2013-Mar/Apr - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

March/April 2013

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Sacramento Cal Expo

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PRESIDENT’S MESSAGE An Exciting Time to be Practicing Medicine

David Herbert, MD

EDITOR’S MESSAGE We Share a Common Blood

Nathan Hitzeman, MD

e-Letters to SSV Medicine

Medical Abbreviations Puzzle

Executive DirecTOR’S MESSAGE Who we are, What we’ve done, Where we’re going

Aileen Wetzel, Executive Director

Cautery to Cutting

Kent Perryman, Ph.D.

Second Term Opportunities and Challenges

Assemblymember Richard Pan, MD, MPH

The Bloody History of Transfusion

Nathan Hitzeman, MD, and Joy Shen, MD

Annual Meeting

BOOK REVIEW “Essentials of Correctional Nursing”

Reviewed by Bruce Barnett, MD

Unintended Outcome of Antimicrobial Use

John Belko, MD

Physician Shortages in the San Joaquin Valley

Maricela Rangel-Garcia, MS I, Kelly Fujikawa, MS II and Christina Thabit, MS II

Laura’s Law – Time to Bring it to Your County?

Adam Dougherty, MPH, MS III

A Posit on Mental Health and Gun Ownership

Meet the Applicants

Board Briefs

Classified Ads

2013 Education Series

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/Publications/SSVMedicine.aspx The practice of blood transfusion is of relatively recent origin. Globally today around 90 million units of blood products are transfused in a given year. Although it only became a practical possibility during and shortly after the Second World War, the concept of transfusion has a longer history. Early transfusions were risky and many resulted in the death of the patient. Nathan Hitzeman, MD, and Joy Shen, MD, explore “The Bloody History of Transfusion” in this issue on page 14. The cover image is of an early transfusion kit from the SSV Museum of Medical History.

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.

March/April 2013

Volume 64/Number 2 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

Sierra Sacramento Valley

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. 2013 Officers & Board of Directors David Herbert, MD President Jose Arevalo, MD, President-Elect Alicia Abels, MD, Immediate Past President District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Lorenzo Rossaro, MD Christian Serdahl, MD District 3 Bhaskara Reddy, MD 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 Tom Ormiston, MD

2013 CMA Delegation Delegates District 1 Robert Kahle, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Earl Washburn, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD Jose Arevalo, MD Richard Gray, MD David Herbert, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Anthony Russell, MD Kuldip Sandhu, MD Boone Seto, MD

District 1 Reinhart Hilzinger, MD District 2 Margaret Parsons, MD District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD District 5 Robert Madrigal, MD District 6 Karen Hopp, MD At-Large Jason Bynum, MD John Belko, MD Jeffrey Cragun, MD Maynard Johnston, MD Olivia Kasirye, MD Rajan Merchant, MD Richard Pan, MD, Assemblyman Vacant Vacant Vacant

CMA Trustees 11th District Barbara Arnold, MD Douglas Brosnan, MD Solo/Small Group Practice Forum Lee Snook, MD CMA President Paul Phinney, MD CMA President-Elect Richard Thorp, MD AMA Delegation Barbara Arnold, MD, Delegate Richard Thorp, MD, Alternate Editorial Committee Nate Hitzeman, MD, Editor/Chair Ann Gerhardt, MD, Vice Chair John Belko, MD George Meyer, MD Sean Deane, MD John Ostrich, MD Sandra Hand, MD Gerald Rogan, MD Albert Kahane, MD Chris Swanson, MD Robert LaPerriere, MD Lee Welter, MD John Loofbourow, MD Gilbert Wright, MD John McCarthy, MD Adam Dougherty, MS III Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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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. ©2013 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 Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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President’s Message

An Exciting Time to be Practicing Medicine By David Herbert, MD LAST YEAR AT THIS TIME, I began my first column with the hope that I could present topics of some interest to our membership while harboring a fear that I would quickly run out of things to say. With just six columns to write during the year, I figured I could muddle through somehow. Little did I imagine that I would be filling an unexpected vacancy and writing another six columns for another term! Luckily, I have not run out of things to say, and it is still an exciting time to be practicing medicine in the Sacramento area. SSVMS had a remarkably good year in 2012! One of our key missions has been to support CMA, and we were extraordinarily successful in increasing our membership, and thus, CMA’s membership. We added 511 new members, and were a big part of CMA’s ability to start growing again. While the list of CMA accomplishments on behalf of medicine and our community is much too long for this column, I will point out that CMA was instrumental in stopping an end run around MICRA by the trial lawyers and some elements of the legislature, and successfully blocked a 10 percent reduction in Medi-Cal payments, at least temporarily (this continues to be litigated). This is a key time for us to be at the table as the details of health care reform are being worked out. Our membership growth afforded us two more delegates and alternates to the CMA House of Delegates, and has further strengthened our already sound finances. This allows us to expand our local efforts in the many areas that benefit our community and our practices. Our SPIRIT volunteer program has increased the services provided to uninsured community members, with increased funding, thanks to a generous grant from BloodSource.

Since its inception, SPIRIT volunteers have provided over $8.4 million in donated care to the underserved! We have also helped to coordinate the work of volunteer physicians in many local organizations. Through our medical student scholarship fund, and with the help of the Medical Society Alliance, we awarded $7,000 in scholarships. Since it was an election year, we organized a series of candidate interviews and made recommendations to CALPAC regarding candidates to support. And, of course, we now have two SSVMS physicians in office: Ami Bera in Congress, and Richard Pan in the State Assembly for his second term! Adding to this local influence is Paul Phinney, who is the president of CMA. SSVMS has expanded its efforts to communicate with all our local physicians, and to demonstrate to non-members why we all benefit when we stand together. Part of this involves sending SSV Medicine to all physicians. If you are one of these not-yet-members, feel free to offer your contributions to the Journal − and to join SSVMS! We also launched a new, dynamic, interactive website with up-todate information, online dues payment and event registration capabilities. Many of our accomplishments are due in large part to the tireless efforts of our new executive director, Aileen Wetzel. This promises to be an “interesting” year for health care. Your comments and suggestions as to how SSVMS can best assist you and your community as we navigate these challenging times are most welcome!

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.

davidherbert166@gmail.com March/April 2013

Editor’s Message

We Share a Common Blood 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.

EVERY OTHER MONTH, somewhere between the Kohl’s coupons and utility bills, lies my friend the SSVMS magazine. While it doesn’t have celebrity gossip or gorgeous models, it is one of the few pieces of mail I get not wanting something from me. It doesn’t ask me for money or try to sell me something that will fill up another corner of my garage. In fact, I can count on SSV Medicine to reconnect and enrich me. Whether reading a viewpoint from a medical colleague, a story of a doc’s travails — or their hobbies — or learning some trivia and medical history, I find something unique in our magazine that I cannot find in mainstream medical media. In this issue, we celebrate some outstanding physicians honored at our recent awards banquet, delve into the history of blood transfusion and surgical cautery, and discover our members’ views on mental health screening for gun ownership. Physicians are a diverse bunch, and yet we share a common blood that binds us. We have the privilege of seeing and guiding patients through vulnerable moments. We have their trust in keeping them healthy and alive. We know that 12-noon crunch when our bowels and bladder have not been emptied for hours, hunger pains are setting in, and three patients remain to be seen. And yet we enter the next room with a smile. We live for a purpose beyond ourselves and beyond material wealth. Medicine has evolved from the simple patient-physician relationship. Some changes are good: like being more patient-centered, striving for evidence-based medicine and best practices, and having more diversity in the

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workforce. Some changes warrant caution: like standardized practice (“Jiffy Lube” medicine), EMR and its ever-growing demands on our time and style, and increased busy work (forms, audits, committees). External forces are swarming in on us — telling us how to document, how to choose medications, how to fill out paperwork, and how to cater to patients’ needs at the expense of caring for ourselves. SSV Medicine is my “water cooler” moment at the end of the day where I can relax with a glass of wine and actually hear the unadulterated views of my colleagues — be they curmudgeons or sunshine blowers, pragmatists or escapists. Chances are you are a physician curious about others in your profession, interested in what is happening in the local medical community, and wanting some frank discourse on matters that affect your life. You may be interested in volunteering. You may like traveling. Or maybe you are struggling with career burn-out. Whatever the case may be, you are not alone. The medical society is here to help. Let SSV Medicine be that transfusion that brings color to your cheeks and pep to your step. Try us on for size. Better yet, write us a letter or email or send us a story to publish. We would love your contribution. In times of great change and uncertainty, there is comfort in reaching out to others in our community and profession. The medical society has given folks like me fulfillment in a way not easily found in our modern-day medical silos. I hope it enriches and reconnects you as well. hitzemn@sutterhealth.org

e.Letters to SSV Medicine Museum Donations Help Bwindi, Uganda I thoroughly enjoyed reading the article about the donation of supplies and equipment to Bwindi and the history and development of the hospital. In 2008 I had the good fortune to travel to Bwindi for gorilla tracking which was amazing in itself! As part of our itinerary, we were taken to the Bwindi Community Hospital where I met Dr. Scott Kellerman. He and his wife have done something pretty incredible in this remote, inhospitable region of Uganda. Dr. Scott and I had a lot in common (sharing Louisiana roots and Northern California lives), and he was quite up to date on college football standings. I have continued to receive the Bwindi

Newsletter which I read with great interest and send contributions annually. I do hope to go back there again someday. I appreciate the local interest and support of the Bwindi Community. −Barbara Andras, Past President SSVMSA bandras@surewest.net

I like doing things that are new and challenging and in the past year the SSVMS JOURNAL IS GETTING THAT MESSAGE! A big improvement for which you and your colleagues can take credit. −Paul Kelly, MD nocwatch@sbcglobal.net

Medical Abbreviations Puzzle Created by Bob LaPerriere, MD This puzzle features some of the numerous abbreviations used in charting and case presentations. The larger bold letter represents the word in the puzzle. Many of the more common abbreviations can be found at http:// info.dhhs.state.nc.us/olm/manuals/doa/achcm/man/ ACHCMxM.pdf.

Answers to this puzzle are on page 7.

March/April 2013

Executive Director’s Message

Who we are, What we’ve done, Where we’re going By Aileen Wetzel, Executive Director

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.

