@surewest.net

continued from page 11 T minus 8½ hours: I keep waiting for the flood to clear or at least turn yellow. For a while, it was a pretty salmon color, but it’s becoming more and more red! Did this stupid prep cause me to bleed? No! It’s the strawberry Jello!!! I wonder how it would look with lime Jello? T minus 2 hours:

I actually got some sleep. Just a little more ZZ poison to wash away fecund flora, procreating through the night. T minus zero hours: Take off! A clean colon and a happy gastroenterologist. Now, a piece of cake! algerhardt@sbcglobal.net

Colorectal Cancer continued from page 10 duplicative services and a waste of resources. This presents the opportunity for the right champions to take this issue to the community in Sacramento and have a discussion on how the community can do the right thing, putting a mechanism in place to make sure the uninsured get tested, diagnosed and treated for colorectal cancer. The stakeholders are working together to facilitate the removal of financial barriers to CRC screening and treatment, share lessons learned from successful models implemented in other communities, help recruit volunteer GI specialists to perform pro-bono diagnostic colonoscopies, and stimulate or build upon community needs assessment, resource

mapping, and network development to map out a continuum of care for colorectal cancer screening. Screenings will be done via FIT (Fecal Immunochemical Testing) stool tests. The primary care physicians at the clinic(s) will distribute the tests, and positives will be referred to SPIRIT to schedule a colonoscopy, if indicated. For more information about these programs and for future dates, visit www.cacoloncancer.org/. srobinson@thecmafoundation.org 1 California Cancer Facts and Figures 2012 – California Cancer Registry 2 UCLA Center for Health Policy Research, 2009 CA Health Interview Survey

Your care makes all the difference. Roberta Reid, BloodSource employee, head-trauma survivor and grateful platelet recipient.

www.bloodsource.org

not-for-profit since 1948

For every patient, like Roberta, who gratefully receives the gift of blood — and another day to be with family and friends — there are countless medical professionals whose care and support make all the difference. Thank you for the care you give to every man, woman and child whose life depends on the precious gift of blood. Yes, you do save lives.

July/August 2012

The 20 Gram Fat Diet! A Dietary Wake-Up Call After a Heart Attack

By Denette Dengler, MD, MS

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

IN 2005, MY THEN 59-YEAR-OLD, very fit, exceptionally-active, hiking, bicycling, kayaking, cheese and chocolate-loving husband, Malcolm, planned to fly to Vermont for a weeklong cheese-making course. He never made it. On October 14, instead of reveling in the first day of cheese gastronomique, he underwent urgent, five-vessel coronary artery bypass surgery! Like Andrew Kloneke, MD, (“I Flunked My Treadmill,” January/February 2012 SSV Medicine), this prompted Malcolm to seriously reassess his diet and lifestyle. After Malcolm’s surgery, we researched the role of diet and other factors in coronary artery disease. Malcolm has a strong family history of early coronary artery disease and, yes, he was taking a statin. His progression to unstable angina over six months was so gradual — from normal to a slow-hiking pace to extreme shortness of breath upon attempts at jogging — that we were amazed at our capacity for denial. No chest or arm pain, no sweating, nothing to sound the alarm until the severe shortness of breath episode. While we couldn’t do anything about genetics, we elected to make the changes outlined in “Spectrum,” the most recent diet and lifestyle for cardiac reversal book by Dean Ornish, MD. Our cardiology colleagues were supportive, but warned about the difficulty of long-term diet adherence. (How could they doubt our resolve?)

The Role of Animal Fats In a previous life, I was a Public Health Nutritionist and Registered Dietitian with a Masters Degree in nutrition. As such, I had some remorse over our pre-CABG dietary behavior. Concerns regarding the role of Sierra Sacramento Valley Medicine

animal fats and cholesterol in coronary artery disease gained recognition in the late 1970s and early 1980s. Our pre-CABG diet followed reasonably-sound principles, in terms of vitamins, minerals, proteins, carbohydrates and even phytonutrients, aided by my ongoing obsession with the Nutrient Content and Ingredients sections of food labels. Thanks to Malcolm’s brief tango with the Atkins diet, he had come to appreciate fresh fruit. And thanks to reading provided by Malcolm’s human and animal rights-oriented nephew, we had backed off on red meats. However, there was this conscious oblivion when it came to our love affair with, and indulgence in, cheese and chocolate. My own propensity to bake and entertain made me a co-dependent. So post-wake-up call, we did the research, finding a plethora of official dietary recommendations by august-sounding scientific and governing bodies. Some of them even agree. We chose to stick with Dr. Ornish’s recommendations. His ideas are similar to those of many of the health-oriented agencies, with the exception of stronger constraints on the type and amount of dietary fat to achieve coronary artery disease reversal. For instance, he recommends 10 percent of total daily calories from fat vs. general public health guidelines of 20-35 percent. For me, this translates to about 20 g (or about 1.5 Tbsp) total fat intake per day. Consuming less saturated and trans (partially-hydrogenated) fats than is proposed for the general adult population is also recommended. To accomplish this, Dr. Ornish strongly promotes a more plant-based diet for his

cardiac disease reversal plan. Other than that, his plan mimics other public health policy recommendations by emphasizing whole grains, fruits and vegetables and limiting calorically-dense, nutrient-poor foods and beverages. He also stresses de-stressing, suggesting we eliminate activities and behavioral issues that might contribute to poor health. Fast forward to six years later when I naively volunteered to fill a need for a Fats and Oils Glossary for the SSV Medicine food issue in March/April 2012. I thought it would be a snap because I was “up on things.” Wrong. I was not prepared for the complexity and diversity of the science and available fat resources. In my opinion, the literature addressing the interests of the food production and agriculture industries is not adequately in touch with the literature addressing public health issues. One recent exception to this is the change in manufactured and processed food composition related to the much-needed 2006 mandate concerning trans fat content disclosure. That was a big step forward.

Our Results So, how are we doing five years later? Pretty darn good. (I checked with Malcolm and he concurs … or at least deems it prudent to concur.) Thanks to readily-available reduced fat and vegetarian cookbooks and websites, there is no shortage of cooking tips, substitutions and recipes. We’ve lost our taste for red meat, fried food, high-fat desserts and baked goods. Eating out has become easier, as more restaurants accommodate menu adjustments (we call ahead if unsure). After initially resisting, the designated Food Police (that would be me) now look the other way over limited amounts of dark chocolate. (Exactly how small is that “small amount” of dark chocolate that the American Heart Association and Dean Ornish endorse anyway?) For the cheese fix, we shave reduced or no-fat cheese into sandwiches and grate small

amounts of regular parmegianno regianno on pastas and pizzas at the table. Homemade desserts contain significant substitutions and reductions of fat-containing ingredients. We forego or share restaurant desserts (offering some to fellow diners). We eat more beans and legumes, vegetables, fruits and whole grains. I’ve sublimated my cravings into chocolate sorbet, nonfat frozen yogurt and “No Pudge Brownies.” Malcolm remains true to cheese and chocolate, but tries to taste every molecule of tiny portions. He’s also become something of honey connoisseur, as in bees. Sometimes decisions are hard and information is confusing. Many foods these days contain what I call “fat cocktails,” which make the Nutrition Facts fat content listings difficult to interpret. I’ve circumvented this fat conundrum by forbidding entrance into the shopping cart of foods listing an ingredient that might contain undesired saturated, hydrogenated or trans fat. We forego eating most prepared foods sold in grocery stores and bakeries, since they don’t have to disclose nutrition information. Even if restaurant or store personnel tell me that a vegetable oil is used, I know that it may be an “industrial” partially-hydrogenated oil or blend containing a fat that we avoid. I cook with canola and olive oil and incorporate walnut oil into salad dressings. I try to keep saturated fats minimal by eating bean and legume-containing dishes, fish, white meat turkey and chicken (lower in fat than dark meat) and nonfat dairy products. In spite of all this, believe it or not, we love to eat this really good-tasting food! Are we still learning and adjusting? Always. Brands do make a difference in taste and consistency, and ingredients change − I just gave up a favorite nonfat frozen yogurt shop after they changed the ingredients. The good news? Malcolm’s LDL cholesterol is low enough to make us and his cardiologist happy. And I no longer, ever, have to watch my weight!

