Sierra Sacramento Valley
MEDICINE Serving the counties of El Dorado, Sacramento and Yolo
September/October 2013
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Daniel McCrimons, M.D. Hill Physicians provider since 1993. Uses Ascender preventive care reminders, RelayHealth online communication tools, Hill inSite to review eClaims and eligibility and Hill EHR for a comprehensive solution to patient care, practice management and ePrescribing.
Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com
Hill Physicians’ 3,800 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.
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Medicine 3
PRESIDENT’S MESSAGE The Makings of a Great Physician, Then and Now
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Herd Medicine?
John Loofbourow, MD
David Herbert, MD
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The Waves of the Heart A Brief History of Electrocardiography
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EDITOR’S MESSAGE Technology to Save Us From Technology
Kent Perryman, PhD
Nathan Hitzeman, MD
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2013 Education Series
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e-Letter to SSV Medicine
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The View in Bhutan
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ICU Passing
George Meyer, MD
Duncan Johnston, MD
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Call for Awards Nominations
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My Dongle is a Tinké
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Bob LaPerriere, MD
A Posit on Complementary and Alternative Medicine
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My iPhone has a Pigtail for Fitness Data
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IN MEMORIAM Herbert Bauer, MD
Sandra Hand, MD
Captane P. Thomson, MD
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Local Heroes Change Lives! Thank You to Our SPIRIT Volunteers
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Board Briefs
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Meet the Applicants
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Endowment Fund Donors
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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. 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 This issue’s cover image was provided by Sacramento otolaryngologist Dr. David A. Evans, devans@sacent.com. “This image explores the dual themes of this issue: technology and the uncertain future of our medical system under Obamacare. Created during the Endeavor farewell flyover on September 21, 2012, the image highlights the dichotomy between the Old West and the cutting edge technology of the Space Shuttle Program. Further, it reminds us that government programs face an uncertain future: that which is revolutionary today may become a museum curiosity tomorrow.”
September/October 2013
Volume 64/Number 5 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org
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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 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 Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD Boone Seto, MD
District 1 Reinhart Hilzinger, MD District 2 Richard Pan, MD, Assemblyman District 3 Ruenell Adams, MD District 4 Russell Jacoby, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large Jason Bynum, MD John Belko, MD Jeffrey Cragun, MD Alan Ertle, MD Benjamin Franc, MD Maynard Johnston, MD Olivia Kasirye, MD Don Wreden, MD Vacant Vacant Vacant
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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
Richard Thorp, MD
Editorial Committee Nate Hitzeman, MD, Editor/Chair George Meyer, MD John Belko, MD John Ostrich, MD Sean Deane, MD Gerald Rogan, MD Ann Gerhardt, MD Chris Swanson, MD Sandra Hand, MD Lee Welter, MD Albert Kahane, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Adam Dougherty, MS IV John McCarthy, MD Executive Director Managing Editor Webmaster Graphic Design
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.
Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly
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President’s Message
The Makings of a Great Physician, Then and Now By David Herbert, MD OUR SOCIETY’S EXPECTATIONS for what it takes to be a great physician are in flux. Not so long ago, clinical acumen was the key, and those with it were forgiven certain deficits in interpersonal skills (the misanthropic Dr. House comes to mind, although he was several decades past this era). Patients eventually came to value bedside manner (Drs. Ben Casey, Doogie Howser). Courses to teach physicians to better relate to patients proliferated, and patient satisfaction metrics became commonplace: Yelp and Angie’s List sell this to the public, and most health care systems have their own internal measures. And for many of us, it seemed that as long as we were fairly bright and made our patients reasonably happy, our future in medicine was assured. But the goal posts kept moving, and soon it was important to also be a collaborative member of the health care team. This involved everything from soliciting input from non-physicians rather than just deciding on the best way to do things, to creating a culture of safety where others feel safe when they question our decisions, and even not throwing instruments in the operating room. Just as we were getting used to the idea that our pedestal had been shortened somewhat, and perhaps broadened to allow others to join us upon it, it was pointed out that in much of medicine there are evidence-based best practices, and we were not always delivering this level of care to our patients. So best-
practice pathways appeared along with their associated metrics (e.g. HEDIS), often tied to compensation (Medicare). None of this fundamentally addressed the world-leading cost of American medicine with its anything-but-world-leading results, and we are now entering an era where it appears that the government and insurers are poised to say “no more.” The inevitable result will be increasing pressure on physicians with more expensive practice habits than others, perhaps in the form of intensified economic credentialing and/or “1-800-Dial-a-Nurse” gatekeepers. So the modern great physician needs to have outstanding diagnostic and therapeutic skills, wonderful bedside manner, exceptional leadership and listening abilities, a keen interest in and adherence to practice guidelines, and be able to do all of this all at less cost than before. I certainly want and expect my physician to personify all of the above! But most of us fall somewhat short of perfection. How can we move towards this ideal? What systems will be available to back us up when we don’t quite make it? The answers to these questions will form a big part of what the practice of medicine will look like in the near future. And no, I don’t have the answers, but I am anxious to participate in this dialog as part of organized medicine. As I mentioned in the last issue, these are indeed “interesting times” for medicine – perhaps too interesting. davidherbert166@gmail.com
September/October 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.
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EDITOR’s Message
Technology to Save Us From Technology By Nathan Hitzeman, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
I REMEMBER RIDING MY BIKE to school every day in the 1970s and 80s. We had daily physical education at school. A paper route was my first job. I visited my grandparents in Indiana in the summers and enjoyed gardening, felling trees, and harvesting the fields. I remember the first TV remote control which actually had a cord, and Pong had just made its debut as the first video game. I was happy enough with a low technology life and somehow survived without Google, Facebook, or an iPhone app that puts different mustaches on my face while doing FaceTime (GEICO Brostache). The rise of technology and its conveniences has made us unhealthy. Like zombies, we walk (and sometimes drive) the world in a trance with our smartphones. It’s too late to roll back the technology, to wrench away Yelp, or to not take the phone to the grocery store if I need to text my wife if it’s ok to buy medium or firm Tofu in case the extra firm type is out. That ship has sailed. But perhaps we can find a way for technology to make us healthier and not sicker. There is hope. In this issue, we learn about devices called “dongles” that attach to our smartphones and monitor our health. Indeed, just being aware of how much we move or what we eat is a great start. I’ve had patients surprise me with recounts of how they track their steps with their phones, or keep a dietary log with a program like iLose. A flurry of apps is emerging to allow one to monitor blood sugars, asthma, blood pressure, anticoagulation, or to track ovulation. An app exists to enable a smartphone to do ultrasonography (Mobisante). Cardiologist Eric Topol from Scripps recently made headlines
by diagnosing an MI on a plane with his smartphone acting as an EKG (AliveCor). It’s amazing how much smaller this device is from the first EKG machines discussed by Dr. Kent Perryman in this issue. Healthy technology need not only take the form of apps. A recent May 20th New Yorker article extolled the health benefits of having a “walking desk” where a treadmill can be substituted for your desk chair. The AMA announced on June 18th that “prolonged sitting” is a health risk and that employers should provide alternatives to sitting. Still, I worry that today’s children may not find the right balance of technology. The American Academy of Pediatrics recommends less than two hours of screen time a day. That’s hard to police when the screen travels with you. An article in the June 15th Family Practice News stated that 11 percent of Korean children are addicted to smartphones and show psychopathologic behavior. Instead of full playgrounds at recess, kids are clustered on bleachers looking at their smartphones! Like unhealthy food, unhealthy technology just seems so much more appealing to some. As a testament to what we’ve become, there’s an app that simulates the sounds of work (keyboard clicks, crumpling paper) so that you can nod off at your desk while your cubicle neighbor still thinks you are working (iNap@ Work). What’s your experience with technology and health? Feel free to share with us your stories or pictures of your dongles (tasteful pics only please, unless you are running for mayor)! hitzemn@sutterhealth.org
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e.Letter to SSV Medicine Prescribing Doesn’t Kill Patients: Addiction Does!