THE BEGINNING OF A NEW YEAR provides the opportunity to reflect on Sierra Sacramento Valley Medical Society’s (SSVMS) accomplishments in its mission to uphold the authority and autonomy of physicians in the delivery of professional and ethical medical care. 2012 was a year of significant growth for the medical society. We welcomed over 500 new members, making SSVMS one of CMA’s fastest-growing component medical societies. We now represent nearly 3,000 physicians, medical students, residents and fellows in El Dorado, Sacramento and Yolo counties. Our membership is diverse and includes physicians in all modes of practice – from solo and small practice to large groups. Mercy Medical Group, UC Davis Medical Group, The Permanente Medical Group, Radiological Associates of Sacramento, Woodland Clinic, Pulmonary Medicine Associates, Mercy Radiology Group and Sacramento Anesthesia have made significant commitments to their groups’ physicians by paying their annual SSVMS/CMA membership dues. In 2012, SSVMS introduced a dynamic new website, www.ssvms.org, which includes interactive membership and Physician Finder directories. We launched a new e-bulletin, SSV Medical Society News, to keep our members informed about issues impacting the practice of medicine. Our journal, SSV Medicine, now reaches over 5,000 physicians. We remain commited to patient access to care. In 2012, physician volunteers, through SSVMS’ Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT)

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program, treated 1,799 patients who otherwise would not have access to care. Our SPIRIT volunteers donated 28 hernia repair surgeries, 24 cataract surgeries, and 10 other miscellaneous surgeries. Our volunteers treated 245 vision patients, donated 176 retinopathy screenings and 69 pairs of glasses. We recruited and placed new physician volunteers in general surgery, dermatological surgery, and neurology. Compared to the prior year, our staff provided case management services to 49 percent more surgical patients and the hours donated by our physician volunteers increased 38 percent. Since its inception, SPIRIT volunteers have provided over $8.4 million in donated care to the uninsured in our community. SSVMS launched a new community-based program, Walk with a Doc, in 2012. This program features physician-led walks in local parks on Saturday mornings. Walk with a Doc is a free program open to anyone interested in taking steps for a healthier lifestyle. Bring your patients, your family, and your dog. We have a lot of fun. In October, SSVMS member Paul Phinney, MD, was installed as the 145th President of the CMA. SSVMS member Richard Pan, MD, was reelected to the California Assembly and appointed Chair of the Assembly Health Committee. Member Ami Bera, MD, was elected to Congress to represent California’s 7th Congressional district. The voice of organized medicine is being heard at the local, state and national levels by our very own members! On the advocacy front, CMA and SSVMS continue to lead the fight for a permanent fix to the Medicare SGR and are fighting proposed

cuts to Medi-Cal that will have a devestating impact on access to care in our community. Looking forward, 2013 will be a year of significant challenges and changes to healthcare and the practice of medicine. From the impending transition to ICD-10, to the massive overhaul of Workers’ Compensation regulations and rates, to potential cuts in physician payments from Medicare, to protecting MICRA (and did I mention the implementation of the Affordable Care Act?), SSVMS is here for you every step of the way. I invite you to contact me personally to let me know what your needs are and how SSVMS/CMA can help you protect the viability of your practice. awetzel@ssvms.org

New Health Laws 2013 For a summary of new laws impacting physicians this year and beyond, see “Significant New California Laws of Interest to Physicians for 2013” in the California Medical Association’s online resource library at www.cmanet.org/news/ detail/?article=new-health-laws-2013

Free Lecture Technical Challenges: Pitfalls and Solutions in Minimally Invasive Surgery Wednesday, May 1, 2013 5:30 – 6:00 p.m. Welcome Dinner Reception 6:00 – 8:00 p.m. Speakers and Panel Discussion Sutter Cancer Center, Classrooms 1-4 Presented by: Steve Patching, M.D., Bariatric and Advanced Laparoscopic Surgery Harold Humphries, M.D., Anesthesiology Eric London, M.D., General and Advanced Laparoscopic Surgery Brian Naftulin, M.D. – Medical Director, Sutter Institute for Minimally Invasive Surgery Target Audience: Physicians, nurses and allied health professionals involved in the care of patients undergoing minimally invasive surgery. For questions or to RSVP, please contact (916) 733-8614.

March/April 2013

Cautery to Cutting The journey from hot iron cauterization to electrosurgery

By Kent Perryman, Ph.D. EXCESSIVE BLOOD LOSS RESULTS in death. Even the ancient Greeks figured that one out while watching soldiers exsanguinate in the battle of Troy. Accordingly, how to control blood loss from injury has been a major concern during warfare and surgery. Historically, a number of methods have been employed to stop bleeding. The following review traces the evolution of cautery using a hot object or substance to today’s modern electrosurgery.

Early Cauterization

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.

During prehistoric times, heated stones placed against a wound were used to stop bleeding. The Egyptians, as early as 3000 BC, treated tumors and ulcers with a hot iron “fire stick.” The process of applying a hot metal object to tissue to prevent bleeding became known as “Cautery.” Later, Hippocrates encouraged cautery for treatment of hemorrhoids. Hot-iron cauterization was gradually refined during the Moorish occupation of Spain, circa 1000 AD, by El-Zahrawi (Abu Al-Gasium Khalaf Ibn Abbas El-Zahrawi). El-Zahrawi, known as the father of modern surgery, fabricated hot irons with various shapes for application to different regions of the body. He specified that these instruments were to be made of iron rather than gold or copper, and that a red-hot iron be used to coagulate while a white-hot iron was used for cutting tissue. In some Arab communities along the Persian Gulf, a burning cloth and hot oil were substituted for a hot iron to stop bleeding. Further refinements to hemostasis came later during the 16th century in Paris by the French surgeon Ambroise Paré (1510-1590). Dr. Paré routinely used hot-iron cautery in battlefield amputations. Eventually, he substituted ligature Sierra Sacramento Valley Medicine

for cautery to encourage wound healing. His reservations regarding hot iron cautery were later validated: cauterization increases the risk of infection by causing more tissue damage and encouraging bacterial growth. This complication was particularly recognized during the American Civil War by field surgeons who were performing amputations.

Chemical Cautery At the beginning of the 20th century, a variety of chemical agents were employed to stop bleeding in simple medical procedures. Agents that cause vasoconstriction include cocaine, silver nitrate, trichloracetic acid and cantharidin (an extract of the blister beetle). A major disadvantage with chemical cauterization is leaching beyond the wound region. Although a few modern-day applications of chemical cautery still exist (e.g. cocaine for some ENT surgeries, silver nitrate for toenail matrix ablation or granulation tissue bleeding), for most surgical procedures cauterization employing an electrical spark gap has become preferable.

Early Electrosurgery The beginnings of electrocautery can be attributed to William Gilbert (1540-1603), the father of “Electrotherapy” ( see “The Popularity of Early Electrotherapeutic Hokum” in the July/ August 2008 SSV Medicine issue). He employed static electricity from amber to create a hot spark for cauterizing wounds. This was the first known non-heat conduction application of cauterization. Later, between 1781 and 1831, galvanic (direct current) batteries were used experimentally as a current source to close blood vessels. It had been known since the late 19th

century that electrical currents passed through tissue can create a heating effect (see “What’s Hot and What’s Not” in the May/June 2012 SSV Medicine issue). Many of the early 20th century quackery devices, including the Violet Ray Generators marketed for electrotherapeutic purposes, had the additional capability of electrical cauterization using ohmic heating. All of these early cauterizing devices relied on direct current until an Italian physician, Dr. Simon Pozzi, began to treat skin cancers using alternating current in a process he called “fulguration.” A needle-like electrode was employed to destroy malignant tumors using a high-frequency electrical current. Dr. Eugene Louis Doyen modified this procedure by attaching a patient grounding plate to his electrical generator (a considerate gesture). The plate was positioned beneath the patient as a return pathway for the alternating current. This improved procedure, labeled “electrocoagulation,” enabled the surgeon to penetrate deeper into the tissue. Later, in 1910, Dr. William L. Clark further advanced this procedure, while practicing in Philadelphia, by increasing the current and decreasing the voltage to produce an even hotter

electrical spark for deeper penetration. Earlier in 1907, Lee De Forest, the inventor of the vacuum tube, had filed the first American patent for an electrosurgical generator to be used on patients during surgery. The term “desiccation” was also introduced around this time into surgical nomenclature by Dr. Clark to describe the effect of destroying tissue by dehydration using lower voltages and higher currents to produce much hotter sparks for incisions. The medical community gained a greater appreciation for the added surgical capabilities of the “bloodless knife.” Not only could electricity be used to cauterize, but it held the promise to be employed as a precision scalpel. It was Dr. Clark’s pioneering electrosurgical procedures that paved the way for the modern improvements in generators made by William T. Bovie.

Ambroise Paré (1510–1590) performing an amputation using hot oil and hot irons.

Modern Electrosurgical Generators Electrosurgery is a medical term used to describe the application of high-frequency electrical current to tissue as a means to cut and coagulate. Dr. William T. Bovie (1881-1958) received a doctorate in plant physiology from Harvard University and then embarked upon a career that had nothing to do with plants. He joined the Harvard Cancer Commission in the early 1900s. He believed high-frequency

March/April 2013

electrical currents were more effective than the conventional use of radium as a cauterizing technique in treating cancer patients.

Remember When

Bovie’s prototype electrosurgical unit was developed from a diathermy unit using alternating current delivered to a cutting loop. This early device was first employed in a surgical suite at Peter Brent Brigham Hospital in Boston in October 1926. The surgeon was Dr. Harvey Cushing, “the father of neurosurgery.” Dr. Cushing removed a vascular myeloma, a surgical feat at the time. For the remainder of his career, Dr. Cushing embraced the use of Bovie’s device and promoted its use within the medical community. The use of the Bovie during surgery significantly decreased patient mortality. The LiebelFlarsheim Company subsequently purchased the patent rights from Dr. Bovie for $1.00 and agreed to market the device under his name for which he agreed to receive no compensation. The original Bovie was a fairly large appliance and sold for $1250 in 1932. Today, modern electrosurgical generators such as the Bovie are capable of monopolar, bipolar, fulguration, blend-mode and argonenhanced procedures for coagulation and incision. The Sierra Sacramento Valley Medical Society’s Museum of Medical History displays several of the early ohmic, direct current cauterizers and the later Bovie-style alternating current electrosurgical devices for the public to view. kperryman@suddenlink.net Nabri, IA. El Zahrawi (936-1013 AD), the father of operative surgery. Annals of the Royal College of Surgeons of England. 1983; 65: 132-134. Deleon MF, Yeo CT, Maxwell IV, PJ. The evolution of Cauterization: From the Hot Iron to the Bovie. J Amer Surg. 2011; 77(12): 15741575. Russell, J, Cohn, R. Cauterization. Lennex Corp Pub. 2012; Edinburg. Covidien: Energy-based Devices Professional Education www.valleylabeducation.org. Massarweh NN, Cosgriff N, Slakey DP. Electrosurgery: History, Principles and Current and Future Uses. J Am Coll Surg. 1006; 202(3): 520-530. Special thanks should go to the Bovie Medical Corporation for graciously providing an image of their antique Bovie model. The Ambroise Paré illustration came from the Park, Davis and Company’s (now Parke-Davis) “History of Medicine in Pictures.”