Eating out has become easier, as more restaurants accommodate menu adjustments.

denglerdj@comcast.net

July/August 2012

Capitol Display Shows off our Museum’s Treasures By Bob LaPerriere, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

EARLY THIS YEAR OUR MEDICAL museum was approached by the CMA requesting an exhibit at the State Capitol for CMA’s 2012 Legislative Leadership Day. Our museum developed a committee consisting of myself, Dr. Jim Hamill, Dr. Julian Holt, Dr. Jim Rybka, Dr. Malcolm Ettin, Dr. Sandra Hand and Dr. Kent Perryman that worked in conjunction with four representatives from the CMA (Jay Hansen, David Flatter, James Noonan and Nicole Madani). The planned two-week exhibit in April, entitled “California Medicine: From the Frontier to the Cutting-Edge,” was to be on the second floor rotunda of the Capitol in four pre-existing cases built into the wall with a curved base and height over six feet…not an ideal situation for displaying medical artifacts. Ultimately, three of the cases housed artifacts, and one was dedicated to a two-dimensional timeline. The committee “dusted off” photographs and scans dating back a decade or more to accompany the three themes, public health, medical and surgical. About10-20 representative artifacts were selected for each theme. In the Public Health Case, there was information about and artifacts pertaining to communicable diseases “past” (measles, polio, diphtheria, smallpox), “past and present” (tuberculosis, syphilis), and “present” (HIV). Also exhibited were antibiotics, vaccines, a diphtheria “lifesaver,” spitting cups, neoarsphenamine, a comparison of a 1950 and a 2005 Physicians’ Desk Reference and a photo of our iron lung.

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The Medical Case items included archaic medicine bottles, a representation of Chinese medicine, bleeding instruments, several quackery machines including a violet ray instrument, stethoscopes and a microscope. The violet ray instrument (see Dr. Perryman’s article in our May/June 2012 issue) was likely the most common quackery item in the early 1900s. We have about 20 different units, far more than any

other artifact in our collection. The Surgical Case highlighted 19th Century surgery with artifacts including a beautiful Civil War era surgery/amputation kit, a chloroform inhaler, ether can and mask, urethral sounds, an enormous gallstone, person-to-person transfusion kit, tonsillectomy instruments, and a Smeloff mechanical heart valve. In the fourth case was a Timeline that highlighted medical events and issues such as the 1850 Cholera epidemic that swept through Sacramento killing 15 percent of the population, the 1918 outbreak of Spanish Influenza that killed more than 500 people in Sacramento, up to modern-day concerns such as more than 24 percent of the state’s population being obese. Our medical museum would love the opportunity to create more exhibits in the community. We will soon be doing a small exhibit at the office of the Medical Board, and we have an extensive collection of mounted text and images from the major exhibit done at the Sacramento History Museum in Old Sacramento in 1990, entitled “Out of the Doctor’s Bag.” We hope that the April exhibit at the Capitol exposed our museum to a new group of spectators and made more physicians aware of the importance of preserving the history of our profession. xtbob@surewest.net

Previous page: A gallstone approximately one inch by three inches in size, and documentation of a smallpox victim. This page: historic implements from our museum. All were on display April 16–30 at the State Capitol.

July/August 2012

Joint Effort Brings Health Care to Knights Landing By Alexa Calfee, MS II, Co-Director, Knights Landing Clinic

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

WHEN I FIRST LEARNED OF THE Knights Landing Community Engagement Project (KLCEP), I thought it was a dream come true. I came to the UC Davis Rural PRIME program because I want to be a rural family doctor, but I could not believe my luck — I was going to be part of starting a new clinic. This clinic was in the rural community of Knights Landing, just outside of Woodland, providing services geared towards the migrant farmworker community. Being a Yolo County local, I was thrilled to be working so close to home and with a population I had gone to school with over the years. For me, the Knights Landing Clinic aspect of KLCEP started during the first week of medical school, but for most KLCEP members and the Knights Landing Community, the clinic was a long time in coming. As the story has been told to me, both the only public school in the community and the local park were closed due to budget cuts. It may seem strange that a clinic sprang from the closing of a school, but this event was monumental in the organization of a group of community advocates, now known as the grupo de mujeres. These women began to organize and reach outside of the Knights Landing community for help. They found support in California Rural Legal Assistance and UC Davis sociology assistant professor, Natalia Deeb-Sossa, Ph.D. Eventually, the Woodland School District opened the Science and Technology Charter School in 2010. It was also during this time that the community had been hit with the loss of other resources, including the local CommuniCare Clinic, which had been serving the community for several years. It was time for

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the grupo de mujeres to look for another solution. When the CommuniCare Clinic closed, the migrant farmworkers’ access to health care was now not only compromised by the obvious language difficulties, but also by the necessity of transportation to Woodland. With only two weekly buses running to and from Woodland, a visit to the doctor’s office often meant calling in a favor from a neighbor or friend, or spending most of the day using public transportation while missing work. The grupo de mujeres was well organized and had regular weekly meetings by this point. With some help from outside advocates, the women caught the attention of several student co-directors of Clínica Tepati (one of the seven clinics run by UC Davis students) and Rural PRIME students. After nearly three years of long meetings with multiple partners, another UC Davis student-run clinic was going to be a reality. By October 2011, we had a facility, monetary support and a group of very dedicated faculty. We were about to open Clínica Tepati’s first satellite clinic, after smoothing out some lastminute details including setting up an EMR system and developing protocols. This was no small task for a group of first-year medical students with a full load of classes. The Knights Landing Clinic officially opened its doors with a celebration on Sunday, January 29, 2012. The community came out for a town hall meeting and health care screenings. Each patient seen at the health fair has subsequently been followed up on clinic days with appointments scheduled via the EMR. New patients come in on clinic days or

Left to right: Luis Godoy, Kayla Tindall, Alexa Calfee, Manuel Tapia.

call an answering service to leave a message for an appointment. The clinic is now open the third Sunday of each month and is staffed by medical student, undergraduate, nurse and physician volunteers. A core group of graduate and medical student co-directors manage 20 undergraduate volunteers. Following KLCEP sentiments, the Knights Landing Clinic Board has a community member as a voting member, to help maintain community influence in the clinic’s activities. Opening day marked only the beginning of an exciting adventure. The Knights Landing Clinic is joining forces with the UC Davis School of Veterinary Medicine in an effort to promote a broader definition of health, termed “One-Health,” which includes the health of all members of the community, including pets, strays and farm animals. It is going to be a very exciting year for the Knights Landing Community. The creation of the Knights Landing Clinic has been a phenomenal collaboration between many individuals and groups. We would like to especially thank the following: • CommuniCare Health Centers for their continued support; • The UC Davis School of Medicine-Rural PRIME program: Dr. Suzanne Eidson-Ton, Sneha Patel, Dr. Don Hilty, Heather Mora; • UC Davis School of Medicine: Dr. Thomas Nesbitt, Dr. Claire Pomeroy, Dr. Michael