In our May/June issue of the SSVMS magazine, Dr. Bruce Barnett confuses prescribing narcotics with the problem of overtaking them. He forgets that it is addiction that kills people, not doctors. He calls the people who come to doctors with pain “actors,” not patients. Actors go to directors, patients go to doctors. There is, I agree, a problem with doctors, but it is a problem Dr. Barnett also seems to suffer from: the failure to think about making a proper diagnosis. The diagnosis is not thespian; it is addiction or physical dependence (without addiction). Much of what this article seems to address is the problem of people already physically dependent in the context of pain management. His answer is the old punitive and ineffective approach of “denying” patients (aka actors) their “favored drugs.” Where do physicallydependent patients go when doctors refuse to treat, and neglect to diagnose and refer? They may go to other doctors or ERs, but eventually many go to friends or acquaintances who are connected to the dealers of heroin who also “market” pills (Vicodin, Norco, Opana, etc.). The cartels know how to get pills, and it is not from doctors. But all this patient stuff is just the background for the real agenda: the renewal of the war on physicians prescribing opiates. We are told in the opening paragraph that the offending doctor who does dare to prescribe opiates risks “suspension and prison sentences.” This has been going on for the whole 100 years of the failed war on drugs, aka: the war on addicted patients and their doctors. The complete failure of law enforcement approaches to opiate addiction, which has enriched the drug cartels beyond description (trillions in profits every year), has made it necessary to find a diversionary target:
physicians. You see, we are easy prey compared to the undefeatable cartels. Dr. Barnett never mentions the word “treatment” for addiction/dependence. But people working in the criminal justice system often don’t “believe” in treatment, in spite of the overwhelming real science supporting its efficacy. They believe in punishment, in spite of the total lack of evidence it does anything, except worsen addiction. Methadone is the most effective treatment for this illness that we have, but treatment efficacy doesn’t save methadone from negative distortions, as we see. While prescribing narcotics doesn’t kill people, not prescribing narcotics does kill people. We have had 35 years of excellent care for opiate addicts in the Sacramento County Jail, until two years ago when a new medical director decided to force all patients on methadone maintenance to undergo an acute “cold turkey” withdrawal in jail, rather than allowing a humane 21-day methadone withdrawal. This is justified by one of the most perverse delusions in modern medicine: the idea that opiate withdrawal is a “flu-like syndrome.” Acute opiate withdrawal produces seizurelike activity in the locus ceruleus with disordered projections to frontal lobes causing massive anxiety and compromised judgment. At the same time, systemic muscular tremulousness produces profound physical discomfort. Calling this the flu is both cynical and ignorant. Many jails inflict this life-threatening illness on both methadone patients and those in acute heroin or pill withdrawal. One patient at age 43, with no prior cardiac history, had acute myocardial ischemia requiring admission to a local hospital as a consequence. We have this documented, as well as the suffering of many other patients undergoing
September/October 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.
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this abusive “care.” Our jail has had a history of suicides and deaths caused by untreated opiate addiction. All appeals to medical science and conscience have, to date, failed. The jail is breaking the law by denying methadone withdrawal, as County Health Officer Dr. Glennah Trochet pointed out to the jail medical director. In a just system, they should be under threat of “suspensions and prison sentences.” We have gone through a humanizing period in the past 15 years, thanks to many courageous doctors fighting for their patients against the cruelty of “denying.” Locally, we
SSVMS Alliance Holiday Sharing Card Summer is almost over and the holidays will be just around the corner. Be on the watch for the SSVMS Alliance Annual Holiday Sharing Card letter. Your dedicated support has enhanced Sierra Sacramento Valley health projects and the next generation of medical professionals. The 2012 Holiday Sharing Card raised $15,645 for the Alliance’s Community Endowment Fund and the SSVMS William E. Dochterman Medical School Scholarship Fund. Please be generous and give. Thank you! Gabby Neubuerger and Paula Cameto are Co-Chairs. paulacameto@comcast.net
are indebted to the great Sacramento pain physician, Dr. Harvey Rose, who suffered the threat of “suspension and prison sentences” to treat his patients. He fathered The California Intractable Pain Treatment Act, which protects physicians treating pain from “suspension and prison sentences.” Harvey would be turning over in his grave to hear that pain medications do not improve function and that only sickle cell disease benefits from opiates!!! Our magazine published my article, “Government Terrorism Against Physicians” (May/June 2003), a description of one particular horrific law enforcement raid on a pain management doctor. We were able to get legislation passed here in California to at least protect patients from forced loss of care if their prescribing physician was subject to “suspension.” So, for self-protection, as well as good medical care, doctors need to discuss both addiction and physiologic dependence with their patients. A major new NIDA initiative calls for doctors to learn SBIRT: Screening, Brief Intervention, Referral, and Treatment. If they do not, we know one doctor who seems unlikely to be on their side in court. −John McCarthy, MD jackmac@surewest.net
ICU Passing By Duncan Johnston, MD For you my friend, the world Or any bit of comfort We can find In these concrete walls What else could we give you? Despite our oaths and good intentions We’ve done nothing but harm Though we’ve all tried our best
Bright minds and long hours Have succeeded only In leaving your veins in tatters And breaking what little peace was offered So now our act of beneficence: If we haven’t followed The first tenet of Hippocrates, We try to make good on the second
Lines removed Limbs unbound Drips titrated PRNs ordered and ready Small comforts; a trifle More important for us To know we gave you something Even if not the world johnston.duncan@gmail.com
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My Dongle is a Tinké By Bob LaPerriere, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
THIS IS THE FIRST OF A SERIES of reviews and discussions of computer and iOS (iPhone/iPad) software, hardware and related items. Dongle (per pcmag.com): Originally slang for a plug-in module to copy protect software, the term is used for any small module that plugs in and sticks out of a socket; for example, USB flash memory drives and other USB devices. My Tinké dongle allows me to use the Tinké (by Zensorium, a Singapore-based startup) app for my iPhone. But it is also a piece of hardware that measures respiratory rate, pulse, heart rate variability and blood oxygen using optical sensing technology, and it plugs into my iPhone. (The current connector for the Tinké is the 30-pin connector, so it requires an adapter for the iPhone 5 and new iPad.) My Tinké dongle produces two scores: the Vita Index, which measures the cardiorespiratory system, and the Zen Index, which quantifies stress levels. The Zen infers stress levels on the basis of heart rate fluctuations. It has programmed breathing exercises to help decrease stress. Use is fairly simple, but proper pressure on the sensor is critical. A recent software upgrade using a waveform makes it much easier to control the pressure of your thumb, though some people still seem to have trouble establishing the proper pressure. The sensor also can be affected by ambient light. Though this is a very attractive “dongle” (www.zensorium.com/tinke) that appears to give fairly accurate readings once the user becomes comfortable with its use, the $119 cost may be high for most people, as you can purchase a pulse oximeter for less than $50. However, the integration with the iPhone and its app, and its innovative way to aid in relaxation, does make this dongle fun and easy to use. I confess that I’ve become a bit “addicted” to my dongle, and
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often strive to improve my Zen score. I can also share my Tinké dongle data with others through social media links with the “Tinké user population.” I proudly display my dongle data with nifty graphs. Trying to understand my Tinké better, I have looked for technical information on their website, such as how the respiratory rate is determined and a clarification of what they call “heart rate variability.” When questioned regarding this, their email stated that they measure the respiratory rate by determining all the parameters based on the photoplethysmograph waveform, using various algorithms to clean the signals and assess the respiratory rate. The heart rate variability is the rhythm, and they relate that to the level of relaxation. The website does state: “Tinké is NOT a medical device. Tinké
and its associated applications should not be used to diagnose, treat, or prevent any disease or medical condition. Always seek the advice of a qualified medical professional.”