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Second Term Opportunities and Challenges By Assemblymember Richard Pan, MD, MPH

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.

WHAT A DIFFERENCE TWO YEARS makes! When I began my first term in the California Assembly, I had won the most difficult Assembly race in the state and was considered a “target” for the opposing party in the next election. Newly-elected Governor Jerry Brown declared rapid action was needed to close a $28 billion general fund budget deficit that year including significant cuts such as the Medi-Cal 10 percent provider rate cut. The Governor attempted to negotiate a balanced solution to the state’s fiscal woes that included both revenue and cuts, but was stymied by an inability to obtain the twothirds vote needed. Federally, the Affordable Care Act (ACA) is law, but court challenges and political changes made its future uncertain. Circumstances have greatly changed at the beginning of my second term. Redistricting has resulted in my representing the 9th Assembly District, which elected me by an 18 percent margin last November. In addition, 39 of 80 Assemblymembers are newly elected and looking forward to up to 12 years in the Assembly, and Democrats compose a two-thirds supermajority in both houses of the legislature. I am now the only practicing physician in the California Legislature, and I chair the Assembly Health Committee. With the passage of Proposition 30, Governor Brown was able to declare in his State of the State address, “California is back, its budget is balanced and we are on the move.” The U.S. Supreme Court found the ACA constitutional and, with the reelection of President Obama, the next phase of ACA implementation in 2014 is certain. Thus, my second term in the legislature presents new opportunities and challenges.

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With so many new legislators, it is important to educate them about health care in our state. As Health Committee Chair, I partnered with the California Health Care Foundation and California Endowment to provide a briefing on basic facts and concepts in public health and health care to interested members. I also held informational hearings on risk pools and adverse selection and chronic disease and the Patient-Centered Medical Home. It continues to be important for practicing physicians to reach out to legislators and their staff to talk about your practice experiences.

ACA Implementation Among my top priorities is implementation of the ACA in California. California is a national leader in ACA implementation, having established the state exchange, Covered California, and passing several conforming state laws. Yet, there is still a great deal to do to begin the exchange and expand Medi-Cal coverage by January 1, 2014. The Governor called a special legislative session in January so laws needed to reform the individual health insurance market and expand Medi-Cal to uninsured persons below 133 percent of poverty can be adopted in time. The individual market reform legislation I am carrying will codify guaranteed issue and community rating into state law, so patients can no longer be denied coverage for a pre-existing condition. The ACA expands coverage for the poor by including more adults in Medicaid, or MediCal in California. The ACA Medi-Cal expansion is estimated to bring over $2 billion in the first years to California and will create almost

100,000 jobs in the state. While the federal government will cover the entire cost for the expansion population for the first three years, the state is expected to incur its share of the cost on increased enrollment of people who already qualify for Medi-Cal but are not yet enrolled. Thus, policy implementing Medi-Cal expansion will not only involve health care coverage, but budget and economic impacts.

Dental Care for Children As a pediatrician who provides care to MediCal patients, I understand Medi-Cal is in need of transparency and accountability. Findings of the Sacramento First 5 Commission study of the Sacramento Geographic Managed Care Denti-Cal program revealed lack of oversight by the state for over a decade resulting in delayed or absent dental care for children. Last October, I chaired an oversight hearing on MediCal transitions into managed care in which it was noted that Medi-Cal managed care plans averaged the lowest possible rating on the Consumer Assessment of Health Plans, a nationally recognized standard of quality for health plans. While the Department of Health Care Services, which runs Medi-Cal, has committed to quality measurement, action is also needed to improve performance. I am authoring a bill to increase transparency and public accountability in the MediCal program. Increased oversight of Medi-Cal and other state health programs will be a priority for my committee. Fiscal stability for the state government will continue to be critical. Proposition 30 brings in new revenue that closes the structural deficit in the state general fund. However, there is little money to restore cuts, including cuts to MediCal and other health programs, made to close previous yearsâ&#x20AC;&#x2122; deficits. In past years, including my first term, large budget deficits resulted in

efforts to find immediate savings, no matter the cost beyond the budget year. A balanced budget can bring new opportunities for prioritization and long-term planning. I hope there will be increased opportunities for problem solving this term to strengthen the stateâ&#x20AC;&#x2122;s economy and invest in its people. It is a privilege to both care for patients as their physician and represent the people of my district in the California Legislature. I continue to practice medicine so I can continue to understand what my patients and their families face in their lives and what you, my physician colleagues, face in your practices. And with your support, I will continue my work in the legislature to build a healthier Sacramento and California. Richard.Pan@asm.ca.gov

March/April 2013

The Bloody History of Transfusion Still figuring out the right balance

By Nathan Hitzeman, MD, and Joy Shen, 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.

ONE OF THE MORE POWERFUL images in medicine is the patient lying at death’s door with a crimson bag hanging from the IV post, a red line snaking its way to the patient’s arm. Many of us have seen our ghost white patient transformed into ruddy splendor after such treatments. Even famous bicyclists apparently don’t mind a “top off” from time to time. But how much transfusion is too much, and should we be exercising more caution? Like many breakthroughs in medicine, the advent of transfusions did not come without its casualties or mishaps. And like many treatments in medicine, transfusion medicine has vacillated between being a panacea and a last-ditch effort. The current guidelines say to be stingy with giving blood, and there are more and more emerging studies to back this up. Our own experience is that the frequency with which blood products are given is still quite variable and physician-dependent. The lifespan of a red blood cell is roughly three months, but the history of blood runs much further back... In the time of Hippocrates, the humoral theory proposed health as a balance of four humors: yellow bile, phlegm, black bile, and – of course – blood. Imbalance led to inflammation and fever. For centuries, bloodletting was thought to be a way to rebalance the body during a time of illness. Around 200 AD, Greek philosopher (and “physician to the gladiators”), Galen of Pergamum, postulated that blood originated in the liver and migrated

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out like a tide through various organs where it was consumed. Blood was thought to be heated in the heart and to traverse the heart septum through small “pores” (which we now know don’t exist). Not until the early 1600s did London physician, William Harvey, debunk this theory and correctly identify the heart as the pump that circulates blood, and that arteries and veins coordinate in taking blood from and to the heart in a closed fashion. In the mid 1600s, microscopy revealed red blood cells and the structure of capillaries. Dutch microscopist, van Leeuwenhoek, measured RBCs to be “25,000 times smaller than a fine grain of sand.” In the Renaissance, if you were a dog or sheep, a young boy, a poor person, a mentallychallenged soul, or even a Pope, chances are you were the perfect subject for a transfusion experiment! In 1492, legend has it that Pope Innocent VIII, after having a stroke, slipped into a coma and his physician infused the blood of three young boys through the Pope’s mouth. In 1665, English physician, Richard Lower, successfully transfused one dog through its jugular with blood taken from the carotid artery of a second dog. Dr. Lower was a remarkable man who made tremendous strides in this field. An expert anatomist at Oxford and an understudy of Dr. Thomas Willis (whose “circle of Willis” every medical student adores), Dr. Lower devised the precursor to the modern day needle and syringe. Quills were used to draw

This early transfusion kit and others may be seen at the SSV Museum of Medical History.

blood prior to that. Silver proved to be more malleable and durable. The year 1667 saw the first blood transfusions of humans. In June of that year, French physician, Jean-Baptiste Denis, transfused a feverish teenage boy with sheep’s blood. Later that year in England, Dr. Lower transfused an impoverished, mentally-ill man with sheep’s blood. Both patients survived; however, several subsequent patients did not, and the practice was outlawed by French Parliament in 1670. (Why sheep were chosen is a matter of some speculation. Sheep’s blood is also used for blood agar plates, as it seems to be least hostile to bacteria). In 1818, British obstetrician, James Blundell, performed the first human-to-human (husband to wife) transfusion to treat postpartum hemorrhage. He became rich for the discovery although his success rate was roughly 50:50. Later in the 1800s, milk was transfused as a blood substitute, and it didn’t do a body good. The ABO/Rh blood group system was discovered by Austrian scientist, Karl Landsteiner, and colleagues in the early 1900s, leading to a 1930 Nobel Prize in Physiology and Medicine. Blood has been regulated by the FDA since 1938.

Currently, about 30 million blood products are transfused each year in the U.S., and about 90 million worldwide. In the developed world, most transfusions are done to support surgery, chemotherapy, stem-cell transplantation, and management of blood disorders (e.g. sickle cell anemia). In the developing world, whole blood, instead of its components, is more often used, and more allocation is given for trauma, maternal hemorrhage, and hemolytic anemia of malaria. Although not quite as dizzying as your local Starbucks’ selections, blood and its products come in a variety of forms. Apart from your standard packed RBCs (mocha), whole blood (regular coffee) is used in hemorrhage, washed RBCs (decaf) in cases of prior anaphylaxis or IgA deficiency, and irradiated RBCs (extra hot) in patients receiving chemotherapy (to prevent graft versus host disease). Candidates for leukocyte-reduced RBCs (no whip) include patients who are chronically transfused, transplant recipients, those with transfusion related non-hemolytic fevers, those at risk for CMV transmission, and cardiac surgery patients. Currently about 75 percent of U.S. blood products are leukocyte reduced with filtration,

March/April 2013

The diagram below shows how this kit was used in the early days of arm-to-arm transfusions.