Wilkes, Dr. Mark Servis, Dr. Frederick Meyers, Ed Dagang; • Clínica Tepati: Dr. Nate Hitzeman, Dr. Blanca Solis, Dr. Brenden Tu, board members; • Yolo Family Resource Center: Bob Ekstrom, Josie Enriquez, Lina Hernandez; • California Rural Legal Assistance: Juanita Ontiveros; • Dr. Natalia Deeb-Sossa; • Woodland Joint Unified School District; • KLCEP members not previously mentioned: Denise Gutierrez, Kayla Tindall, Luis Godoy, Sarah Ashley, Katie Corley, Oscar Valenzuela, Dolores Pena; • Knights Landing Co-Directors: Fiona Scott, Ashley Scarborough, Luis Ramirez, Jesse Landis, Phil Buss, Nadia Guardado; • All of the nurse and physician preceptor volunteers who come every clinic day. These individuals and groups are a perfect example of the collaboration needed to provide patients with accessible health care. None of this would have been possible without the support and continued support of these individuals and groups. Thank you! If you are interested in volunteering or would like more information about the Knights Landing Clinic, please contact us at klclinc. ucdsom@gmail.com. alcalfee@gmail.com

July/August 2012

Mallard Math By John Loofbourow, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

A PAIR OF MALLARDS HAS INVADED our yard and pool in late January for the past four years. At first the hen nested in the surrounding ground cover, but her eggs were taken by feral cats, skunks, hawks, owls, or some other opportunist. During the past two years, she’s used a thick mantle of ivy and jasmine covering a patio-fire pit area. Even so, the fate of the eggs was the same; by mid-March broken eggshells appeared on the deck beneath the nest. Outside my window, it’s March again. Earth births its timeless child: Spring. The mallards are at it again. Yet, here indoors, is an eternal winter of media-mediated unreason, and unreasonableness, featuring a fear of abusing the earth, the water, the sea, and air, even by breathing; wars with drugs, diabetes, fat, famine, unfairness, religion and science. Money is made speech so that our elected elect are bought, sold and branded like cattle. Language loses shared meaning; we ingest and regurgitate designer phrases not meant to nourish a rational mind, but to inflame the spleen. Constant exposure to noxious antigens of blame promotes anaphylaxis to contrary ideas or assertions; in a free society, we become afraid to speak freely. When I look outside again for the crop of broken duck egg shells, instead the mallard hen sits quietly by the pool sheltering 12 chicks in her hugely fluff-feathered warmth. I approach to take a photo, but she quickly leads them all to the center of the pool, slowly moving about quacking orders, while her close-packed squad of ducklings follows obediently. By the next morning, one chick has drowned, unable to mount the coping at the pool edge. Another is still desperately attempting to escape the water. I try to scoop up the failing chick with the leaf basket, but the outraged hen and her chicks flee immediately back to pool center. After

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a few tries, I retreat in defeat, and watch from a distance as the remaining 11 chicks manage to escape the water without my assistance. They follow their indignant mama, single file, to a narrow space under the fence, and disappear. The next morning, I hear only one plaintive and continuously-repeating, three-note peeppeep-peep, clearly a distress call from a single duckling next door; more accurately, it’s a call to brunch for a cat. My neighbor, Cyrena, whose husband died recently, has lived on a 2-½ acre creekside lot for 85 years; she was born there, and considers latecomers intruders of a low sort. Yet she’s always a lady, civil, if dismissive. Tall, skeletal, an active golfer, she’s at the 19th green of life; nonetheless, she cares for herself and drives her big old Cadillac determinedly. Her leathery skin and spindly arms are an essay on the effects of chronic exposure to country clubs, sun and money. Yet, I admire her from a distance, believing that anyone who has lived so long is a national treasure; or at least a monument. But today Cyrena is not home and I don’t consider exploring her back yard for the lost kitty-lunch chick. That afternoon, I see her supervising the care of her exquisitely-manicured front yard, and am impelled to ask; “I’m sorry to bother you, but did you see any ducks in your yard this morning?” “Yes. I did. In the pool. I filled it to the brim so the little ones could get out; but then I had to chase them all off. It’s unlawful, but they are terribly dirty, you know.” The phone rings from inside her house. “I’ve been waiting for a call.” So ends our longest and most informative conversation of the past two years. Surely, I think, all the chicks are dead. I must await the mallard’s return next year. But in a few days, the hen reappears, sitting dejectedly for long periods by the pool; no swimming,

Backyard pool guests! Mallards can live from 10 to 15 years. If they hatch 48 chicks yearly and all survive, that would amount to at least 480 ducks per mallard pair!

no bathing or feather flipping, no self grooming; and no male. I wonder if both he and the ducklings became a predator’s happy meal. But in a few more days he begins to reappear; his lady furiously and repeatedly chases him off, until one morning I find him bobbing his neck up and down, glorious in male mating mallard colors, hot and foolish, puffed and proud; she swims languidly, coyly eying his displays. Soon she is nesting again; he floats alertly in the middle of the pool pretending to look for signs of trouble. I plug the hole under the fence, and plan to keep the pool water level high enough for ducklings to hop out onto the coping. On the night of May 8th, the full moon is huge, just over 220,000 miles away. An oblivious Little Dipper wheels around the North Star on its spindly handle and the next morning another duckling dozen swims in the pool. The irritated male strikes and chases the chicks when they get close. The hen pays no attention. On May 11th I watch as one chick takes off to the driveway. The mother leads the rest away abandoning the strayed baby. I object: “Hey! It’s Mother’s Day! What

about your kid in the driveway?” She looks back derisively and quacks clearly: “Do the math!” I try: Mallards can live from 10 to 15 years. If they hatch 48 chicks yearly and all survive, that would amount to at least 480 ducks per mallard pair. It’s only thanks to inhumane duck-style parenting, error, disease, and predators that we aren’t awash in mallards; likewise with other life forms. Are we, who seem to have dominion over all the earth, the only exception? Maybe some old books I have forgotten or understand differently now have some merit. I “Kindle” up Thomas, Friedrich, Paul, and Him. A nighttime satellite view of earth reveals a world afire with electric lights; but according to ducks, it’s not all about Us. john@loofbourow.com 1 Malthus, Reverend Thomas Robert: An essay on the Principle of Population, 1798. Darwin, Charles: Narrative of the Surveying Voyages of HMS Adventure and Beagle, 1838. Ehrlich, Paul R: The Population Bomb, 1968. Him: Genesis 2:15-3:19 (which could today be subtitled: Serpent Power 2.0 because knowledge may ultimately make it possible for anyone to destroy everyone, and cancel humanity’s great voyages to Alpha Centuri and the Magellanic Clouds.

July/August 2012

A Posit on HPV Immunization “The State of California should add age-appropriate (Gardasil) Human Papillomavirus (HPV) immunization to the requirements for public school students.”

Background: The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians recommend that Gardasil, anti-HPV immunization, be encouraged for all girls age 9-26 and all boys age 11-26, to prevent 70 percent of cervical and vaginal cancers, 50 percent of vulvar cancers, and 90 percent of genital warts. In addition, HPV may be a factor in the increased incidence of oral and anal cancers. By Albert J. Kahane, MD.