A Bluetooth dongle – the Fitbit One The Fitbit One could be considered a wireless dongle. I recently purchased it ($99.99) and so far am impressed. It is an activity tracker similar to the Jawbone Up ($129.99), but is a small clip-on unit rather than a wristband (though Fitbit has also just released a wristband model). The wristband type does not seem to work as well when using a treadmill, likely due to the relative immobility of arms as compared to arm movement when walking. (See article by Sandra Hand, MD, who evaluates the Jawbone.) The Fitbit One measures steps taken, floors climbed (through an altimeter) and converts that data into miles walked and calories burned. It also has the ability to allow the user to input and track calories and water intake, and will determine a weight loss program based on user input. It syncs efficiently and wirelessly by Bluetooth with the iPhone or iPad, and also with a computer through its website, which provides more information than the app, and will email a weekly summary. In addition, it will monitor sleep patterns through the use of a wristband which the Fitbit fits cozily into at bedtime. I have found that this kind of feedback does stimulate me to increase my activity and to watch my intake more closely. The Fitbit One in its wrist strap can also wake you with a vibrating alarm. It will show you when the battery is running low, and is charged easily by removing it from its silicone clip and inserting it into the charger cable which is powered by USB. In my experience so far, it does not need to be charged more frequently than weekly, and the silicone holder with clip is an extremely secure unit. I have not evaluated the new wrist model (Fitbit Flex), but the advantage of that unit would be the lack of needing to switch it from various clothing items throughout the day − more of a problem for a retiree in the summer than someone wearing the same set of clothes
all day − and the website states it can be worn in the shower. It can also be worn swimming and is water resistant to 10 meters, though it is not designed to accurately track the distance traveled in water. As the Fitbit Flex has just been released, I note that some dealers are selling it at significantly above the retail price, but it seems to be readily available online for the actual retail price of $99.95 ($30 less than the Jawbone UP). Another tempting item to add to my wish list.
Other dongle stories ipega 0.9” LCD Digital Alcohol Tester for iPhone/iPad/iPod − I purchased this from Widgets N Things with a Living Social offer for $29.95. Lesson learned: It is best purchased through Amazon.com as they have this item for $17.99 or less. The only use of the iPhone for this dongle is to get power. Reviews on this item have not been good, and I suspect that it
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measures more alcohol on the breath rather than blood level.
A few of my favorite apps (iPhone and iPad)
Some commercial weight-loss companies say they are struggling to recruit and retain members because it is hard to convince dieters to pay for meetings and subscriptions when there is an abundance of free smartphone apps and gadgets to help track calories and exercise.
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These apps may also be available for other smart phone platforms, but as I have been a dedicated Mac user for over 25 years, I will confine my reviews to the iPhone/iPad Mac versions. Dropbox – One of the earlier “clouds” to become widely available, it provides storage in their cloud (giant servers) which you can access through an application for your computer or through an app for the iPhone/iPad. There is an incredible number of apps that interface with Dropbox. Cloud use enables you to access your data no matter where you are. On computers, a folder with all your data is also kept on the hard drive, so if you do not have an internet connection, you can still access it. The data will sync with the cloud whenever there is an internet connection. You can get a free account with two gigabytes of storage to try it out. It can also be used to share files too large to email. Documents – Documents by Readdle is now my favorite document manager. It is fast, contains a media player and is very intuitive. It is free, and recently the iPhone version was released (iPad was first). It stores and allows you to view files in all common formats, and also allows you to sync contents via iCloud. It has a built-in browser and will handle music, photographs, videos, ebooks, PDFs and more. It also can interface with other clouds including Dropbox. It has a very clean interface using folders. Through its browser you can download and save PDFs from websites. PDF Printer – This is a neat app that will accept a wide variety of data and convert it into a PDF. It has the ability to save it to Dropbox, or to open the PDF in another program such as Documents. Using the copy command, such as in an email, PDF Printer will take the data in the clipboard and produce a PDF. The PDF can then be saved in the program, put in Dropbox, or opened in another app such as Documents. It also works great with email attachments.
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Through its browser, you can also download and save PDFs from websites. Google Search – This newly-upgraded app for iPhone/iPad uses voice control to search the web, and it seems to be incredibly accurate and fast, like one to two seconds to bring up your search results. I love it. It seems to even be faster and easier to use than Siri. Please feel free to email me with any questions you have, or to share your experiences with the “dongle world” and your favorite apps. ssvmsmus@winfirst.com
My iPhone has a Pigtail for Fitness Data By Sandra Hand, MD I AM USING SEVERAL FITNESS applications downloaded onto my 4G iPhone to assist in my personal remodeling program. The UP by Jawbone uses a narrow wristband which comes in a number of attractive colors (mine is black to match my phone). It contains multiple components jammed into an unbelievably small, waterproof space which measure activity and download information about exercise in the form of steps. You can enter workouts in preset categories. It also measures sleep, based on movement. The wristband costs a little over $100 and downloads information through the microphone port on the top of the phone, which then appears to have sprouted a cute pigtail. It charges through a USB port and runs about 10 days on a charge. It is able to provide alerts for prolonged inactivity to get you up and moving. It also functions as an alarm to awaken you after power naps, which it bases on your known sleep patterns, and in the morning at a time you pre-specify. You can link up with a teammate who is wearing their own UP wristband and view their data. I have discovered that it has several drawbacks to accurate data collection. If you walk, as I do, with a hand in your pocket or carry items such as a purse with that hand, it does not record. If you are marching around a big box store with your hands on a shopping cart, it does not record those steps. If you hold onto the rails of the treadmill, it won’t record that workout. I am often wide awake at night while the armband cheerfully informs me that, at that
precise time, I have been enjoying light to deep sleep. I have very quiet insomnia, apparently. It only records wakefulness when I actually get out of bed. As well as connecting to other UP wristbands (by permission only), it connects to other apps such as Calorie King, to record nutritional information. You either scan in by barcode or enter on the keyboard. It then calculates various nutritional components from an extensive database which expands as you add data to it, and aggregates them daily. UP has seamlessly upgraded the software twice in the few months I have owned it, including linking it to another remote device we acquired called Withings. This is a scale that communicates via Wifi to the phone your weight, BMI, fat content (not very consistent and an imperfection in this app), and heart rate. Withings can also be downloaded as a separate app and does a nice job of graphing, aggregating and tracking these parameters. It has a blood pressure meter available separately or can integrate manual entries of this data for tracking. I think UP has a way to go to be really sensitive to activity, and I do not recommend it in its current state as an activity tracker for everyone. It has many positive features in the food category, however. My husband likes his and uses it extensively. I will be interested in what anyone has to say about the Fitbit, which is a competing unit. smh9142@comcast.net
September/October 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.