and we are moving towards a policy of universal leukocyte reduction (ULR) similar to France and the U.K. The golden target of a hemoglobin and hematocrit (H&H) of 10/30 for transfusing blood is fast becoming outdated. Multiple studies have shown equal or better outcomes when employing restrictive transfusion practices (Hgb < 7-8) as opposed to liberal transfusion (Hgb < 10). The TRICC trial of 1999 showed

this in ICU patients. The FOCUS trial of 2011 showed this with post-surgical patients. The recent Villanueva et al. study published in the NEJM shows us that most patients with upper GI bleeding should have transfusion withheld until Hgb is <7. More than 450,000 patients a year are hospitalized for GI bleeding, so this has broad implications. Apart from the traditional risks of transfusion (fluid overload, fever, infection, hemolysis, allergic reaction), the theorized mechanism of injury from liberal transfusion is that even small amounts of exposure to blood products can cause immune suppression in the critically ill. The 2012 guidelines from the American Association of Blood Banks recommend transfusion of patients with Hgb <7 in the critical care setting (even with a history of significant CAD), and Hgb <8 in medical and post surgical units. In the setting of active myocardial infarct or unstable angina, traditional thinking has been to maintain higher Hgb levels for better oxygen delivery, and to transfuse when Hgb is < 10. But trials are conflicting, and there are no firm recommendations for transfusing these patients. In summary, blood is important to me and you! It is also important to our medical society that helped found BloodSource in 1948. BloodSource is a not-for-profit, communitybased organization that exclusively supplies blood products to over 40 hospitals in Northern and Central California each year. They recently donated $50,000 to our SPIRIT program, and their medical director, Dr. Chris Gresens, received the Medical Honor Award at our Annual Awards banquet. Other fun and interactive resources to learn about the history of blood can be found at PBS www.pbs.org/wnet/redgold/history/timeline3.html and at the American Red Cross website www. redcrossblood.org/learn-about-blood/history-bloodtransfusion. Feel free to visit the SSVMS museum to see our old transfusion kits. And above all else, please, be kind to sheep! hitzemn@sutterhealth.org

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Annual Meeting

Annual Meeting THE 2013 SSVMS AND ALLIANCE Annual Awards and Installation Dinner was held January 17 at the Hyatt Regency Hotel in Sacramento. David Herbert, MD, a specialist in Critical Care and Infectious Diseases with The Permanente Medical Group, was installed as the 139th President, and became the first president in recent history to serve a second term. Also installed were the following SSVMS 2013 Officers and Board of Directors: Drs. Jose A. Arevalo, President-Elect; Jason Bynum, Secretary; Bhaskara Reddy, Treasurer; Alicia Abels, Immediate Past President; and Directors, Drs. Paul Akins, John Belko, Ann Gerhardt, Russell Jacoby, Robert Kahle, Steven Kelly-Reif, Tom Ormiston, Kristen Robinson, Lorenzo Rossaro and Christian Serdahl. The Society’s highest honor, the Golden Stethoscope Award, was presented to Marion Leff, MD, a family practice physician with Sutter Medical Group, for her devotion to patient care and the medical needs of the community. In her acceptance speech, Dr. Leff stated, “The stethoscope is such a perfect symbol and metaphor for all I hold dear about medicine. With it we listen hard, and more importantly, we try to hear well. Wearing the stethoscope grants us unique privileges. From the bottom of my heart, dear colleagues and friends, HEAR ME WELL, Thank you!” The Medical Honor Award was presented to Christopher Gresens, MD, for his passionate work to maintain a safe blood supply, both locally and throughout the world. Dr. Gresens is Senior Medical Director and Vice President of Global Medicine at BloodSource. Sister Clare Marie Dalton, Vice President of Mission Integration for Mercy General Hospital, was the recipient of the Medical Community Service Award, recognizing her as a tireless

advocate for the underserved population in our community. Paula Cameto received the Alliance’s highest honor, the Dorothy Dozier Helping Hands Award, for devoting her time, energy and talents to the Alliance. Guests at the event were entertained by Grammy-nominated guitarist/lutenist Richard Savino, who was accompanied by Adam LaMotte, violin, and William Skeen, viola da gamba. They provided an exceptional performance of musical selections from sixteenth- through nineteen-century Spanish and Italian chamber music.

March/April 2013

2013 President David Herbert, MD

Annual Meeting

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Annual Meeting

Former Assemblymember, Helen Thomson, Dr. Captane Thomson, and Dr. Dale Smith with 103 year old Dr. Herbert Bauer

Some of the UC Davis medical students attending the annual meeting.

Drs. Denise Satterfield, Dale Smith and Gail Pirie

Alliance President, Celeste Chin and Paula Cameto, Recipient of the Allianceâ&#x20AC;&#x2122;s Dorothy Dozier Helping Hands Award

Dr. Lee Snook, CMA Trustee, Cindy Snook, and Dr. Paul Phinney, CMA President

Dr. Bob LaPerriere, Curator, Sierra Sacramento Valley Medical History Museum, and Dr. Don Lyman, Chair, Public and Environmental Health Committee

Dr. Nate Hitzeman (left) and Drs. Stanley Leff and Marion Leff (center) joined by members of the Sutter Health Family Medicine Residency Program.

Sister Clare Marie Dalton, Recipient of the Medical Community Service Award, and President Dr. David Herbert

Richard Savino (right) joined by musicians Adam LaMotte, Violin, (left) and William Skeen, playing the Viola da gamba

10 World Renown Guitarist/Lutenist and Grammy Award Nominee, Richard Savino, holding a Theorbo Photo Credit: David Flatter (flickr.com/davidflatter)

March/April 2013

Annual Meeting

11 Board Member, Dr. Ann Gerhardt, and Dr. Lydia Wytrzes

12 Guests enjoying the event 13 Drs. Stephen Skinner and Past President Jon Finkler 14 Medical Honor Award Recipient, Dr. Christopher Gresens (right), and spouse, Monique Gresens 15 President Dr. David Herbert and Dr. Marion Leff, Recipient of the Golden Stethoscope Award 16 Drs. Michael Carl, Bill Eng, Pandu Rangareddy Yenumula, Vijay Rathore

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Book Review

Essentials of Correctional Nursing Edited by Lorry Schoenly, Ph.D., RN, CCHP-RN, and Catherine M. Knox, RN, MN, CCHP-RN, Springer Publishing Company, 2012. ISBN-13: 978-0826109514, paperback 404 pages, $75

Reviewed by Bruce P. Barnett, MD, JD, MBA, President of the California/Nevada Chapter of the American Correctional Health Services Association IN RECENT YEARS, NO FEWER than two million Americans have been receiving their healthcare while incarcerated, either in jails or prisons, as more than one percent of the adult US population is behind bars in any year. But there are very few medical texts to guide the many thousands of healthcare providers engaged in the care of this population. Lorry Schoenly and Catherine Knox provide in their 2012 text a welcome addition to the very limited inventory of text books on the subject. By its title, Essentials of Correctional Nursing appears to be a companion volume to the 1998 medical text, Clinical Practice in Correctional Medicine, first published in 1998 (second edition in 2006). But that notion does not do justice to this new book. Schoenly and Knox have edited and written a comprehensive review of the healthcare issues and treatment options for US inmates equal or superior in its value to any prior issued publication. This book is worth reading by anyone caring for the incarcerated patient, regardless of discipline. Essentials of Correctional Nursing has much to recommend it. It is affordable. The soft cover format is convenient and possibly more practical for use on a prison yard than a hard cover version might be. In addition, an e-book version is available for digital readers. Most importantly, it is relevant and readable. Thankfully, the editors do not reiterate material about such common diseases as hepatitis C and diabetes, already put forth adequately in many other authoritative textbooks. Instead, each of the chapters informs

readers about aspects of healthcare unique to the correctional environment. The book begins appropriately with an overview of ethical, legal and practical considerations for the delivery of healthcare in correctional facilities. Additional chapters tackle all the main concerns for inmate healthcare such as drug habituation, chronic pain, end-oflife care, mental health and dental health. The book’s last chapters touch upon management topics and modern strategies for quality improvement. This is a textbook ostensibly directed to nurses. The authors are all nurses, many with doctorate degrees. There is not one MD author. Yet, despite the lack of MD writing, the textbook is extremely relevant and informative for any physician treating inmates. That a nursing text has so much to teach me is no surprise, because nurses provide more direct healthcare to inmates than do physicians. Essentials of Correctional Nursing is the first new and comprehensive text about this growing field to be published in the last decade. Fortunately, the editors have done a great job in all respects. The writing is clear and pertinent to the practice of medicine “behind the wire,” and the references are sufficiently erudite to satisfy the most critical academic. This book should be required reading for all medical practitioners and administrators working in jails or prisons. It certainly belongs on the shelf of every health care professional and administrator involved in care of incarcerated patients. Bruce.Barnett@cdcr.ca.gov March/April 2013

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. 21

Unintended Outcome of Antimicrobial Use Bacterial resistance, altered fecal microbiomes, and childhood obesity, asthma, and atopy

By John Belko, 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.

AS A CLINICIAN, I HAVE always been concerned about the judicious use of antimicrobials. I grew up during the golden age of antimicrobials; that time when, if you went to the doctor and didn’t leave with a prescription for amoxicillin or some other antimicrobial, you changed doctors. This was also the time of the launch of the Presidential Fitness Program and the time of making school lunches healthier (e.g. ketchup is a vegetable!) to combat childhood obesity. It’s pretty clear that the causes of obesity are multifactorial and very complicated. I didn’t start to read up on obesity until I found some provocative articles a few years ago, which talked about widespread antimicrobial use in agribusiness for the purpose of increasing animal weight to maximize value. This was next to an article that talked about the evolution of antimicrobial-resistant organisms in pigs in Holland. Since the Second World War, food animal production in the U.S. and other developed countries has been characterized by fewer but larger farms. This has, in turn, led to an increase in illness within animal herds, necessitating the use of antimicrobials to treat infected animals. Antimicrobials have also been used in animal production for the prevention of infection. In conjunction with better nutrition, this contributes to larger animal size, leading to a better price at market for the animal. Many antimicrobials, including common ones like amoxicillin, erythromycin, gentamicin, and tetracycline, are used both for the treatment of ill animals and also for growth promotion.