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Results: A distinct majority of respondents (58/76) agreed with this posit. By contrast, a slight majority (9/17) of comments were in disagreement for various reasons, despite a general acceptance of the reported safety and efficacy of HPV immunization. Commentary follows: This is a hard one. While I fully support Gardasil or any HPV vaccine for both sexes, most required school vaccinations are for communicable diseases and not sexually transmitted diseases. The cost would also be prohibitive for a large segment of the population, and without public health support it would unlikely be feasible. Trying to limit HPV by immunizing our young before sexual maturity is a very worthy goal, but at present, it is hard to envision being able to afford it, regardless of the public outcry this requirement would be likely to create. —Sidney Scudder, MD I think it is premature to require it for school entry. The proper way to do this is to have it optional until it is well accepted in the community, and only then add a school-entry

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requirement (with exception for those with medical or conscience-related reasons) in order to pick up the stragglers who just need the extra incentive to get the vaccination. We saw what “over-reach” did in Texas: it became a political issue, and anti-vaccine people put out the false story that children were being forced to take the vaccine as part of a plot to sexualize them. In fact, there was an opt-out clause for those with medical or conscience-related reasons to decline. Let’s avoid this scenario by waiting until the vaccine is well accepted for itself. Also, the estimates for protective level are just that — estimates — and it will be helpful to get some data based on experience. —Stephen A. McCurdy, MD You cannot fairly propose a new and mandatory health care intervention without mentioning the cost. I believe the current price of three injections, exclusive of services charges, is over $300. Unless and until one also proposes a mechanism to pay for this worthy immunization, it is premature to require it in public schools. —Howard Slyter, MD The importance of being proactive in all aspects of health care is undervalued in our current medical approach. Using vaccines that are economical, effective and safe to avoid future social and economical costs makes common sense. The requirement that our public schools enforce this may not [make common sense]. It seems to me that our schools are burdened as it is, and we ask too much of them already. Is there another way of encouraging our youth to obtain a vaccine that benefits all? Could an incentive program be offered through an

organization such as Planned Parenthood or through personal physicians? Perhaps we use the stick too often in schools? Could a carrot approach be utilized for the HPV vaccine? — Charles Perry, MD Even more important than AAP, ACOG, and AAFP recommendations, the broader evidencebased medical literature as reflected in www. uptodate.com supports this. —Michael Patmas, MD Where do we cross the line from public health to interference in people’s lives? Since my kid would get measles, chickenpox, etc., just from casual contact with classmates, it is an obvious public health measure to vaccinate our public school children. However, HPV is not transmitted by casual contact, so this is not a public health issue, but a recommendation that physicians need to encourage their patients to follow. —Richard Gray Jr., MD This should be a simple question of a recommendation based on proven efficacy. Unfortunately, it has been caught up in the antivaccination hysteria, not to mention those who fear it will promote sexual promiscuity. —Mark Blum, MD The infrastructure is already in place for entry to middle school to be the time for such patients to get that vaccination. As long as there is a “Religious Beliefs Exemption” (as there is for all school-mandated vaccines), such a law should not offend parents. It’s simply the right thing to do for public health. This vaccine has an amazingly high rate of success at preventing HPV-related diseases from occurring in vaccinated individuals. Amazingly high efficacy! And it has a proven safety record. At least it will bring the discussion of HPV to the forefront, which gives parents and health educators (doctors, school nurses and biology teachers) the opportunity to reinforce the benefits of abstinence and consistent use of barrier methods of protection for at-risk individuals. —Ruth Haskins, MD [Agree,] provided that any possible adverse reactions from the vaccine are well spelled out. —Frank Palumbo, MD [Disagree] 9- and 11-year-old girls and boys

are barely showing signs of puberty and are too young to understand the benefits of the vaccine. Since it is a sexually-transmitted virus, parents frequently decline consent for this age group. The age limit should be 13-26 years old for both sexes. —Mitra Choudri, MD, HPV infection is not universal, and does not require vaccination of everyone in the world. Let us not get influenced by the recommendations of the pharmaceutical companies or a select few who are at risk. That is it. —Rugmini Shah, MD The HPV vaccine is unique in that it protects against cancer. Only the hepatitis B vaccine shares that distinction. However, cervical cancer is much more common and is a leading cause of death in women in developing countries. Fortunately, cervical cancer is rare in the U.S. due to 80 percent or more of women being routinely screened. In fact, only 4,220 women are estimated to die from cervical cancer in the U.S. this year according to the Jan/Feb Cancer Journal for Clinicians. In contrast, the same journal estimated 242,000 cervical cancer deaths in developing countries in 2008. Unfortunately, the vaccine series is expensive (around $400) and rolling it out to these countries will take time. Locally it still makes sense for us. The genital wart protection is a bonus. The vaccination of males, who are often silent HPV carriers, adds an interesting dynamic to the campaign and will likely upset many parents. However, if my kid’s preschool won’t allow peanut butter because of 100-150 peanut allergy deaths a year in the U.S., it makes sense to promote a vaccine that will save several thousand lives! —Nate Hitzeman, MD On a may-decline basis, with parental education. –Jody Gordon, MD Unfortunately, there are so many government mandates that the good ideas get mixed up with the bad ones, and inefficient bureaucracies get created to carry out nominal enforcement. I certainly believe that Gardasil is a good idea for my own grandchildren, but I am hesitant to endorse yet another legal requirement. Perhaps what should be mandated is exposure to appropriate highquality educational material for parents and

July/August 2012

Where do we cross the line from public health to interference in people’s lives?

students; it would be wonderful if individual responsibility would regain a prominent place in our society. —Alfredo Czerwinski, MD It should be a recommendation, not a school requirement. Perhaps after some years of widespread use, there will be more evidence and more consensus on making it a requirement. — Nancy Gilbert, MD Immunization for communicable disease is the primary reason the average life span has more than doubled in the past 100 years. HPV immunization is a significant advance in public health. Unfortunately, large sectors of the public continue to object to scientific advances and do not and would not voluntarily immunize their children. —Richard Park, MD While the proposal has appeal, it seems at worst ill-conceived, and at best premature: 1) The rough math is daunting: 11 million Californians age 9-26 x /$360 is $3.96 Billion. That doesn’t include outlays of time, mileage,

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aggravation, lost work, or admin expense to schools. 2) Credible published data indicates there’s a reasonable projection of 71 deaths here; that is statistically, but added to information/ misinformation about “complications” like blood clots, paralysis, seizures, etc., it can inflame sound-bite voters and stampede polldriven politicians. 3) If there is a simple, hasslefree “opt-out,” a prime objective of universal HPV immunization will be lost; if there is an oppressive opt-out, (or none,) the matter seems sure to be tied up in litigation. 4) A charge of crony capitalism seems likely. 5) The process by which drugs are tested and marketed is so often opaque that when there is so much money and so much hype involved, it seems wise not to accept this matter at face value. Time and timing matter. —John Loofbourow, MD Why stop at 26 y/o? –Kathryn Amirikia, MD

Origins of the Medical Societies Excerpted from the Santa Clara County Medical Association, and expanded on by Bob LaPerriere, MD IN THE EARLY PART OF THE 19TH CENTURY, medical education was in a deplorable state. There were approximately 450 proprietary medical schools. Their primary aim was to collect tuition from students for the privilege of attending lectures for 10-20 weeks. There were no entrance requirements beyond the ability to pay for the courses. There were few examinations and the resulting diploma was accepted as a license to practice medicine.

American Medical Association (AMA) The American Medical Association was organized on May 7, 1847. This “drastic measure” was to establish standards of care and improve medical education. A program of medical ethics was introduced, as well as the promotion of public service. The first meeting was at the Academy of Natural Sciences in Philadelphia, PA. The 250 delegates present elected Dr. Nathaniel Chapman as its first president. An initial committee of nine doctors, headed by Dr. Nathan Smith Davis, was established to develop recommendations to improve medical education. Dr. Davis was the first African-American graduate from Rush Medical School. He is often credited as the father of the AMA and was the first editor of JAMA. Despite the good intentions of the AMA, the society had no vested authority to change policy of the proprietary medical schools. However, the AMA set standards and pointed the way towards reform.