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Endowment Fund Donors The SSVMS Alliance is pleased and grateful to acknowledge the following donors to our Community Endowment Fund Spring 2013 Fundraiser. Generous donations of $8,515 will help to fund our grants in future years. Gold Level ($500-$999) – John Ballenger, MD; Dr. and Mrs. Franklin Chinn, Sr.; Dr. and Mrs. George Chiu; Jonathan Hartman, MD; Dr. and Mrs. Dennis Marks; Amy Wandel, MD; and Sacramento Cardiovascular Surgeons. Silver Level ($100-$499) – Dr. and Mrs. Franklin “Bud” Banker; Drs. Andrea and John Belko; E. Lawrence Bingham, MD; Marcia Britton-Gray, MD; Mrs. Peggy Brown; Dr. Rebecca Chinn and Mr. Colin Spears; Dr. and Mrs. Jose Cueto; Dr. and Mrs. R.L. Scotte Doggett; Dr. and Mrs. Ray Fitch; Ann Gerhardt, MD; Henry Go, MD; Dr. and Mrs. J. Robert Griffin; Dr. and Mrs. Julian Holt; Dr. and Mrs. Willie Johnson; Richard Johnson, MD; Richard Jones,
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MD; Robert Kahle, MD; Suzanne Kilmer, MD; Dr. and Mrs. Larry Lieb; Dr. and Mrs. John McCarthy; Dr. and Mrs. Robert Meagher; Dr. and Mrs. Col. George Meyer; Milo Nittler, MD; Dr. and Mrs. Steven Orkand; Frank Palumbo, MD; Edward Panacek, MD; Dr. and Mrs. Harold Ray; Dr. and Mrs. Harold Renollet; Dr. and Mrs. Jack Rozance; Patricia Samuelson, MD; Dr. and Mrs. Norman Schwilk, Jr.; Dr. and Mrs. Sidney Scudder; Kuppe Shankar, MD; and Dr. and Mrs. William Vetter. Bronze Level ($50-$99) – Drs. Sallie and Jesse Adams; Drs. Marie and John Babich; Drs. Joi Barrett and Seth Rosenthal; David Dozier, MD; Dr. and Mrs. R. J. Frink; Dr. and Mrs. Forrest Junod; Ms. Dair Rausch; Dr. and Mrs. James Reece, Sr.; Dr. and Mrs. John Reitan; and Peter Wu, MD.
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Herd Medicine? By John Loofbourow, MD “…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” From the American College of Physicians Ethics Manual, 6th Edition.
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.
AFTER 10 DAYS ON THE CAPE at the southwest corner of South Africa, 10 days driving thousands of miles overland on the “wrong” side of the road, and 10 days in Kruger Park at the northeast extreme of the country, I hated to leave. Similarities and contrasts between our two nations is evident everywhere: the clash of humanity with nature, cultural present with past, progress with preservation, power with poverty, national language with dialect; all were apparent, even in the relatively sheltered and civilized “rest camps” of Kruger Park. Of course, I was at Kruger for the wildlife. Perhaps there is nowhere else in the world where an English-speaking stranger can be sheltered at night in “rest camps,” which are luxurious, electric-fenced, two- or five-acre cages, yet be free roaming by day in a different sort of cage − a car − while being ignored by herds of wild animals a few feet away. At the same time, the visitor is relatively sheltered from political and social events. Yet, even the park exists within the margins of history. The newest and largest rest camp is named “Skukuza,” a native term for “broom,” because Kruger swept the native peoples from this 19,633-square-kilometer area, creating a 360x40 km park bordered by rivers and by a similar park in Swaziland to the East. The current president, Jacob Zuma, in contrast to Nelson Mandela, epitomizes racial and tribal values. He declares that South Africa is for all (black) Africans; therefore, the nation’s borders are open to all black Africans, and so
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is the park; poaching has increased, although there are so many herds of elephants they must be thinned and exported to other preserves. The Zuma position on open borders is herd politics. It is disturbing and yet arguably justified to counter wrongs, and has the support of the majority. While it may be very destabilizing, it may open the way to a better future for all. It was imposed by a government with similar turmoil, justification, and objections as our Affordable Health Care Act. The veterinary medical term, “Herd medicine,” when applied to human health care, is disturbing to those who see the ACA in terms of Huxley’s Brave New World, while others find our current “system” antiquated, inefficient, and as unfair as the sweat shops of the Industrial Revolution. I will suggest both views are flawed, and that the individually-focused care and herdfocused care are complementary and necessary in a sustainable national health program. Our
veterinary medical colleagues, for example, use a dual care system. “Herd Medicine” is focused on the greatest benefit to the greatest number of animals, and the economics of health care. “Companion Animal Medicine” is focused on the benefit to individual animals. The table, at left, provides side-by-side comparisons between what I will call Herd-Vet (large population medical care), and Pet-Vet (Companion Animal) medicine. “Pet-vets” practice a type of fee-for-service medical care. The ACA attempts to retain that kind of care, but requires practicing herd medicine, also. These two aspects of national health care need not be mutually exclusive. Indeed, every nation that has an ongoing viable national health program allows or employs a dual system: one focused on large numbers, outcomes, and economics; and the other focused on outcomes and options for individuals. Both rest on ethical and practical considerations which address different aspects of national health care. Where does that leave us in the current medical perfect storm? I confess to optimism. Any objective look at human life on this earth makes clear that over the centuries, people, in general, have lived progressively longer, healthier, more comfortable lives. I expect our nation will develop a uniquely U.S. functional, ethical, and viable system of national health
The lions ponder this bicycle as we ponder Obamacare.
care consistent with both Hippocratic/Oslerian medicine and with the medicine of large numbers, as revealed by the most significant word in the ACA title. That word is Affordable.
Quotes: “Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care...The primary function of regulation in health care... is to constrain decentralized individualized decision making.” From New Rules by Troyen A. Brennan and Donald M. Berwick, 1995, ISBN-10: 0787901490. “MDs do not think of…patients as [a] herd [but] future health care decision-makers will.” From Obama’s Herd Health Program by Heather McCauley, DVM. john@loofbourow.com Large animal medicine focuses on designing a Herd Health Program, where the outcome of an individual case takes a backseat to the cost and benefit for the overall group.
September/October 2013
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The Waves of the Heart A Brief History of Electrocardiography
By Kent Perryman, PhD MEDICAL KNOWLEDGE OF THE heart’s bioelectric activity acquired over the last 150 years has made an enormous diagnostic contribution and saved countless lives. It required decades of research and equipment development to accurately measure and understand how the individual deflections, called waves, in a electrocardiographic tracing, were linked to cardiac function. This brief historical perspective of electrocardiography is meant to emphasize the technological developments in cardiac recording.
Early Attempts to Measure Cardiac Biopotentials
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.