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Starting in the early 2000s, several national veterinary organizations developed principles of antimicrobial use to help guide agribusiness. In 2000, the Union of Concerned Scientists published some statistics showing that about 25 million pounds of antimicrobials are fed to chickens, pigs, and cows for non-therapeutic purposes each year (specifically for the prevention of infection or growth promotion). They also estimated that about 3 million pounds of antimicrobials are administered to people annually with about another 1.5 million pounds used in topical creams, soaps, and disinfectants annually. According to the Animal Health Institute, 17.8 million pounds of antimicrobials were used in animal production in 1998, with 14.7 million pounds (83 percent) geared for prevention and treatment of disease, and 3.1 million pounds (17 percent) for growth promotion. In 2000, the Institutes of Medicine estimated that U.S. production of antimicrobials was about 44 million pounds annually. While these figures are quite large, most of the antimicrobials used by farmers are not used in human medicine and may not contribute to the evolution to antimicrobial resistance. However, other antimicrobials like amoxicillin, teicoplanin (vancomycin), erythromycin, tetracycline, and fluoroquinolones, are used widely, raising the concern that their use may have some influence on the evolution of antimicrobial resistance. An example of where antimicrobial use has led to antimicrobial resistance can be seen

in a case study from Holland. A specific clone (ST398) of methicillin-resistant Staphylococcus aureus (MRSA) appeared clinically in several hog farmers in Holland in 2005. With further investigation, it was found that this clone of MRSA had originally been seen in the 1980s as a methicillin-susceptible strain of Staphylococcus aures isolated from hog farmers and also in some of the pigs. Because there were many infections in the herds, farmers started feeding their pigs tetracycline to combat the infections. Infections in the farmers and the pigs seemed to abate for a while and then in 2004-2005 started up again and this clone was no longer methicillinsusceptible. Colonization with this strain of MRSA spread rapidly in areas where there is intensive pig farming, not just in Holland. It has been found in neighboring countries in the EU and around the world, generally associated with swine and pig farmers. This past October, I attended a national Infectious Disease Meeting where there was a major focus on fecal microbiomes (the collective group of bacteria that make up our intestinal flora), how they change over time, especially under the influence of antimicrobials and how these changes affect our health. Amid the many presentations, there was one that suggested that childhood antimicrobial use contributed to obesity in children. A Danish study to attempt to understand the factors that contribute to childhood obesity followed 28,354 mother-infant dyads for seven years and looked at a number of criteria to see what might impact the development on obesity. What they learned was that by six months of age, 33 percent of infants had received at least one course of antimicrobials. By two years of age, this increased to about 74 percent. Exposure to antibiotics in the first six months of life was found to be associated with an increased incidence of obesity in the children of moms with normal pre-pregnancy BMI (<25) and those that were obese (BMI >30), but to a lesser extent, in children of moms that were overweight (BMI 25-30) prior to the pregnancy. In one study, overweight pregnant women

and those with high gestational weight gain had higher concentrations of bacteroides, clostridia, and staphylococci in their stool. An excess of these same bacteria have also been found in overweight children. The use of antimicrobials in the first month of life alters fecal microbiomes by reducing concentrations of bifidobacteria and bacteroides. Reductions in bifidobacteria has also been associated with a higher risk of asthma and atopy. It’s clear that there is still a lot more research to do to confirm and understand the basis of any association, but it is intriguing. I have come to appreciate an important lesson I learned from my first mentor. “It’s always easy to start antibiotics on a sick infant. It’s a lot harder to convince people to stop or not take antibiotics that aren’t needed,” he’d always state. “In every generation there emerges some drug-resistant super-bug and every generation clamors for more and new antibiotics. What every generation learns the hard way, as they wait for the new blockbuster drug, is that the best way to help people is by prescribing fewer antibiotics.” He’d stop for a minute and survey our team with a mischievous grin, before saying “History. Ain’t it funny how quick everyone forgets it?”

“It’s always easy to start antibiotics on a sick infant. It’s a lot harder to convince people to stop…

John.Belko@kp.org

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March/April 2013

Physician Shortages in the San Joaquin Valley Local students wanting to make a difference

By Maricela Rangel-Garcia, MS I, Kelly Fujikawa, MS II, and Christina Thabit, MS II

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.

THE SAN JOAQUIN VALLEY provides 30 percent of the fresh produce consumed in the nation, but its eight counties are among the least healthy in California. An insufficient physician workforce hinders improvement (less than two licensed physicians per 1,000 people in the region). To help train the next generation of valley physician leaders, UC Davis, UC Merced and UCSF Fresno formed the UC Merced San Joaquin Valley Program in Medical Education (SJV PRIME). Three current SJV PRIME medical students were recently interviewed. Meet Christina Thabit (MS II) from Bakersfield, Kelly Fujikawa (MS II) from Fowler, and Maricela Rangel-Garcia (MS I) from Fresno. What is your connection to San Joaquin Valley? Maricela: My mother’s family has been in the valley for three generations. My grandparents and parents worked in the fields as laborers and my parents are now faculty members at CSU, Fresno. My family lives on a pecan orchard in Clovis. The valley is where my heart is, and there is no other community that I would rather serve. Kelly: I was born and raised in Fowler – a small town south of Fresno – on a four generation family peach and nectarine farm. I plan to return to the valley to help improve the health of this region. Christina: My parents met when my dad was a surgical resident at Kern Medical Center in Bakersfield and my mother was an OR nurse. Their love of medicine inspired me

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to become a physician. However, my Tularenative grandfather taught me the importance of serving one’s community through leadership and activism. He told me that giving back wasn’t a choice, it was my duty. I hope to follow in these footsteps to care for those in Tulare and Kern Counties – my hometowns. Are your SJV PRIME colleagues also from the valley? Maricela: Yes! We are joined by eight other students representing the valley and surrounding regions: Sidra Ayub and Karina Martinez Juarez are from Modesto, Randell Rueda, Christine Ongaigui and Katy Ruch are Fresno natives, Agustin Morales is from Salinas, Fabian Alberto is from Soledad, and Filmon Mehanzel is originally from Eritrea, and his family now calls Manteca home. Did you attend college in the valley? Maricela: Yes, I was part of the inaugural class at UC Merced. I volunteered in the Emergency Department at Mercy Medical Center Merced and participated in the Community Scholars Program. After graduation, I was a Health Career Connections Intern with UCSF Fresno’s Latino Center for Medical Education and Research. Kelly : I did not go to college in the valley. I wanted to broaden my experiences, but with the intention of returning home. I attended UC Berkeley where my interest in working with the geriatric population began. I then received a masters degree in gerontology at USC and managed a multi-disciplinary elder abuse center. Christina : I attended CSU Long Beach, then

returned to Bakersfield to work in a cancer center where I received my first fulfilling experience in valley health. What are you plans after completing the program? Maricela: I am very interested in OB/GYN, particularly working with women with high-risk pregnancies. I want to be a culturally competent and humble physician for women and families. I have seen humility play a critical role in healthcare while increasing the quality of life, and care, for families. Kelly: I would like to return to the valley and work mainly with the older adult population. Geriatrics is certainly a possibility, but I am keeping an open mind, as physicians practicing in almost every medical discipline work with the older adult population. Christina: I would love to match into a residency program within the valley. I see myself as a committed community member who strives to rewrite the script of poor health in my hometown. Eventually, I’d like to work in public health and/or public policy to make systemwide changes to improve health outcomes. Tell us why you chose this program. Maricela: The SJV PRIME program will help me to become an effective physician for valley populations. My faculty mentors are familiar with valley challenges and help me to learn how to advocate for patients. I also participate in enriching extracurricular clinical experiences focused on the health of medically vulnerable communities. I could not pass up the opportunity to obtain a medical education crafted by three University of California campuses! Christina: I’m excited to participate in a unique third-year clerkship at UCSF Fresno called the Longitudinal Integrated Fresno Experience (LIFE) program. LIFE emphasizes continuity of care and patient-centered care by integrating psychiatry, internal medicine, and family medicine into a six-month longitudinal clerkship in which we will follow patients throughout Fresno’s health care system. This innovative program allows students to build

relationships with patients and better reinforce clinical knowledge. Having the opportunity to work at UCSF Fresno greatly influenced my decision to join SJV PRIME. Is there anything else you would like to share with us? Christina: I was lucky to have great mentors on my path to medicine. However, the pipeline to medical education in the valley is sorely compromised by having no medical school within its boundaries. Many cities experience a “brain drain” phenomenon in which motivated youth obtain degrees, then never return home because they don’t see opportunities in the valley. I hope that SJV PRIME students serve as an example for youth who cannot yet see themselves as professional students. I hope that we can convince them that they are valuable and can join a neighboring university to eventually serve their hometowns. We would like to acknowledge UC Merced, UCSF, UCSF Fresno, UC Davis and the people of the great Central Valley for creating SJV PRIME. We are particularly grateful to Dr. Tonya Fancher, Dr. Fred Meyers, Dr. Kenny Bahn, Dr. Jose Morfin and Patricia Gonzalez for helping us to attain our dreams.

Left to Right: Christina Thabit, Maricela RangelGarcia, Kelly Fujikawa

cthabit@gmail.com

March/April 2013

Laura’s Law – Time to Bring it to Your County? By Adam Dougherty, MPH, MS III

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.

MENTAL ILLNESS HAS TOUCHED most of us in some way − be it a personal struggle, a loved one’s troubles, a news story of mass murder, or simply witnessing a disturbed soul on the street corner. Fortunately, there is growing recognition of the importance of mental health services as a mainstay of comprehensive medical care. But what if an individual is too ill and disorganized to even seek out care? Tragically, people with the greatest need are the same ones with the most trouble navigating the system. If these people are lucky enough to find some mental health services, it is usually limited to acute short-term hospitalization or care within the criminal justice system after a crime has been committed. Our patients with mental illness are forever in a revolving door between the emergency department, county mental health clinics, and jail psychiatric services. With no ability to provide sufficient follow up, doctors are forced to discharge these patients back to the streets until they fall into the cycle again. This was the case in 2001 when Scott Thorpe, an untreated schizophrenic, made headlines for gunning down 19-year-old Laura Wilcox and two other employees in a Nevada City clinic. Following the tragedy, the California Legislature passed Laura’s Law. It expands services to severely ill, often-untreated individuals. The law allows counties to require Assisted Outpatient Treatment (AOT) for needy people who have a history of violence and repeated hospitalization and have failed voluntary treatment. More specifically, AOT is court-ordered therapy that is designed to intervene before an individual further deteriorates into the vicious

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cycle. Unlike high-cost acute hospitalization, AOT includes a menu of options tailored to an individual’s unique needs and circumstances. It focuses on outpatient services such as psychotherapy, medication management, crisis intervention, in-home nursing and social services. Counties have the prerogative to decide whether to implement the law or not; and unfortunately for most of California’s severely mentally ill, only one county − Nevada County − has done so. Local government has been hesitant to implement the law, given a sense that it limits people’s autonomy. However, many of us would argue for a greater good to promote public safety and a moral responsibility to help those who truly can’t help themselves. AOT shouldn’t be construed as “forced treatment,” but rather it is an opportunity to bring relief to a vulnerable, high-risk and costly group, providing services to those who have been unable to benefit from the medical system other than re-hospitalization or incarceration. For every Scott Thorpe, there are hundreds more who don’t make headlines, but continue to suffer in the community − many with malnutrition, medical illness and treatable mental health conditions that severely limit their ability to become functioning members of society. Governor Jerry Brown recently signed legislation extending Laura’s Law to 2017, and it is time for Sacramento and surrounding counties to take a closer look at the benefits of implementation. Not only would it save lives, but AOT also makes fiscal sense. In a recent study of the law’s implementation, the Nevada County Behavioral Health Department found

that AOT significantly reduced hospitalization and incarcerations rates, resulting in savings of $1.81 for every $1.00 invested in the program. For these efforts, Nevada County was bestowed the 2011 National Association of Counties Achievement Award.