California Medical Society (CMA) The Medical Society of the State of California was established in 1856, behind the leadership of Dr. Elias Cooper and Dr. Thomas Logan. They wrote letters to their colleagues asking for support of a state organization that promoted medical education “and develop, in the highest degree, the scientific truths embodied in the profession.” Another goal of the society was to root out quackery. Their first meeting was March 12, 1856, at Pioneer Hall, located on J Street in Sacramento. The first president was Dr. Benjamin Franklin Keene, from El Dorado County. Unfortunately, Dr. Keene died a few months after taking office. The second president was Dr. Elias Cooper, from San Francisco. Dr. Cooper was the head of the Medical Department of the University of the Pacific, which was California’s first medical school. Dr. Thomas Logan, a Sacramento physician, assisted in the formation of the medical society of California. He became the first president of the AMA from the west coast. He brought the national AMA meeting to San Francisco in 1871. Logan also promoted state public health departments and he lobbied for county medical societies. His role in the California Public Health Department is legendary. Dr. Logan felt it imperative that physicians track births, diseases, deaths, and their causes. In 1870, he authored a law to establish the State Board of Health. California was the second state to have a public health board. Logan also promoted childhood vaccinations. Another important person in early CMA history was Dr. John Frederick Morse, a Sacramento Physician who wrote the first history of Sacramento, published in the City July/August 2012

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Directory of 1853-54. Dr. Morse set up the first credential committee of the CMA in an attempt to prevent unqualified physicians from practicing in the state. He is also credited with starting the first journal of the medical society in 1873. It was called, The California State Journal of Medicine. The Medical Society of California was renamed California Medical Association in 1923.

Sacramento Medical Societies On March 17, 1868, twelve physicians met at 46 J Street for their own mutual improvement and to promote medical science. They formed the Sacramento Society for Medical Improvement, which continues to be the incorporated name of the organization now known as the Sierra Sacramento Valley Medical Society, the oldest county medical society in continuous existence in California. In 1979, there was a name change to the Sacramento-El Dorado Medical Society when the El Dorado County Medical Society became associated with our Society. The merger of the Sacramento-El Dorado Medical Society and the Yolo County Medical Society in 2000 triggered the name change to its current title. There had been earlier societies. The MedicoChirurgical Association of Sacramento (1850-

1850 Cholera Preventive There are many ways of warding off the attacks of this dreaded disease. All agree however, that nothing is more essential to safety than a cheerful mind and temperate habits. It is an easy matter to be temperate, but persons subject to the “blue devils” sometimes find it hard to “drive dull care away” at pleasure. We would recommend all such unfortunates to go to the book stand of George Lovegrove, on Second Street, near the Post Office, and buy a copy of Dr. Valentine’s comic lectures — the reading of which has caused many a misanthrope to laugh himself into the most indescribable happiness. Read Dr. Valentine, go to the Tehama Theatre, forget everything unpleasant, indulge in no excess, and few other “cholera preventives” will be needed, by those in good general health. (Sacramento Transcript Oct. 29, 1850)

Sierra Sacramento Valley Medicine

1856) was the first medical society in California, at a time when the city had 6,000-10,000 in population (half of them transients). It was created to rid Sacramento of the unqualified persons of ill repute posing as doctors. The Sacramento Medical Society was formed in 1855 to protect the community from the irregular practitioners and “quacks.” It dissolved in 1863 and had as Article II in its constitution the following paragraph, which certainly represents the philosophy of both prior and subsequent organizations: It shall be the object of this society to cultivate the science of medicine, and to promote harmony among its members, and concert of action with a view to the common good of the profession, as well as of the community at large. The short-lived Sacramento County Pathological Society was formed in 1858 and was the last of our precursor societies. Before 1950, our Medical Society was located at the private office of the physician who served as secretary. In 1950, the first office was opened on 26th Street and an executive secretary was hired. Three years later it moved to the corner of 28th Street and Capitol Avenue, and in 1960, it moved to its current location at 5380 Elvas Avenue. Since the first organizational meeting in 1868, there have been 138 presidents of the Sacramento Society for Medical Improvement. In 1996, the organization elected its first woman president, Joanne Berkowitz, MD. Three other women physicians have followed over the years in this leadership role. Bill Sandberg, SSVMS Executive Director from 1986-2011, commented, “March 17, 2012 marks the 144th Anniversary of the Medical Society’s incorporation and its 162nd year of operation. Our history and heritage is important because in a fast-changing health care environment, we can sometimes see the challenges and future facing the organization as almost insurmountable. However, when you ponder all the profession has gone through in the last 162 years, the current situations seem like simple bumps in the road.”

Board Briefs May 14, 2012 The Board: Received a report from J. Douglas Kirk, MD, Chair of the Emergency Care Committee, highlighting the past successes of the committee and summarizing issues being addressed in 2012. Approved the 2011 Audit Report presented by Auditor, Lindsey Kate Lane, CPA. Approved the First Quarter 2012 Financial Statements and Investment Reports, and ratified recommendations implemented by and on the recommendation of the Society’s investment advisor. Approved the 2012 Nominating Committee. The Nominating Committee is in charge of nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. The 2012 members are: Alicia Abels, MD, Chair; Ruth Haskins, MD, District 1; Pat Samuelson, MD, District 2; Barbara Arnold, MD, District 3; Ulrich Hacker, MD, District 4; Anthony Russell, MD, District 5; Marcia Gollober, MD, District 6; Richard Jones, MD, At-Large Member; Katherine Gillogley, MD, At-Large Member. Approved the following re-nominations to the 2012-2013 CMA Councils and Committees: Jose Arevalo, MD, Council on Information Technology and Council on Legislation; Ruth Haskins, MD, Council on Legislation; Tom Ormiston, MD, Council on Legislation; Mary Jess Wilson, MD, Council on Legislation. The nominations will be considered by the CMA Board of Trustees for recommendation to the 2012 CMA House of Delegates. Ratified the following actions taken at the Board Retreat on March 17, 2012: 1) To allocate funds to mail the May/June 2012 issue of Sierra Sacramento Valley Medicine to members and nonmembers; 2) To provide funding for the re-development of the SSVMS website.

As a follow-up to the discussion held at the Board Retreat, the Board received a report from staff regarding the recruitment of Residents for membership. It was noted that at the 2012 CMA House of Delegates a resolution will be considered from the CMA Membership Technical Advisory Committee to extend CMA membership to Resident members at no cost. The resolution, as it is currently written, encourages component medical societies to adopt similar policy. Presentations by SSVMS regarding membership have been scheduled for the new Resident orientation sessions in June at UC Davis. The Board will continue discussion considering the recruitment of Resident members at its next meeting. Received a report that BloodSource has approved a three-year grant to the SSVMS Community Service, Education and Research Fund’s SPIRIT Program. Approved the April 9, 2012 and the May 14, 2012 Membership Reports: For Active Membership — Parag Agnihotri, MD; Arshad Ali, MD; Khurram B. Ali, MD; Enass A. Arahman, MD; Khuram Arif, MD; Samir G. Artoul, MD; Antonio B. Balatbat, MD; Monette S. Balite-Lacap, MD; Michael T. Barger, MD; Elaine A. Barrios, MD; Richard A. Bermudes, MD; Dakane A. Billow, MD; Christine L. Braid, DO; Mark T. Burniston, MD; James J. Cafarella, MD; Kimberly Cafarella, MD; Peter S. Chang, MD; Robert M. Coates, Jr., MD; Edwin A. Cruz, MD; Himdip K. Dehal, MD; Michael K. Dengel, MD; Thomas M. Do, MD; Elvira S. Drljevic, MD; Marwa A. El-Menshawi, MD; Evelyn G. Fainsztein, MD; Kamyar Farhangfar, MD; Emiley S. Ford, MD; Sharnjit S. Grewal, MD; Olivia H. Griffiths, MD; Samuel J. Hu, MD; Joseph Huh, MD; Syeda R. Inamdar, MD; Joelle L. Jakobsen, MD; Ashkan H. Javaheri, MD; Donna R. Jordan, continued on next page