Common knowledge has it that Luigi Galvani, an Italian physician, was responsible for discovering bioelectric potentials in a frog’s muscle – activity he referred to it as “animal electricity.” In 1878, British physiologists John Burden Sanderson and Frederick Page recorded electrical currents from a frog and tortoise heart using a capillary electrometer demonstrating the first Q, R, S and T waves. Later in 1887, another British physiologist, Augustus Desiree Waller, was the first to record electric potentials associated with the beating human heart from the body surface using a capillary electrometer. Waller was also the first investigator to publish a human electrocardiogram at the same time. Waller would frequently demonstrate his dog‘s ECG with the animal’s paws submersed in glass jars of saline used as electrodes. Still later (1891-1895), a Dutch physician, William Einthoven, coined the term “electrocardiogram” for the heart’s bioelectrical wave and published detailed descriptions of the P, Q, R, S and T deflections also using a
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capillary electrometer. Prior to the development of the capillary electrometer, moving-coil type galvanometers were employed to detect and measure action currents from living tissue; however, these instruments were extremely insensitive. The Lippmann capillary electrometer that Waller and Einthoven employed consisted of a capillary tube half-filled with mercury with a small amount of sulfuric acid above the mercury column. Metal wires were inserted into each end of the capillary tube. When a pulse of electricity was conducted through the wires, it would change the surface tension of the mercury moving the column a short distance up the tube. This turned out to be a crude, effective, but rather insensitive method for detecting minor surface deflections associated with abnormal cardiac potentials. It wasn’t until the introduction of the string galvanometer in 1903 by William Einthoven that a reliable and practical method of electrocardiography was made available for the first time. The early string galvonometer consisted
of six feet of a silver-coated quartz filament (wire) that conducted electrical currents. Massive 600-pound, water-cooled electromagnets connected to the subject’s heart were situated on either side of the delicate filament. Potential variations of the heart created magnetic fluctuations that, in turn, displaced the filament in much the same way a beam of electrons is deflected in a cathode ray tube. The filament displacement was optically magnified and projected upon a moving photographic plate. Mechanically tightening or loosening the tension on the filament adjusted the sensitivity of the string galvonometer. Electrodes, at that time, consisted of saline-filled glass jars in which the subject’s hands and feet were immersed. Once commercial versions of the string galvonometer were manufactured by companies such as Siemens and Halske, Fahr-Stoppani and Eldelman, many European physicians got on board for a new medical specialty. Cambridge Instrument Company of London manufactured the first table-mounted version of the string galvonometer in 1911. These devices, although more reliable than their predecessors, were still very temperamental. A compensating box was quite frequently employed by physicians during the recording process to compensate for differences in skin resistance. Most clinicians endured a steep learning curve to familiarize themselves with interpreting the ECG waveforms associated with cardiac abnormalities. Eventually, various waveforms associated with cardiac disorders were published as diagnostic aids. Einthoven went on to win the Nobel Prize in Medicine in 1924 for developing the string galvonometer electrocardiograph.
Vacuum Tube and Digital Technology Contributions It wasn’t until John Ambrose Fleming and Lee De Forest developed the vacuum tube diode and triode in 1906 that the millivolt potentials generated by the cardiac muscle could be electronically amplified and reliably recorded by mirror galvanometers from the abdominal surface. By 1928, the Sanborn Company had
marketed the first really portable ECG machine that weighed under 50 pounds and could be powered from a six-volt automobile battery. With the later German invention of the cathode ray tube incorporated as a display device, the fidelity of ECG recording became even more refined. Pen-writing (direct writing) instruments also provided clinicians with much better fidelity and more reliable paper traces compared with the earlier kymograph smoke drum tracings. The incorporation of the current digital revolution into electrocardiography writeout systems has improved the signal-to-noise ratio of cardiac potentials. Hewlett Packard began marketing digital ECG machines in 2003 employing signal processing chips and specialized software algorithms for feature
September/October 2013
The SSVMS Museum of Medical History has several of the early vacuum tube ECG machines from the 1930s and 1940s in its viewing collection.
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This concoction was eventually marketed as a paste. Modern adhesive disposable electrodes come in sterile packets with snaps requiring very little preparation before recording. The SSVMS Museum of Medical History has several of the early vacuum tube ECG machines from the 1930s and 1940s in its viewing collection. The museum, located at 5380 Elvas Avenue, Sacramento, is free to the public and is open from 9 am to 4 pm MondayFriday, except holidays. kperryman@suddenlink.net extraction of waveforms. Automated ECG interpretation using pattern recognition software and knowledge bases have aided clinicians in the diagnostic identification of cardiac abnormalities. The digital ECG machines are especially beneficial in a health care facility where a trained cardiologist is not available. Telemedicine and emergency mobile medical services have also greatly benefited from diagnostic information these digital devices provide.
Electrode Development The early string galvonometers employed electrodes that consisted of jars of electrolytic (saline) solution that the subject’s hands and feet were immersed in. Strap-on, coated electrodes were introduced in the United States around 1920. These were constructed of either metal foil or copper mesh encased in a flannel cloth that had been saturated with an electrolytic solution. By 1930, a direct-contact, silver plate electrode was introduced by the Cambridge Instrument Company. It was also about this time that the 12-lead precordial suction electrodes were incorporated into general clinical use. In order to lower the natural skin resistance, saline-saturated gauze was wrapped around the extremities under the contact electrodes. With the use of precordial electrocardiography, green soap (potassium oleate and glycerin), water and powdered pumice was rubbed onto the skin’s surface and the electrodes placed into position.
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REFERENCES Burch, GE, De Pasquale, NP. A History of Electrocardiography. Year Book Medical Publishers, Inc. 1964; Chicago. Zywietz, C. A Brief History of Electrocardiography-Progress through Technology. Biosigna Institue for Biosignal Processing and Systems Research. Hannover, Germany. History of the Development of the EKG Machine. http://rmccrory. tripod.com/historyekg.html. Stock, JT. Gabriel Lippmann and the Capillary Electrometer. Bull. Hist. Chem., Vol 29(1), 2004. A Brief History of Electrocardiography. www.sh.lsuhsc.edu/fammed/ outpatientmanual/ekg/ecghist.html. A (not so) Brief History of Electrocardiography. www.ecglibrary.com/ ecghist.html.
September/October 2013
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The View in Bhutan By George Meyer, MD
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.