One a Day…

Laura’s Law would be a promising patch to help mend our fragmented local mental health system, reduce disparities for the neediest among us, provide rehabilitation and prevent tragedy. Sacramento and its neighboring counties could lead the way by enabling funding streams available through the Medi-Cal program, the Prop. 63 Mental Health Services Act, and the recently unveiled bipartisan federal legislation, The Excellence in Mental Health Act, introduced by our very own Congresswoman Doris Matsui. Local law enforcement, county health services and their affiliates, and patient advocates also all have a part to play in making this program a reality. apdougherty@gmail.com Adam Dougherty is a third year medical student at the UC Davis School of Medicine and sits on the Sacramento County Public Health Advisory Board (PHAB).

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

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March/April 2013

A Posit on Mental Health and Gun Ownership “A mental health competency certificate should be required for all gun purchases as a justifiable cost of owning a gun.”

Background: Given recent tragic events involving gun violence, the country is debating what roles the gun industry, government, and health care can play. We asked our members to comment. Responses to the posit are Agree=71/ Disagree=21. Some of the commentary follows. (Posits are pointed statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or Board of Directors.) ****** Some mental problems develop in previously healthy gun owners. And most gunshot wounds are not the result of use of a gun by a mentally ill person. The focus of any regulation should be to remove guns from the hands of persons who misuse them or are at risk of doing so. −Sandra Hand, 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.

While at first glance one could easily agree, the question of what would be the yardstick upon which mental health competency would be judged immediately comes to mind. Further, who would issue the certificate...if an MD and if the individual getting the gun then injured or killed someone, would the certifying individual be held legally accountable? Yes...a sticky issue. I mentioned this posit with several employees at work. Interestingly, one responded and others agreed by asking whether we should also issue mental health competency certificates before anyone could have a child. −Frank Apgar, MD

Sierra Sacramento Valley Medicine

This is not a mental health problem, it is an access to guns problem for anyone. It is also a public health problem and should be treated as such. Look to Australia for a constructive approach. We license cars; there is no reason not to license guns, and we require that cars have all kinds of safety requirements. Guns are no different. Less access to guns and ammunition means less shooting, less shooting means fewer dead, fewer dead is why I signed up to be a physician. −Thomas Atkins, MD All assault rifles should be banned except for the military and law enforcement personnel. −Mark Chang, MD Families housing mental health members should not be allowed to keep guns at their home either, even if they are locked up. Mental health providers should make a mandatory report to a special safety service that needs to be created [just like CPS]. This special unit can perform routine inspections of all homes housing mental health members for guns and report violations to authorities. −Mitra Choudri, MD The history of gun regulation in Scotland and Australia suggests that courageous citizens can indeed direct politicians to do the right thing. −Alfredo Czerwinski, MD Probably something close to a formal license with screening for mental issues would be appropriate indeed. −Cristian Dinescu, MD

Good idea, but I am not sure how practical. Who will do them and what criteria? We mostly need to ban assault weapons and other multipleround firearms from private ownership. The sole purpose of the design of these is to kill multiple people quickly, and they are an extreme public health hazard. As long as they are readily available, we will never entirely succeed in keeping them out of the wrong hands. −Thomas J. Curran, MD With the exception of law inforcement qualified personel etc., owning a militarytype assault weapon with a magazine holding multiple rounds may be an indication of mental incompetency in itself. −Malcolm Ettin, MD Gun ownership is a constitutional right; this requirement would make it onerous to exercise that right. In addition, requiring such a certificate would not have prevented this tragedy [Newtown, CT]. The guns were owned by the murderer’s mother, who was not mentally deranged. As heartbreaking and heinous as this crime was, in a free society there are some tragedies which are unavoidable. “Those who are willing to sacrifice freedom for security will find themselves without either.” −John Gisla, MD Not only should it be required at the time of purchase, but would need to be updated on a regular basis. −Richard Gray, MD While I am in favor of gun control − a “mental health competency certificate” is not easy to define (I have never heard of one) and it is too easy to fake. The elimination of assault weapons from the pool would be more definitive. The concept that assault weapons are acceptable for sport or safety is ridiculous. −David Greenhalgh, MD We need a strong national ban on assault weapons. −Debra Horney, MD Just outlaw guns period. −Anne Igbokwe, MD

The same test should be used to screen for people wishing to hold elected public office, corporate CEO positions and for the right to vote. −Reinhardt Hilzinger, MD I would rather see improved compliance and mandatory national reporting for those already deemed mentally ill or incompetent to be included in the federal background database used in gun sales. New York state reports over 100,000 individuals, yet some states have no one on the database. −Monte Ikemire, MD Anything that would restrict the amount of guns on the street is a great idea. I’m amazed that this question even needs to be asked. ALL guns should be outlawed and if found, destroyed. There is no rational, the operative word is “rational,” reason for owning guns. I could go for paragraphs, but the essence of the problem is “the easy access to killing machines.” −Maynard Johnston, MD While I like the idea of limiting access to “assault weapons,” I dislike even more the idea of a “mental health competency certificate.” Who is going to issue that and how long is it good for and so on? −Paul Kelly, MD All guns should be outlawed aside from those used by police officers in the course of their work. The disadvantages of gun ownership vastly outweigh the benefits. I’d be thinking differently if it were not for the fact that a single gun shot can irreversibly kill someone. This happens far too often. −Jonathan Kern, MD

…owning a militarytype assault weapon with a magazine holding multiple rounds may be an indication of mental incompetency in itself.

Mental health competency should be required if someone is diagnosed with a mental illness should they desire to be a gun owner. Mental health records of those who are not competent to possess firearms, however, should be placed in a confidential database as part of licencing for purchase of a firearm. −Stephen Mandaro, MD The Sacramento Bee reported that Australia passed restrictive gun policy legislation

March/April 2013

following the Port Arthur massacre in 1996 where 35 people were killed and 21 wounded. Since then, there have not been any mass shootings recorded in Australia. There were 11 recorded mass shootings in the decade from 1986 to 1996. I support reapplying the ban on assault weapons. −Charles Maas, MD

The above proposal involves the same reasoning that the TSA employs to explain airport patdowns of seven-yearolds…

Most mentally ill patients are not violent. This requirement might backfire. My two recommendations are: 1) An absolute ban on “assault” weapons − a one-shot rifle or pistol would have prevented most of the deaths in Connecticut. 2) Total news blackout on the perpetrators − I am convinced that there is much copy-cat and contagion in these mass shootings. −James Margolis, MD This will do nothing to stop the mentally ill from accessing weapons, it will only hurt law-abiding citizens. There are enough laws on the books now. We need better ideas than this to keep weapons out of the hands of the mentally ill and criminals. −David Moitoza, MD In addition to gun control, we need to improve mental health treatment in this country. −Aimee Moulin, MD The above proposal involves the same reasoning that the TSA employs to explain airport patdowns of seven-year-olds and wheelchairbound octogenarians. Evidence-based medicine teaches us to target interventions to the highest risk groups for greatest benefit. The same should be true for mental health screening. Don’t screen everyone applying for gun ownership. Screen those with mental health diagnoses. − Ryan Nicholas, MD I disagree unless the method chosen is realistic, evidence-based and has accurate production of an actionable result. If we believe in evidenced-based medicine, then any “test” that picks up a mental propensity to shoot up a school needs to be evidenced-based. Note, I wish such were the case now, but I doubt it is. −Eugene Ogrod, MD

Sierra Sacramento Valley Medicine

In the US, many of the mass shootings occurred in areas with the most restrictive gun laws. Washington, DC, for example has completely banned guns, yet has the highest per capita gun-related homicide rate. If restricting access to guns reduced gun-related homicide, one would expect a strong correlation between such laws and a reduced homicide rate. It does not appear that there is any such correlation. In fact, it may be just the opposite. The more you restrict legal gun ownership, the more you encourage illegal gun ownership creating, in effect, a defenseless society – precisely what existed in that school. One could make a plausible argument that if one or more of the teachers in that school had concealed weapons permits and marksmanship training, that fewer children would have died. Instead of lunging at the shooter in a heroic, sacrificial and ineffective act, had the principle instead shot the individual, at least some of the tragedy could have been averted. The same would have been true at Columbine or Virginia Tech or in the movie theater. These gunmen are counting on the fact that no one else is armed but them. The Swiss example is very instructive. Every household has a rifle and every male citizen has compulsory rifle training, and as a result, they have a much safer society. The goal should be to keep guns out of the hands of criminals and the mentally ill, while not restricting gun ownership by mature, law abiding, rational and trained individuals. −Michael Patmas, MD I strongly support gun control. No assault weapons. No large ammunition holders. − Eugene Reames, MD There would need to be guidance on what elements would need to be included for competency evaluation, and what red flags. We would also need to evaluate how this would prevent patients from gaming the system by hiding health information because they want to obtain a gun. −Seth Robinson, MD I agree. But it would likely become another black market item. −Ronald Rogers, MD