July/August 2012

MD; Ajay K. Joshi, MD; William A. Junglas, MD; Kalwinder Kaur, MD; Guru N.S. Khalsa, MD; Robert M. Kirchner, MD; Jesse M. Kramer, MD; Vasanthi Krishna, MD; David S. Lao, MD; Diana D. Lee, MD: Engene R. Leyble, MD; Andrew J. Linn, MD; Yasser H. K. Mansour, MD; Faryal B. Michaud, DO; Taffere N. Mihretu, MD; R. Paul Miller, MD; Michael D. Moore, MD; Alison W. Newman, MD; Ryan H. Nicholas, MD; Mylapore S. Niranjan kumar, MD; Saiqua Nooreen, MD; Abdirahman S. Nuh, MD; Christopher R. Olson, MD; Jennifer L. Ozeir, MD; Ravi J. Patel, MD; Anna A. Petrovich, DO; Mei Qiang, MD; Jennifer N. Redd, MD; Frank S. Reynolds, MD; Mira Roganovic, MD; Anwar Saeed, MD; Christopher B. Seaman, MD; Geethanjali Sennimalai, MD; Shekiba Shahabzada, MD; Gurvinder S. Shaheed, MD; Mohammed O. Shareef, MD; Shahzad A. Siddique, MD; Shoab A. Siddique, MD; Inder M. Singh, MD; Tarnveer Singh, MD; Sae H. Sohn, MD; Gregory R. Spears, DO; Christopher L. Stephenson, MD; John M. Stevenson, MD; Christian A. Swanson, MD; Theam L. Tay, MD; Milie M. Tolentino, MD; Harrison H. Tong, MD; Mohammadreza M. Toussi, MD; Richard T. A. Tu, MD; Nelson N. Tun, MD; Phani K. S. Vadarevu, MD; Syama S. Varudu, MD; Qais M. Wahidi, MD; Amy G. Wandel, MD; John T. Waring, MD; Anthony E. Wartell, MD; Patricia L. Wiggins, MD; Arash N. Yazd, MD; Don S. Yokoyama, MD; Barry K.

1-800-901-5830 • • • • • •

33 years of medical experience 1,600 Northern California physicians 45 well-trained & professional operators State of the art computer technology Discounted rates for new SSVMS accounts Spanish, Chinese and Russian spoken

Sierra Sacramento Valley Medicine

Young, MD; Mohammad A. Yusufazai, MD; Karl N. Zeff, MD. For Reinstatement to Active Membership — Daniel D. Anderson, MD; Robert D. Bellinoff, MD; Henry K. Chang, MD; Frank J. Chinn, Jr., MD; Marie-Claude L. David, MD; Lawrence W. Davis, MD; Denette J. Dengler, MD; Wendy Z. Dyer, MD; John F. Gisla, Jr., MD; Ron James, MD; Javid Javidan-Nejad, MD; Danton T. Kono, MD; James J. Liu, MD; Kim-Oanh T. Ly, MD; Elizabeth (Lisa) Madarang, MD; Mark C. Maltzer, MD; Thomas B. McIlraith, MD; Stephen L. Morrison, MD; Sean J. Nealon, MD; Patricia L. Ostrander, MD; Andres Pena, MD; Tommy J. Poirier, MD: Kathleen K. Quadro, MD; Mark L. Ratley, MD; Paul Rosenberg, MD; Shefali Shah, MD; Kingshuk Sharma, MD; Alan J. Shatzel, DO; Anissa L. Slifer, MD; Fern S. S. Takemoto, MD; Kevin A. Vu, MD; Jill A. Walsh, MD; John Young, MD. For a Change in Membership Status from Active to Government Membership — Alan J. Frueh, MD. For Retired Membership — Stephen R. Skinner, MD. For Resignation — Sebastian Conti, MD; David M. Follette, MD; Elena V. Gelfand, MD; Syed A. Khasimuddin, MD (moved to Ontario, CA); Philip McDonald, MD (moved to Madera, CA); Stephen Melcher, MD; William Taylor, MD; Narin Wongngamnit, MD (moved to Colorado).

PLANET

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Kelly Rackham [916] 616 6270 planetkelly@me.com www.planetkelly.com Out-of-this-world design

Meet the Applicants The following applications have been received by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. —Robert A. Kahle, MD, Secretary. NOTE: The Sierra Sacramento Valley Medical Society (SSVMS) is pleased to welcome the physicians of Mercy Medical Group to membership in SSVMS and CMA. Under the leadership of Chief Executive Officer Gregory Cooper, DPM, MBA, Mercy Medical Group has announced that they will sponsor membership dues for any physician within their medical group that wishes to join SSVMS/CMA. Thank you, Mercy Medical Group, for your commitment to organized medicine! AGNIHOTRI, Parag, Internal Medicine, MGM Med Col, India 1993, Mercy Medical Group, 3000 Q S., Sacramento, 95816, (916) 733-3460

BRAID, Christine, L., Family Practice, Midwestern Univ. 2003, Mercy Medical Group, 8001 Madison Ave., Citrus Heights, 95610, (916) 536-2420

ALI, Arshad, Pulmonary Diseases, Hamdard College of Medicine & Dentistry, Pakistan 2000, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (936) 733-3304

BURNISTON, Mark, T., Internal Medicine, Med Col Ohio 2002, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400

ALI, Khurram, B., Internal Medicine, Univ. Karachi, Pakistan 1992, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079 ANDERSON, Daniel, D., Orthopedic Surgery, George Washington Univ. 1985, Mercy Medical Group, 1700 Prairie City Rd., Folsom, 95630, (916) 351-4800 ARAHMAN, Enass, A., Occupational Medicine, Univ. Khartoum Faculty of Med, Sudan 1994, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333 ARIF, Khuram, Pediatrics, Aga Khan Medical Col, Pakistan 1996, Mercy Medical Group, 7911 Laguna Blvd., Elk Grove, 95758, (916) 733-5801 ARTOUL, Samir, G., Cardiology, Hebrew Univ., Hadassah Med School, Israel 1981, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3300 BALATBAT, Antonio, B., Infectious Disease, Univ. Philippines 1987, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400

CAFARELLA, James, J., Pediatrics, Loyola Stritch 1999, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 409-1400 CAFARELLA, Kimberly, D., Family Practice, Loyola Stritch 1999, Mercy Medical Group, 1700 Prairie City Rd., Folsom, 95630, (916) 351-4800 CHANG, Peter, S., Anesthesiology, Univ. Tennessee 2003, The Permanente Medical Group, 2025 Morse Ave., Sacramento, 95825, (916) 973-5000 CHINN, Franklin, J., Internal Medicine, Jefferson Med Col 1982, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3390 CRUZ, Edwin, A., Neurology, St Louis Univ. School of Med, Philippines 1987, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-5779 DAVID, Marie-Claude, L., Pediatrics, Faculty Medicine Paris 1980, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3305 DEHAL, Himdip, K., Family Practice, Ross Univ. Dominica 2006, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 295-5700