I HAVE VISITED SEVERAL countries as an internist/gastroenterologist, most recently serving at the Jigme Dorji Wangchuck National Referral Hospital (or to simplify, JDWNRH) National Referral Center in Thimphu, Bhutan. I volunteered with Health Volunteers Overseas (HVO). Bhutan, a small country of about 700,000 people just north of the northeastern-most section of India, is separated from Nepal by Sikkim, a small kingdom that now is part of India. Bhutan was consolidated as a country in 1907 by the first king. The current king, the fifth in the series of the current family, is a young man who took over from his father who abdicated in 2005. In progressive fashion, Jigme Khesar Namgyal Wangchuck then gave up his total power in order to move the country from an absolute monarchy to a democratic constitutional monarchy in 2008. Their elections are scheduled to occur every five years (they just finished their second elections in June/July 2013.) It sounds as if the king still has veto power over much of the laws passed, however. The country is a Buddhist country and, while they have many high Himalayan mountains, mountain climbing seems to be discouraged. The country is also thought to have the happiest people in Asia, and prior king, Jigme Singye Wangchuck, had the distinction of starting the Gross National Happiness movement in the 1970s. (Please see Dr. Scott Sattler’s article on Bhutan in the Sept/Oct 2011 issue of SSV Medicine.) The country is divided into 20 districts, each district having at least one hospital, depending on the number of people living nearby. There are multiple Basic Health Units (BHUs) in a district, staffed by either two or three trained
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personnel who are not doctors. One, called a Health Assistant (HA), is trained at the level of an NP or PA and does much of the health care; if this person is a man, then a woman is also assigned who functions as a nurse midwife. The other member, the Basic Health Worker (BHW), is an outreach person whose job it is to go out to the villages and farms to try to educate the people. There are three referral hospitals: the easternmost one located in Mongar, a central hospital in the south in Gelephu, and the JDWNRH in Thimphu. JDWNRH serves not only to cover referrals from the western part of the country, but also referrals from the other two referral centers. The Royal Institute of Health Sciences
(RIHS) is responsible for the training of most of the non-physician health care personnel of Bhutan. Physician education is in the developing stage in Bhutan. In the past all Bhutanese physicians were trained outside of the country – usually in India, Pakistan, Bangladesh, Thailand, or Sri Lanka. Currently, they have internal medicine subspecialists in GI, cardiology, hematology, and chest diseases. This year for the first time they had nine PGY-1 physicians doing rotations throughout the hospital. There was discussion about starting residency programs this July in IM, surgery, Ob/ Gyn, pediatrics, ophthalmology and, perhaps, anesthesiology. There are plans to start a medical
school in 2015-16; many potential faculty have been studying in other countries for several years. Many diseases we used to see commonly in the U.S. remain common in Bhutan. Tuberculosis is widespread, and it is not uncommon to see patients with TB peritonitis, Pott’s disease or TB abscesses. Hepatitis B is common while hepatitis C is not; however, drug abuse seems to be a growing concern so hepatitis C may become more widespread. Gastric carcinoma (greater than 60 percent of the population seems to have Helicobacter pylori) is common while colon cancer is not. An iron-deficient patient will have an upper GI endoscopy performed first rather than a colonoscopy, which we would do first in the U.S. Typhoid is not rare in the spring and summer months. The diagnosis is often made with a chief complaint of diarrhea and a normal wbc; it is confirmed with a Widal test. Rheumatic heart disease is also widespread with lots of mitral disease and some of the loudest diastolic rumbles I have ever heard. Mushroom poisoning occurs regularly in the Spring and Summer when inexperienced persons cook with wild mushrooms collected in the countryside. The Bhutan medical system is modernizing rapidly. They have excellent ultrasound capabilities (including cardiac), and CT and MRI are available. One MRI case from Bhutan was of better quality than that from the referral hospital in India. They have upper endoscopy and colonoscopy; they received
September/October 2013
At near left is the Tiger’s Nest Monastery near Paro, with prayer flags flying. The flags are inscribed with symbols, invocations, prayers, and mantras which are said to bring happiness, long life and prosperity to the flag planter and those in the vicinity. Photo by George Meyer, MD. Photo at far left is by Peter Oftedahl, MD.
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new scopes and a new digital light source last month. An automated scope cleaner is on order as is a digital receiver. The cardiologist can perform transesophageal ultrasonography. They are progressing rapidly, but still have a long way to go. I was really impressed by the enthusiasm of their medical community and the feeling of social responsibility. I learned more than I taught. geowmeyer1@earthlink.net
Photo from Peter Oftedahl, MD; large Buddha outside Thimphu, Bhutan. L to R: Peter and Elaine Oftedahl, George and Lynn Meyer.
Call for Awards Nominations Nominations are being sought for the Society’s most prestigious awards to be presented to the recipients at the annual meeting in January 2014. The Golden Stethoscope Award, the Society’s highest honor, is awarded to a member who has demonstrated a career oriented to his or her practice, and the care of his or her individual patients in an environment of unselfishness, compassion and empathy. The nominee must be an SSVMS member for at least 15 years. The Medical Honor Award, is given to a member who is currently in practice, or retired, whose high achievement has allowed a contribution of great significance to medicine or community health in the El
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Dorado-Sacramento-Yolo region. The candidate must be an SSVMS member for at least five years. The Medical Community Service Award is presented to a non-physician community member or leader of a community organization in the El Dorado-Sacramento-Yolo region who has made a significant contribution to a medical or public health problem. Please send letters of nomination to SSVMS, c/o Margaret Parsons, MD, Chair, Scholarship and Awards Committee, 5380 Elvas Avenue, #101, Sacramento, CA 95819. For more information, contact Chris Stincelli at (916) 456-2018, cstincelli@ssvms.org. Deadline: November 1, 2013.
A Posit on Complementary and Alternative Medicine “Practices considered complementary and alternative medicine are far more helpful than harmful to our patients.”
Background: According to SSVMS Museum curator Dr. Bob LaPerriere, “One of the major reasons our medical society was founded in 1868 was to protect the Sacramentans from the ‘irregular’ physicians...homeopaths, hydropaths, eclectics, Thomsonians etc. However, back then with the ‘regular’ physician using bleeding, cupping, puking, purging, arsenic, mercury and strychnine, the practitioners of ‘alternative’ medicine were attractive to many...and probably would have been to me had I lived in the 1800s.” Note: Posits are aggressive statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 29/Agree – 23/Disagree. Commentary follows: Dr. Bob LaPerriere’s comment is interesting; however, in my opinion, it is a comment regarding historical data and no longer applicable to the modern practice of medicine. The internet has created a public which has more detailed and exact knowledge than the physicians Dr. LaPerriere refers to in his historical perspective. I regard the practice of medicine as a serious endeavor and, unfortunately, patients with significant problems are attracted to alternative medicine providers based on anecdotal claims which are not based on evidence-based medicine. Every Monday The Sacramento Bee has ads from chiropractors luring patients with thyroid problems and diabetes to attend seminars. The July 14, Sunday Sac Bee, had a full page touting the benefit of “a new technology” for the treatment of disc injury.
This new technology is the use of traction for lumbar spine disc herniation and is not new, nor is it based on any evidence-based data. The only positive aspect is that it includes six to nine weeks of treatment and allows tincture of time to resolve the pain, which would have occurred anyway. It also costs $9,000, which is another reason for it being so effective. Naturopaths encourage the use of herbal medicines for a plethora of symptoms, the majority of which are psychosomatic. The current hype regarding “cleansing” has attracted a large following among those who are unable to accept that our liver, kidneys and GI tract have been providing excellent excretional pathways for at least the past two to four million years. Acupuncture has no Level I evidence to support its use; however, it is hard to argue with the success reported by some patients. It again is minimally effective, other than allowing Mother Nature and tincture of time to work, but not get credit for “healing the problem.” I can understand the public looking for alternatives when inundated with the poor outcomes from some spinal procedures performed by aggressive surgeons who do not encourage weight loss and exercise for the deconditioned, obese patient with low-back pain who wants a “quick fix.” We all have a responsibility to educate our patients when asked about alternative approaches by being honest and using the database in our specialty to share the pros and cons with the patient attracted to the internet ads and “my friend said...” comments. −Michael Klein, Jr., MD I am biased as I come from Seattle, WA. The Naturopathic Medical School there, Bastyr, is an September/October 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. 25
…some CAM will always be shrouded in mystery − but if it has stood the test of time, there is probably merit to it.