I believe the recent shooting in Connecticut of innocent, young children and their teachers is the most recent evidence that guns are not protecting our families, but killing the most innocent members of our society. I hope this tragic event brings a change in our attitude towards guns and that the many lives lost were not lost in vain. Perhaps the right to carry guns was necessary several hundred years ago in the Wild West, but it does not apply today. Time to move on. −Susan Scholey, MD Mental health competency certificates must be issued and signed by a certified mental health care professional who is accountable in ways similar to physicians who provide statements for patients to operate a motorized vehicle. −Boone Seto, MD I agree! I think Australia has the right idea. The second amendment should be changed so that the purchase of a gun requires a legitimate reason for ownership. There should also be a ban on assault weapons with a mandatory buy back by the government. −Stewart Teal, MD I agree with this posit. I do not currently own a gun, but I am considering buying one or more over the next few years. I shot several guns with my dad as a child and I enjoyed the technical challenge; I also live in an area with ample hunting opportunities. Home/familydefense is a plus, but also carries considerable risk. I believe safety training and a keen understanding of the risks of gun ownership are paramount before any gun acquisition. No one with even a questionable psychiatric history should be allowed to acquire a firearm without very serious vetting. That being said, I also sympathize with the Swiss system that requires “combat readiness” of all of its able-bodied men. I would only add that they must be ableminded and level-headed as well, and not just men. −Don Udall, MD I disagree. This would mean that the majority of people seeking to purchase a gun would have to go at their own expense and get a “mental

health certificate.” There should be a data bank with information on anyone who has been treated for mental illness, whether outpatient or inpatient. No one with a conviction for drugs or violent crime or anyone who has been incarcerated should be able to purchase a gun. −Amy Wandel, MD Emotional reactions which disregard evidence, logic, and reality may help elect politicians, but will harm most of us. Should a mental health competency certificate be required for political candidates or for voters? For an example of “fitness for leadership” (and their control of guns and other instruments of coercion) determined by politicians and their voters, read “The Hitler Test” by Butler Shaffer, www.lewrockwell.com/shaffer/shaffer52. html. Wayne Lapierre (NRA) offers this cogent analysis of a related phenomenon: http://xa.yimg. com/kq/groups/19050141/2012850073/name/ WayneNRATranscript_PDF.pdf. −Lee Welter, MD There is precedent for establishing that a patient does not have a medical condition that would prohibit their safely driving a car. I think it is reasonable to establish a similar standard for gun ownership. −Tia Will, MD Can a psychiatrist determine who is fit to own an assault rifle? Who in their right mind needs a personal weapon of mass destruction (PWMD) that allows you to kill 20-30 people in a few seconds? Isn’t the psychological need for such weapons a reflection of a grossly disturbed mind? But the problem of gun violence goes much deeper than guns. Violence is glorified in our culture. The average American child watching TV will see 200,000 violent acts and 16,000 murders by the age of 18. The NRA now wants armed killers guarding our schools: educating children that violence is the only solution to violence. This will last till some trigger-happy gunhead kills some parent or child who “looks suspicious.” When the aliens come down to save our planet, they will ban violence in media and take away all these guns. –Jack McCarthy, MD

March/April 2013

I agree with this posit. I do not currently own a gun, but I am considering buying one…

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. — Jason P. Bynum, MD, Secretary.

Altamirano, Hugo E., Anesthesiology, SUNY Stony Brook 2010, UCDMC, 4150 V St #1200, Sacramento 95817 (916) 734-2011 (Resident Member)

Cheung, Mandy, Pediatrics, UC San Diego 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Golden, Julia B., DO, Urology, New York Col of Osteopathic Med 2006, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Bean, Meredith A., Family Medicine/Sports Medicine, New York Med Col 2000, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6160

Chiu, Peter B., Radiology/Neuroradiology, UC San Diego 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Granzella-Rogers, Janice A., Geriatric/Internal Medicine, UC San Diego 1986, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Bigler, Joshua B., Emergency Medicine, Ross Univ 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Boone, Susan L., Dermatology/MOHS Surgery, UC San Diego 2004, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5671

Chow, Michael I., Cardio/Thoracic/Vascular Surgery, University of Hawaii 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Hay, Jana D., DO, Family Medicine, Touro Univ 2012, Sutter Health Family Practice Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Chow, Norman S., Pulmonary/Critical Care Med, Cornell Med Col 1984, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821

Kappel, Stefani T., Dermatologic Surgery, UC Irvine 2007, UCDMC, 3301 C St #1300, Sacramento 95816 (916) 734-6111 (Resident Member)

Collantes, Abbegail M., Family Medicine, Univ of the East Ramon Magsaysay, Philippines 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Keller, Benjamin A., General Surgery, Medical College of Wisconsin 2010, UCDMC, 2221 Stockton Blvd., Sacramento 95817 (916) 734-3528 (Resident Member)

Currlin, Nicholas A., Pediatrics, Univ Texas 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Khaletskiy, Alexander, Emergency Medicine, UC Davis 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Bryant, Burch R., Internal Medicine, Medical College of Georgia 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Dang, Anh NH, Radiology, Tufts Univ 1992, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Khan, Ruksaana, Internal Medicine, Khyber Med Col, Pakistan 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Burnham, Kevin J., Internal Medicine, UC San Diego 2009, UCDMC, 4860 Y St #B400, Sacramento 95817 (916) 734-2011 (Resident Member)

Danielson, Matthew D., Radiology, Tufts Univ 2004, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-4000

Carlisle, Marie R., Nuclear Medicine, Stanford Univ 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Davis, Catherine A., Pediatrics, John A. Burns/Univ Hawaii 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Carlisle, Robert C., Radiology, Loma Linda Univ 1993, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5720

Davis, Kimberly J., Psychiatry, Meharry Med Col 2005, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100

Chan, Chung-Yin “Stanley”, Dermatology, Baylor College of Med 2007, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5660

Donnelly, Matthew L., Emergency Medicine, UC Irvine 2002, CEP-Mercy/Methodist Hospital, 7500 Hospital Dr, Sacramento 95823 (916) 423-3000

Briercheck, Bradley S., Psychiatry, Wayne State Univ 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5300 Brown, Stephanie K., Psychiatry/Child & Adolescent Psychiatry, UC San Francisco 1992, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5300

Kordouni, Mohammad R., Internal Medicine, Nat’ Univ Iran 1989, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Laohaburanakit, Petey, Pulmonary/Critical Care Medicine, Chulalongkong Univ, Thailand 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821 Lee, Andrew H, DO, Radiology/Neuroradiology, Michigan State Univ/Col of Osteopathic Medicine 1991, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Chan, Michael, Neurosurgery, Med Col of Ohio 2004, Capital Neurological Surgeons, 3939 J St #380, Sacramento 95819 (916) 453-0911

Duncan Robert C., DO, Family Medicine, Touro University 2006, Mercy Medical Group/Mercy San Juan Medical Center, 6501 Coyle Ave, Carmichael 95608 (916) 989-2899

Chandra, Abhinay, Emergency Medicine, Ohio State Univ 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Ertle, Alan R., Pulmonary Disease, University of Oregon 1980, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-5303

Logan, Julia S., Preventive Medicine, Drexel Univ 2005, Calif Dept. Public Health Preventive Med, PO Box 997377, Sacramento 95899 (916) 558-1784 (Resident Member)

Chen, Elbert H., Dermatology, Duke Univ 1999, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-2142

Farrales, Roel D., Emergency Medicine, UHS/The Chicago Med School 2001, CEP-Mercy General Hospital, 4001 J St, Sacramento 95819 (916) 453-4545

Mamidi, Rekha, Internal Medicine, UHS/Osmania Med Col, India 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Gillis, Artha JE, Psychiatry, UC Davis 2010, UCDMC, 2230 Stockton Blvd., Sacramento 95817 (916) 734-3574 (Resident Member)

Mendez, Sandra, OB-GYN, University of Wisconsin 1985, 7501 Hospital Dr #204, Sacramento 95823 (916) 681-2660

Cheong, Hui M., OB-GYN, University of Western Ontario 2000, Mercy Medical Group, 8120 Timberlake Wy #102, Sacramento 95823 (916) 681-6102

Sierra Sacramento Valley Medicine

Leinen, Jeffery J., Emergency Medicine, University of Texas 1991, CEP-Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 983-7400

Morris, Craig H., Emergency Medicine, Vanderbilt University 1997, CEP-Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 983-7400

Ramos, Cynthia B., OB-GYN, Univ of Texas 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Ta, Vu D., Cardiology, Albert Einstein 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4000

Mosley, Christopher K., Radiology/Nuclear Medicine, St. Louis Univ 2002, Mercy Radiology Medical Group, 3291 Ramos Cir, Sacramento 95827 (916) 363-4040

Ramos, Wilfredo R., OB-GYN, Central Univ of The Caribbean, PR 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Taff, Lon J., OB-GYN, Rush Med Col 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Nakra, Navin C., Cardiology/Interventional Cardiology, Boston Univ 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Ratanasen, Milin M., Internal Medicine, UC Los Angeles 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Nichols, Kristen L., Internal Medicine, Oregon Health Sciences Univ 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Offerman, Steven R., Emergency/Toxicology Medicine, Univ of Southern California 1997, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Oshita, Masaru H., Emergency Medicine, Wayne State Univ 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Parayno, Maria L., Radiology/Nuclear Medicine, Tulane University 2006, Mercy Radiology Medical Group, 3291 Cir, Sacramento 95827 (916) 363-4040 Patriquin, Edward C., OB-GYN, Univ Rochester 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 Peng, James S., Emergency Medicine, SUNY Downstate 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600 Pham, Tan H., Urology, Tufts Univ 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2081 Pirau, Mihaela, Child & Adolescent Psychiatry, Univ of Med & Pharmacy, Romania 1981, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100 Poplawski, Donna A., Child & Adolescent Psychiatry, Medical Univ of Warsaw, Poland 1973, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6710 Poblete, Roy A., Neurology, Loma Linda University 2011, UCDMC, 4860 Y St, Sacramento 95817 (916) 734-3588 (Resident Member) Posner, David A., Family Medicine, Univ of Michigan 2012, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member) Preiss-Farzanegan, Sarah J., Sport Med/ Physical Med & Rehab, Albany Med Col 2004, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6160 Rabin, Gregory J., Ophthalmology, UC Davis 1999, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6400 Ramkumar, Sujatha, Psychiatry, Univ Bombay, India 1980, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 525-6100

Rathbun, Kristen T., General Surgery, Univ Rochester 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2014 Rathore, Vijay S., Nephrology, Univ Rajasthan, India 1989, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6988 Reddy, Karimereddy J., Pathology, UHS/Gandi Med Col 2000, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2300 Ritter, Mary E., Pediatrics, Loma Linda Univ 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800 Rodgerson, Jeff D., Emergency Medicine, Univ Utah 1996, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Rodriguez-Fahrni, Ana M., Hematology/Oncology, Wright State Med School 2006, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Takekawa, Sarah R., OB-GYN, Univ Hawaii 2010, UCDMC, 4860 Y St #2500, Sacramento 95817 (916) 734-6978 (Resident Member) Tang, Jin, Family Medicine, Chekiang Medical Univ, China 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Thomas, Seth C., Emergency Medicine, Albany Med Col 2006, California Emergency Physicians/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5000 Tilton, Patti A., OB-GYN, UC Davis 1982, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 Tran, Serene N., Family Medicine, UC Los Angeles 2002, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 688-2106 Truong, Hai V., Pediatrics, University of Wisconsin 2006, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5000 Trythall, William S., Emergency Medicine, George Washington Univ 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Sahu, Mukesh K., Anesthesiology, UC San Francisco 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Tsai, Virginia W., Emergency Medicine, George Washington Univ 2004, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Sanchez, Miguel A., Pediatrics, Michigan State Univ 2008, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95758 (916) 544-6600