BALITE-LACAP, Monette, S., Internal Medicine, Univ. Santo Tomas, Manila 1996, Mercy General Hospital, 3000 Q St., Sacramento, 95816, (916) 733-3333

DENGEL, Michael, K., Neurology, Case Western Reserve Univ. 2002, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3670

BARGER, Michael, T., Rheumatology, Univ. Nevada 1982, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3346

DO, Thomas, M., Internal Medicine, Hahnemann Univ. 1994, Mercy-Methodist Hospital, 7500 Hospital Dr., Sacramento, 95823, (916) 423-3000

BARRIOS, Elaine, A., Pediatrics, Univ. Minnesota 1982, Mercy Medical Group, 3427 Robin Ln. #100, Cameron Park, 95682, (530) 676-7337

DRLJEVIC, Elvira, S., Child & Adolescent Psychiatry, Univ. Sarajevo Faculty of Med, Bosnia-Herzegovina 1987, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

BELLINOFF, Robert, D., Ophthalmology, Loma Linda Univ. 1982, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3311 BERMUDES, Richard, A., Psychiatry, UC San Diego 1997, Mindful Health Solutions, 1020 Suncast Ln. #108, El Dorado Hills, 95762, (916) 932-0380 BILLOW, Dakane, A., Internal Medicine, Gazi Univ. Faculty of Medicine, Turkey 2000, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

DYER, Wendy, Z., Internal Medicine, Univ. Tennessee 1987, Mercy Medical Group, 3427 Robin Ln. #100, Cameron Park, 95682, (530) 676-7337 EL-MENSHAWI, Marwa, A., Geriatric Medicine, Univ. Alabama 2004, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

FAINSZTEIN, Evelyn, G., Internal Medicine, Univ. Nacional Cordoba, Argentina 1994, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333 FARHANGFAR, Kamyar, Internal Medicine, Univ. South Dakota 1995, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400 FORD, Emiley, F., Pediatrics, Temple Univ. 2008, The Permanente Medical Group, 2155 Iron Point Rd., Folsom, 95630, (916) 817-5428 GREWAL, Sharnjit, S., Family Practice, UHS Chicago Med School 2003, Mercy General Hospital, 4001 J St., Sacramento, 95819, (916) 453-4966 GRIFFITHS, Olivia, H., Pediatrics, Johns Hopkins Univ. 2007, The Permanente Medical Group, 1650 Response Rd., Sacramento, 95815, (916) 614-4060 HU, Samuel, J., Orthopedic Surgery, Med Col Georgia 1999, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-5700 HUH, Joseph, Thoracic/Cardiovascular Surgery, Med Col Wisconsin 1990, The Permanente Medical Group, 2025 Morse Ave., Sacramento, 95825, (916) 973-7594 INAMDAR, Syeda, R., Allergy & Immunology, Northwestern Univ. 1997, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3304 JAKOBSEN, Joelle, L., Surgical Critical Care, Loma Linda Univ. 1996, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3600 JAVAHERI, Ashkan, H., Geriatric Medicine, Natl. Univ. of Iran 1998, Mercy Medical Group, 3000 Q St, Sacramento, 95816, (916) 733-3460 JAVIDAN-NEJAD, Javid, Urology, UHS Chicago Med School 1994, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3310 JORDAN, Donna, R., Internal Medicine, Hahnemann Univ. 1985, Mercy Medical Group, 3427 Robin Ln. #100, Cameron Park, 95682, (530) 676-7337 JOSHI, Ajay, K., Cardiology, Calcutta National Med Col, India 1991, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3560 JUNGLAS, William, A., Orthopedic Surgery, Case Western Reserve Univ. 1985, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-5700

July/August 2012

KAUR, Kalwinder, Internal Medicine, St George School Med 2004, Mercy Methodist Hospital, 7500 Hospital Dr., Sacramento, 95823, (916) 423-3000

MILLER, R., Paul, Internal Medicine, UC Davis 1979, The Permanente Medical Group, 1001 Riverside Ave., Roseville, 95678, (916) 784-4414

KHALSA, Guru, N.S., Internal Medicine, USC 2005, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

MOORE, Michael, D., Ophthalmology, SUNY Syracuse 1990, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3550

KIRCHNER, Robert, M., Cardiology, Drexel Univ. Col. of Medicine 1999, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

NASSIM-YAZD, Arash, Internal Medicine, Univ. Debrecen Faculty of Med, Hungary 1996, Mercy Medical Group, 4400 Duckhorn Dr., Sacramento, 95834, (916) 575-8000

KONO, Danton, T., Pediatrics, New York Med College 2000, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3520 KRAMER, Jesse, M., Dermatology, USC 1987, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3304 KRISHNA, Vasanthi, Neurology, Mahadevappa Rampure Med Col, India 1993, Mercy Medical Group, 9394 Big Horn Blvd., Elk Grove, 95758, (916) 691-8500

NICHOLAS, Ryan, H., Family Practice, UHS Chicago Med School 2005, Mercy Medical Group, 1700 Prairie City Rd., Folsom, 95630, (916) 351-4800 NIRANJANKUMAR, Mylapore, S., Internal Medicine, Madras Univ., India 1992, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 536-2500 NOOREEN, Saiqua, Internal Medicine, Siddhartha Med Col, India 2001, Mercy General Hospital, 4001 J St., Sacramento, 95819, (916) 453-4966

ROGANOVIC, Mira, Internal Medicine, Univ. Belgrade Faculty of Medicine, Yugoslavia 1979, Mercy Medical Group, 7911 Laguna Blvd., Elk Grove, 95758, (916) 733-5801 SAEED, Anwar, Infectious Disease, Univ. Karachi, Pakistan 1988, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3540 SEAMAN, Christopher, B., Internal Medicine, New York Med College 2006, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333 SENNIMALAI, Geethanjali, Internal Medicine, Stanley Medical College, India 1998, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333 SHAH, Shefali, Internal Medicine, M P Shah Med Coll, India 1996, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400 SHAHABZADA, Shekiba, Family Practice, Ross Univ., Dominica 2005, Mercy Medical Group, 4400 Duckhorn Dr. #100, Sacramento, 95834, (916) 575-8000

LAO, David, S., Cardiology, Yale University 2003, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3500

NUH, Abdirahman, S., Internal Medicine, Univ. Instanbul, Turkey 1999, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5000

LEE, Diana, D., Internal Medicine, Capital Inst Med Sci, China 1991, Mercy General Hospital, 4001 J St., Sacramento, 95819, (916) 733-3333

OLSON, Christopher, R., Family Practice, Univ. Connecticut 2001, Mercy Medical Group, 1700 Prairie City Rd., Folsom, 95630, (916) 351-4800

LEYBLE, Eugene, R., Internal Medicine, Univ. Philippines 2001, Mercy San Juan Hospital, 65001 Coyle Ave., Carmichael, 95608, (916) 537-5079

OZEIR, Jennifer, L., Obstetrics & Gynecology, Wayne State Univ 1996, Mercy Medical Group, 4400 Duckhorn Dr., Sacramento, 95834, (916) 575-8000

LINN, Andrew, J., Pain Management (Anesthesiology), UC San Diego 2003, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

PATEL, Ravi, J., Orthopedic Surgery, UC Davis 2004, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

SHARMA, Kingshuk, Internal Medicine, Dhaka Medical College, Bangladesh 1990, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400