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amazing school with a very rigorous program. When I went to medical school at the University of Washington, we had lectures from community Naturopathic Docs (NDs) on specific topics (such as massage, acupuncture, homeopathy, etc.), where they presented evidence and background. I feel that a “properly trained” naturopath or alternative medical practitioner can be of great benefit. −Noel Hastings, MD Alternative medicine to Western medicine will always be a fact of life. I can’t say I’ve seen a lot of people maimed by it, no more than by traditional medicine, at least. I have seen a lot of wallets emptied and some expectations that weren’t met. Obviously, it is hard to quantify and categorize everything that might be therapeutic – and some CAM will always be shrouded in mystery − but if it has stood the test of time, there is probably merit to it. Patients often feel empowered and involved in the care. Perhaps like having an affair, there seems to be some excitement and thrill to it, and unfortunately, a reluctance to share information with one’s wedded physician. Much CAM is based on actual interaction with the patient and their mind-body balance, which Western medicine sucks at. Some of the more fringe stuff I’ve seen: bee sting therapy for MS, eating by blood type, colonics, and special crystals. −Nathan Hitzeman, MD I disagree. But, I also have to say that many mainstream medical practices, such as cholesterol monitoring, [much of] back surgery for pain, coronary artery bypass surgery, etc., are no better than homeopathy, either. −Steven Dorfman, MD While complementary or alternative therapies may be valuable adjuncts to standard of care therapy, often they are used in place of standard of care therapy. The cost of many alternative therapies is exorbitant with no documented research to validate many of the claims made. However, since most are considered “nutritional,” they are not subject to FDA regulation and do not require any validating research. The best use should be in the context of a coordinated team approach to patient care. −Sidney Scudder, MD Sierra Sacramento Valley Medicine
CAM has a vital role where traditional medicine lacks. −Kingshuk Sharma, MD Though not all traditional medicine is harmful, and not all “alternative medicine” is helpful, there are some in each category. Bureaucratic regulation must not be used to limit choice; but patients who are sometimes gullible must seek competent advice. Here are some examples: Until the presence of H. pylori was recognized as a cause of peptic ulcer and treated with antibiotics, drastic surgery was common for severe cases. Toxic mercury and poisonous fluoride are commonly accepted treatments, despite lack of evidence that advantages (none can be demonstrated) outweigh their harm. Sure, we can blame the dentists, but many physicians accept or promote this harm. The toxicity of both mercury and fluoride are well recognized. Many new drugs have been withdrawn after clinical surveillance revealed that their risks outweigh their benefits. Hyperbaric oxygen therapy is under recognized and underutilized, despite its cost-effective benefits in many instances. −Lee Welter, MD Quite simply, we don’t know the answer to this question without subjecting the treatments to prospective randomized controlled trials. Some alternative treatments have turned out to have merit. Others have turned out to be worthless, while some have proven dangerous. Let every therapy, drug, procedure and alternative treatment be subject to the same objective evaluation of efficacy – the prospective randomized controlled trial. Let the bright light of objective evaluation illuminate this issue. Those treatments, whether conventional or alternative, that can prove efficacy will survive while those that can’t should be relegated to the dust bin of history. I, for one, don’t want my tax dollars supporting any treatment that has not proven its value in prospective randomized controlled trials. −Michael Patmas, MD Where is your evidence? −Mohammad Kabbesh, MD Once again SSVMS simplifies a complex subject to an absurdity. SOME of these practices are harmless, some are not, and some are very harmful, either directly or by diverting care from truly helpful therapy. “Mainstream” medicine
is also harmful if abused, or improperly understood. It can also be lifesaving. Case in point, current cancer treatments are clearly harmful to cancer cells and patients alike. Yet, in many cases lifesaving. Coffee enemas cause only minimal harm, yet are worthless as far as curing cancer. Currently published on the web – To cure all cancers, a “juicing protocol with the right type of juicer and using coffee enemas to detox the liver could be added with laetrile use [a neutroceutical from stone fruits and almonds].” It’s hard to go wrong with that healthy combination. On the other hand, these ineffective suggestions are a lot cheaper for society than providing effective treatment or extending the lives of people afflicted with cancer. −Gerald Upcraft, MD I think some/a lot are helpful. However, I had to pick “all or none.” I think more are harmful, either directly by causing physical or mental harm, or indirectly by doing “nothing” and thus, delaying proper care or raising hopes that are never realized. A difficult question very simply answered. −Maynard Johnston, MD I agree and would add that a physician should consider discussing alternative and complementary treatments with his/ her patients. I would also propose that each physician be prepared to discuss alternate medicine treatments with his/her patient if the patient brings in information regarding this modality. −Amy Wandel, MD Depends on whether they are complementary to Western Medical Treatment or an alternative to. Diet, meditation, yoga – probably helpful…herbs, alternative healing approaches – probably harmful, particularly if they are an alternative to Western Medical Treatment. − Robert Kahle, MD I disagree. Though some alternative practices turn out to be correct after the fact, which does not mean that all alternative practices in general are “far more helpful.” −Pankaj Patel, MD As written, this implies the inclusion of practitioners of alternative medicine who are not licensed. That is why I disagree. −Gregory Joy, MD There is certainly a place for alternative therapies as a part of a “traditional” treatment
plan, and even robust academic investigations on these therapies have shown tangible benefits. However, the problem arises when patients make these therapies their SOLE regimen while forsaking proven pharmacologic/ surgical remedies. When patients believe that herbal concoctions, meditation, and even soul transplants (yes, this scheme actually exists) by themselves are the pathway to recovery, irreparable harm can result. −Mukesh Sahu, MD I disagree with this statement on the basis of its generality. There are numerous “alternative” practices that are clearly harmful, such as avoiding potentially curative surgery for early-stage resectable pancreatic cancer in favor of meditation and veganism, or embracing hydrotherapy in favor of standard treatments for diabetes. However, there are many therapies that have not been proven through large multicenter, double-blinded, randomized controlled trials that may be nevertheless, far more effective and (probably?) safer than those therapies that have undergone a thorough, albeit, extremely expensive scientific vetting. I have heard good things about acupuncture in the treatment of pain and stress, veganism as a primary approach to deal with a large number of diseases, yoga and meditation in the management of stress, depression, and anxiety, and essential oils and aromatherapy in the management of certain ailments. My favorite example is a recent and personal one: Twice now, my wife’s blend of 100 percent natural organic herbal essential oils applied to chest and under the tongue have worked much better at relieving severe paroxysmal heartburn than any overthe-counter regimen I have tried (bismuth, antacids, omeprazole, ranitidine). But, that does not mean I should ignore the other standard management: Avoid the triggers, and consider an EGD or upper GI series under the hands of a fellow professional to look for treatable reflux, hiatal hernia, dysmotility, or Barret esophagus or other worrisome changes. Workin’ on it. − Don Udall, MD I believe that alternative medicine is useful when substantiated by a study that establishes efficacy. −Emil Tanghetti, MD September/October 2013
There are numerous “alternative” practices that are clearly harmful…
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In Memoriam
Herbert Bauer, MD 1910–2013
Herbert Bauer, MD