Turgasen, Sarah E., Internal Medicine, University of Minnesota 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Shiu, Gertrude, OB-GYN, Jefferson Med Col 1994, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Vila, Andy H., Family Medicine, Univ Sarajevo 1993, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 544-6300

Smith, Gregory M., Emergency Medicine, Univ Colorado 1993, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Vazquez, Antonio E., Radiology/Nuclear Med/ Neuoradiology, UC Irvine 1992, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Sorbo, Sonja, Anesthesiology, Stanford Univ 1979, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Vuong, Cuong T., Radiology, Pennsylvania State Univ 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Spybrook, Mark G., Internal Medicine, Wayne State Univ 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Walker, Janet M., OB-GYN, UC Davis 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Stalker, Dwight B., Emergency Medicine, Boston University 2003, CEP-Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 983-7400

Watkins, Zenja J., OB-GYN, UC Davis 1994, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6500

Stevenson, Kathryn M., Pediatrics, Virginia Commonwealth 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Webb, John M., Nuclear Medicine/Radiology, UC Davis 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029

Stoltz, Sarah, OB-GYN, Univ Iowa 1981, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055

Whiting, Bradley L., Emergency Medicine, George Washington Univ 2008, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

March/April 2013

Board Briefs January 14, 2013 The Board: Welcomed new Directors Tom Ormiston, MD, and Christian Serdahl, MD. Continuing as Directors in 2013 are: David Herbert, MD, President; Alicia Abels, MD, Immediate Past President; Jose A. Arevalo, MD, President-Elect; Paul Akins, MD; John Belko, MD; Jason Bynum, MD; Ann L. Gerhardt, MD; Russell Jacoby, MD; Robert A. Kahle, MD; Steve Kelly-Reif, MD; Bhaskara G. Reddy, MD; Kristen Robinson, MD; and Lorenzo Rossaro, MD. Elected Jason Bynum, MD, 2013 Secretary, and Bhaskara Reddy, MD, 2013 Treasurer. Approved the Membership Report: For Active Membership — Joshua B. Bigler, MD; Mandy Cheung, MD; Alexander Khaletskiy, MD; Ruksaana Khan, MD; Cynthia B. Ramos, MD; Mary E. Ritter, MD; Ana M. Rodriguez-

Fahrni, MD; Gregory M. Smith, MD; Mark G. Spybrook, MD; Kathryn M. Stevenson, MD; Sarah Stoltz, MD; Vu D. Ta, MD; Lon J. Taff, MD; Jin Tang, MD; Seth C. Thomas, MD; Patti A. Tilton, MD; Serene N. Tran, MD; Hai V. Truong, MD; William S. Trythall, MD; Virginia W-Y Tsai, MD; Sarah E. Turgasen, MD; Antonio E. Vazquez, MD; Cuong T. Vuong, MD; Janet M. Walker, MD; Zenja J. Watkins, MD; John M. Webb, MD; Bradley L. Whiting, MD; Gary W. Whiting, MD; Jared M. Whitson, MD; Anthony T. Wills, MD; Lisa Wong, MD; Patrick Wong, MD; Sudha R. Yenumula, MD; Woojin M. Yu, MD. For Resident Membership — Hugo E. Altamirano, MD; Artha J.E. Gillis, MD; Jana D. Hay, DO; Julia S. Logan, MD. For Reinstatement to Active Membership — Richard B. Meister, MD. For Retired Membership — Prabhas Tung, MD.

Meet the Applicants continued from page 33 Whiting, Gary W., OB-GYN, University of Utah 1979, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2055 Whitson, Jared M., Urologic Oncology, Columbia Univ 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2081

Yenumula, Sudha R., Family Medicine, Osmania Med Col, India 1995, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Zhu, Henry L., Thoracic & Cardiac Surgery, Harvard 1994, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Yu, Woojin M., Pathology, Univ of Michigan 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2300

Wills, Anthony L., Pediatrics, UC Davis 2005, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 478-5200 Wong, Lisa, Internal Medicine, Loyola/Stritch Univ 1993, The Permanente Medical Group, 9201 Big Horn Blvd., Elk Grove 95758 (916) 688-2106 Wong, Patrick, Psychiatry, Texas A & M Univ 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 525-6100 Yenumula, Pandu R., General Surgery/Bariatric Surgery, Guntur Medical College, India 1987, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000

Sierra Sacramento Valley Medicine

AD INDEX Page BloodSource............................................................................27. J & L Teamworks.....................................................................23 Marsh.......................................................................................11 Moss Adams...................................................Inside Back Cover NORCAL Mutual Insurance Company.........Outside Back Cover Serotonin Surge............................................. Inside Front Cover Sutter Health ............................................................................7 The Doctors Center...................................................................2 Tracy Zweig Associates...........................................................13 Walk With a Doc.............................................Inside Back Cover

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Office Space Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494. Share Office: Surgeon looking for another doctor or medical professional to share a brand new office on Scripps Drive, Sacramento. (916) 924-1400; (916) 718-8882. Office Space to Share: 7600 Hospital Dr. next to Methodist Hosp. of Sacramento. 2400sqft, 6 exam/procedure rooms. Ideal for FP or OB/GYN. Contact K.A. Overton MD by email kaomdinc@netzero.net or (916) 681-4434.

PHYSICIANS FOR JUDICIAL REVIEW COMMITTEES The Institute for Medical Quality (IMQ) is seeking primary care physicians, board certified in either Family Practice or Internal Medicine, to serve on Judicial Review Committees (JRC) for the California Department of Corrections and Rehabilitation (CDCR). These review committees hear evidence regarding the quality of care provided by a CDCR physician. Interested physicians must be available to serve for 5 consecutive days, once or twice per year. Hearings will be scheduled in various geographic locations in California, most probably in Sacramento, Los Angeles, and San Diego. IMQ physicians credentialed to serve on JRC panels will be employed as Special Consultants to the State, and will be afforded civil liability protection to the same extent as any Special Consultant. Physicians will be paid on an hourly basis and reimbursed travel expenses. Please contact Leslie Anne Iacopi (liacopi@imq.org) if interested.

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Office Supplies/Equipment-Staples, Inc. To access the members only discount link visit: Save up to 80% www.cmanet.org/membership-benefits Reimbursement Helpline Contact CMA at 888.401.5911 or email Assistance with contracting or reimbursement economicservices@cmanet.org Security Prescriptions Products

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March/April 2013

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more information or to register, visit www.cmanet.org/events or call CMA’s Member Help Center at (800) 786-4262. March 6: Fraud and Abuse: Dangers and Defenses 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will discuss the importance of documentation, suggestions for implementing internal controls, and increasing preventive measures to protect your practice from fraud or abuse. March 7: Essentials for ICD-10-CM: Part 1 7:45 - 8:45a.m. or 12:15 - 1:15 p.m. Continued on March 14 and 21. This three-part series gives your staff a high-level overview and fundamental knowledge of ICD-10 and how it will affect each business area of your practice. March 13: Utilizing the New State Disability Insurance (SDI) Online System 12:15 - 1:15 p.m. Learn how to create an SDI online physician’s account and how to complete the new online doctor’s certificate. March 14: Essentials for ICD-10-CM: Part 2. 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued from March 7 and ends March 21. See description above. March 20: EHR Selection – Top 10 Tips for Success 12:15 – 1:15 p.m. Learn top 10 tips for selecting and implementing HER and determine the best EHR for your practice. March 21: Essentials for ICD-10-CM: Part 3. 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued from March 7 and 14. See description above. March 27: Successful Medi-Cal Provider Enrollment for Physician Providers. 12:15 – 1:15 p.m. Physicians must reenroll in Medi-Cal as part of the ACA. Learn program requirements, how to avoid common mistakes, and how to re-enroll.

April 3: Strategic Planning From Vision to Action - A SelfGuided Process 12:15 – 1:15 p.m. Learn how simplified strategic planning and personal coaching can get you, your practice or your organization where you want to go. April 10: Preparing for EHR Implementation and Conversion 12:15 – 1:15 p.m. Learn common pitfalls for EHR implementation and what you should insist your vendor provide, such as project plans and time-lines, Learn how to set up files such as order sets and pick lists. April 17: Valuing, Selling, Buying or Transitioning a Practice 12:15 – 1:15 p.m. Considering retirement? Selling or wanting to buy a practice? This webinar will discuss options, transition planning, as well as the latest information on practice valuation methodology. April 24: California’s Health Benefit Exchange: How it Will Impact Your Practice and Change Commercial Insurance. 12:15 – 1:45 p.m. Learn about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of contracting to provide services to exchange enrollees. May 1: The Power of the Pen – The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, understand the physician’s role in prescribing/ordering/referring, and increase awareness of fraud and abuse in prescribing and referring. May 8: Time Management – How to Quickly Make Decisions on What Matters Most. 12:15-1:15pm. This interactive webinar will provide live one-on-one coaching to demonstrate techniques for finding solutions and acting on them.

Physician members of Sierra Sacramento Valley Medical Society and the California Medical Association may register for webinars at no cost. Call CMA’s Member Help Center at (800) 786-4262 to register or for more information.

When change moves you in a new direction, choose the right navigator. In health care, success requires diligence and foresight—two qualities that will prove important in the days to come. As reforms take effect over the next decade, will your organization be ready?

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Walk With A Doc is a FREE walking program for anyone who is interested in taking steps to improve their heart health. Each walk is hosted by a friendly local physician. In addition to the numerous health benefits you’ll enjoy just by walking, you’ll also get the chance to talk with the doc while you walk.

Saturday, March 16, 2013 LOCATION: Phoenix Park 9050 Sunset Avenue, Fair Oaks

Saturday, April 20, 2013

Walking for as little as 30 minutes a day can reduce your risk of coronary heart disease, improve your blood pressure and blood sugar levels, elevate your mood, and reduce your risk of osteoporosis, cancer and diabetes. Sponsored by:

LOCATION: North Natomas Regional Park Natomas Blvd and New Market WHO CAN ATTEND: ANYONE. Bring a friend! Registration starts at 8:15 a.m. Walk starts at 8:45 a.m. Keep up with our walk calendar at http://www.ssvms.org/Events.aspx

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