PENA, Andres, Physical Medicine & Rehabilitation, Natl. Univ. of Colombia 1994, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-2408

SIDDIQUE, Shahzad, A., Hematology/Oncology, St Louis Univ. 2001, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-5300

PETROVICH, Anna, A., Family Practice, NY Col Osteo Med 2001, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3540

SIDDIQUE, Shoab, A., Otolaryngology, Univ. Illinois 1995, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3312

POIRIER, Tommy, J., Gastroenterology, Vanderbilt Univ. 1967, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3400

SINGH, Inder, M., Cardiology, Ovidius Univ. Faculty of Medicine, Romania 1999, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3344

QIANG, Mei, Internal Medicine, Wannan Medical College, China 1983 , Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

SINGH, Tarnveer, Family Practice, UHS Chicago Med School 2005, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

QUADRO, Kathleen, K., Family Practice, Jefferson Med Col 1979, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

SLIFER, Anissa, L., Internal Medicine, Georgetown Univ. 1997, Mercy Folsom Hospital, 1650 Creekside Dr., Folsom, 95630, (916) 351-4800

RATLEY, Mark, L., Family Practice, UT Southwestern 2001, Mercy Medical Group, Mercy General-4001 J St., Sacramento, 95819, (916) 453-4966

SOHN, Sae, H., Obstetrics & Gynecology, Jefferson Med Col 1988, The Permanente Medical Group, 1650 Response Rd., Sacramento, 95815, (916) 614-4055

REDD, Jennifer, N., Obstetrics & Gynecology, Wayne State Univ 2004, Mercy Medical Group, 8120 Timberlake Way #102, Sacramento, 95823, (916) 681-6000

SPEARS, Gregory, R., Family Practice, WUHS Col Osteo Med 2005, Mercy Medical Group, 1700 Prairie City Rd., Folsom, 95630, (916) 351-4800

LIU, Jibang, James, Internal Medicine, Guangzhou Medical College, China 1982, Mercy Medical Group, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079 LY, Kim-Oanh, T., Psychiatry, Univ. Saigon, Vietnam 1986, Mercy Medical Group, 1792 Tribute Rd. #350, Sacramento, 95815, (916) 924-6400 MADARANG, Elizabeth, T., Internal Medicine, Ross Univ., Dominica 2000, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3620 MALTZER, Mark, C., Gynecology, Univ. Michigan 1976, The Permanente Medical Group, 2025 Morse Ave., Sacramento, 95825, (916) 973-5000 MANSOUR, Yasser, H.K., Internal Medicine, Univ. Alexandria, Egypt 1996, Mercy General Hospital, 4001 J St., Sacramento, 95819, (916) 453-4966 MCILRAITH, Thomas, B., Internal Medicine, Univ. Wisconsin 1996, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 537-5079 MICHAUD, Faryal, B., Internal Medicine, Michigan State Univ. 2001, Mercy General Hospital, 4001 J St., Sacramento, 95819, (916) 453-4966 MIHRETU, Taffere, N., Internal Medicine, Addis Ababa Univ. Faculty of Med, Ethiopia 1998, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

REYNOLDS, Frank, S., Gastroenterology, Brown Univ. 1978, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

Sierra Sacramento Valley Medicine

SHAHEED, Gurvinder, S., Hematology/Oncology, Punjab Univ., India 1992, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333 SHAREEF, Mohammed, O., Internal Medicine, Dalhousie Univ., Canada 2000, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

STEPHENSON, Christopher, L., Physical Medicine & Rehabilitation, Univ. New Mexico 2004, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3373 STEVENSON, John, M., Radiation Oncology, Loyola Stritch 1987, Mercy Medical Group, 3301 C St. #550, Sacramento, 95816, (916) 556-3200

SWANSON, Christian, A., General Surgery, St Louis Univ. 1990, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3314

TUN, Nelson, N., Internal Medicine, Inst Medicine, Rangoon 1995, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

TAY, Theam, L., Family Practice, Univ. Alberta, Canada 2000, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

VADAREVU, Phani, K., Internal Medicine, Nagarjuna Univ/Guntur Med College, India 1993, The Permanente Medical Group, 2025 Morse Ave., Sacramento, 95825, (916) 973-5000

TOLENTINO, Milie, M., Family Practice, Ramon Magsaysay Memorial Med, Philippines 1993, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3500 TONG, Harrison, H., Family Practice, Univ. Osteopathic Med 1998, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento, 95825, (916) 480-3442 TOUSSI, Reza, M., Family Practice, Mashhad Univ Medical Sci, Iran 1990, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3540 TU, Richard, T.A., Internal Medicine, Inst Medicine, Rangoon 1988, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 536-3540

WANDEL, Amy, G., Plastic Surgery, UHS Chicago Med School 1983, Mercy Medical Group, 2200 Sunrise Blvd., #250, Gold River, 95670, (916) 536-2400 WARING, John, T., Anesthesiology, Emory Univ. 2003, Sac Anesthesia Med Grp., 3939 J St. #310, Sacramento, 95819, (916) 733-6990

VARUDU, Syama, S., Internal Medicine, Rangaraya Med Col, India 1997, Mercy Methodist Hospital, 7500 Hospital Dr., Sacramento, 95823, (916) 423-3000

WIGGINS, Patricia, L., Internal Medicine, Bowman Gray 1980, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3333

VU, Kevin, A., Internal Medicine, Ross Univ., Dominica 2006, Mercy Methodist Hospital, 7500 Hospital Dr., Sacramento, 95823, (916) 733-5801

YOKOYAMA, Don, S., Family Practice, Stanford 1983, Mercy Medical Group, 3000 Q St., Sacramento, 95816, (916) 733-3316

WAHIDI, Qais, M., Internal Medicine, UHS Chicago Med School 2007, Mercy Methodist Hospital, 7500 Hospital Dr., Sacramento, 95823, (916) 423-3000

YUSUFZAI, Mohammad, A., Internal Medicine, St George School Med 2008, Mercy San Juan Hospital, 6501 Coyle Ave., Carmichael, 95608, (916) 537-5079

WALSH, Jill, A., Pediatrics, Loyola Stritch 1988, Mercy Medical Group, 6555 Coyle Ave., Carmichael, 95608, (916) 536-3520

ZEFF, Karl, N., Psychiatry, Uniformed Serv Univ. 1984, Mercy Medical Group, 1792 Tribute Rd. #350, Sacramento, 95815, (916) 924-6400

An Intersection in Nicaragua By Nathan Hitzeman, MD My mama’s eyes wrinkle when she smiles. I make my first tortilla. My brother chases chickens. Papa smokes Marlboros with his Sandinista friends Watching Mexican game shows with large-breasted women. Rain cuts through the sticky heat and puts me to sleep.

I go to the other side of town Hawking wares at intersections Walking through sooty rows of cars. Cold faces, pity, occasionally a kind gesture. Most just ignore me. My belly grows.

Mama says we have to move To make way for a plantation for gringos. Papa is coughing up blood again. Brother chases “chicas” now. One gets a swollen belly.

No wares today. Just empty hands. Would my mama still smile if she saw me? A gringo looks at me from a taxi. He probably never wanted for shoes or food.

I go to the big city to find a job. Men touch me too much; Sometimes they hurt me.

I press against the window, Will he turn away or share a peso? “Solo un peso?” The light changes. hitzemn@sutterhealth.org

July/August 2012

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Insurance Marsh Life, Disability, Long Term Care 1.800.842.3761 Medical/Dental, Workers’ Comp, more… www.CountyCMAMemberInsurance.com Legal Services & CMA On-Call Documents

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Sierra Sacramento Valley Medicine

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