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HERBERT BAUER DIED AT HOME on May 7, 2013, at the age of 103. He was a fearless health care pioneer and a lifelong committed liberal and promoter of peace. Born in Vienna, Austria, on January 21, 1910, he was home-schooled by his mother to age 10. He caught up quickly when he entered school and was soon teaching classical Latin and Greek to help support his family and his own education in college and medical school. He was a resident in Internal Medicine when the Nazis took over Austria and targeted him as a liberal student leader. He left through the back window as the Nazis knocked on his front door. He traveled to Milan, Italy, where he had an aunt, and then to London where he tutored Hanna Goldsmith, who would become his future wife. In 1939, he and Hanna arrived in California. While Hanna studied psychology at UC Berkeley, Herbert completed a one-year internship at French Hospital in San Francisco. Following completion of the training, he accepted a position at San Luis Obispo County Hospital where he was the only physician to care for indigent patients throughout WWII. He and Hanna were married at the courthouse in Santa Barbara. After the war, he entered the first class at the UC Berkeley School of Public Health. Following graduation, he became the Tuberculosis Control Officer in Sacramento County. In 1952, he accepted the position as the first full-time Public Health Officer in Yolo County. Always on the cutting edge, he personally vaccinated more people against polio than anyone in the state. His Well Baby Clinics were known far and wide for their “good sense” parenting advice. He established the first family planning clinics to
Sierra Sacramento Valley Medicine
help people have as many – or as few – children as they wanted. In routine health screenings, he would ask if patients had ever considered killing themselves, and based on the replies, he began volunteer suicide prevention groups. He advocated for the passage in California of the Short Doyle Legislation to establish community mental health programs, and once enacted, set about to bring those services to the Yolo community by gaining the support of the Board of Supervisors in that trail-blazing endeavor. After 20 years serving as Yolo County’s Public Health Officer, he retired from that position and went on to complete a residency in child psychiatry at the UC Davis Medical Center. He practiced for the next 20 years as a child psychiatrist and as Professor of Preventive Medicine. He then studied at both Pacific School of Religion in Berkeley and Oxford, and obtained a certificate in Bioethics. He was one of the few physicians who provided treatment services to Medi-Cal recipients, especially children, and would see foster children as far away as the foothills. He also served many uninsured patients who otherwise would have had difficulty accessing care. He was a member of the clinical faculty in the Department of Community Health at the UC Davis School of Medicine where he participated in an active teaching format that was very well-received by all of his students. He also bridged the medical-legal divide by teaching at the UC Davis School of Law. One of his great gifts was succinctness, and his favorite poetic style was the limerick. He complained that many speakers lacked “terminal facility,” the ability to make their point and stop. Herbert was an active member of a wide array of health, justice, and peace organizations
including the Davis Unitarian Church of which he was a founding member, the Davis Democratic Club, the United Nations Chapter in Davis, the Yolo County Family Services Agency, the Physicians for Social Responsibility, the Chowder and Marching Society, and he was a charter member of the Yolo County Mental Health Association. He was also a founding member and Past President of the Yolo County Medical Society. Both Herbert and Hanna were named Covell Citizens of the Year in Davis in 1976. In 1996, the California Medical Association awarded Herbert the Plessner Memorial Award as “the physician who best exemplifies the practice and ethics of a rural practitioner.” In 2000, the Sierra Sacramento Valley Medical Society awarded him the Golden Stethoscope, recognizing him as a “mentor, advisor, teacher, resource and friend.” In 2006, the Yolo County Board of Supervisors named the new Health, Alcohol, Drug and Mental Health building in Woodland for Herbert Bauer, MD. He will be remembered for his sharp wit, pithy observations on the world and human condition, his “Letters to the Editor,” and substitute columns for Bob Dunning who called him the “Conscience of Davis.” He is survived by his sons Timothy Bauer of Seattle, Washington, and Christopher Bauer of Nashville, Tennessee, as well as grandchildren Jonathan Bauer of Los Angeles and Zoe Bauer of Nashville.
Dr. Bauer celebrated his 101st birthday at the 2011 SSVMS Annual Dinner.
−Captane P. Thomson, MD AD INDEX Page BloodSource............................................................................14 Central Valley Bank..................................................................36 Comcast..........................................................Inside Back Cover Cornish & Carey Commercial..................................................35 Hill Physicians................................................ Inside Front Cover J & L Teamworks.....................................................................29 Marsh.......................................................................................15 Med 7......................................................................................35 MICRA Savings Chart................................................................7 Moss Adams...................................................Inside Back Cover NORCAL Mutual Insurance Company.........Outside Back Cover The Doctors Center...................................................................2 Tracy Zweig Associates...........................................................31 Walk with a Doc......................................................................35
September/October 2013
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Board Briefs July 8, 2013 The Board: Received a report from Ed Dagang, Manager of the UC Davis Student-Run Clinics, and Charlotte Pickett, MS II, Student Director of the Knights Landing UCD Student-Run Clinic. The clinics, operating in Sacramento and Yolo Counties, provide free health care to uninsured, low-income and other underserved populations. Operating on weekends, the clinics serve several distinct groups of patients and offer people what is often their only access to health care services. The program gives medical students and undergraduates opportunities to learn firsthand about the challenges and rewards of patient care and community medicine. Each clinic benefits from volunteer physicians who give time to mentor students and oversee patient care. The clinics rely on generous donor support to help fund the medicines, equipment, vaccines and other important materials to meet their patients’ needs. Volunteer physicians are needed. Professional liability insurance is provided by UC Davis. Physicians interested in volunteering should contact Kris Wallach, Program Director, at (916) 453-0254 or kwallach@ssvms.org. Approved the 2013 Second Quarter Financial Statements noting that SSVMS membership is at a historic high of 2,876, and as of June 30, 2013, the annual budget for dues-related income has been exceeded. Approved the following changes in the CMA Delegation Roster for the 2013 House of Delegates: 1) Move Karen Hopp, MD from Alternate-Delegate Office 6 to Delegate At-Large Office 17; Move Rajan Merchant, MD, from Alternate-Delegate At-Large Office 12 to Alternate-Delegate District 6, Office 6; Move Margaret Parsons, MD from AlternateDelegate Office 2 to Delegate At-Large Office 18; Move Assemblymember Richard Pan, MD from Alternate-Delegate At-Large Office 11 to
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Alternate-Delegate District 2 Office 2. Received an update on MICRA, the Medical Injury Compensation Reform Act of 1975. California trial attorneys recently launched an all-out assault on California’s historic tort reform law. MICRA is a series of statutes crafted to ensure that injured patients are fairly compensated, medical liability rates are kept in check, and physicians and clinics can remain in practice treating patients. The law has been targeted by the trial lawyers because it restricts the amount of money they can collect in damage awards. California’s critical MICRA protections are a national success story, safeguarding patients and their access to care for almost 40 years. Trial lawyers are backing risky reforms that would impede the ability to provide critical care for California’s most vulnerable citizens. The Board was asked to strongly encourage their colleagues to support the defense of MICRA by donating to the MICRA Education Fund through CMA’s political action committee, CALPAC, at www. cmanet.org/micra. Approved the Membership Report: For Active Membership — Megan F. Brennan, MD; Alison M. Chow, MD; Victor M. Gellineau, III, MD; Gregory S. Kann, MD; Robyn L. Kimura, MD; Lev A. Libet, MD; Cindy M. Loh, MD; Ghayyur A. Qureshi, MD; Sriharsha M. Rao, MD. For Resident Membership — Sam R. Abbassi, MD; Saba F. Ali, MD; Runalia Bahar, MD; Myla J. Canales, MD; Anna G. Carlson, MD; Ashley M. Cepeda, MD; Derrick W. Chan, MD; Adrian L. Chase, MD; Katerina N. Christiansen, MD; Steven F. Cocciardi, MD; Mari L. Cosentino, MD; Amanda R. Davis, MD; Jeremy M. DeMartini, MD; Heather M. Ealry, MD; Kyle N. Erickson, DO; Jenifer J. Fan, MD; Terri L. Ferrari, MD; Allison S. Glass, MD; Nicole G. Gomez, MD; Monica M. Grova, MD; Brianna N. Harris, MD;
Nassier Heyrani, MD; Katherine M. Hinchcliff, MD; Eve A. Hood, MD; Justin N. Hopkins, MD; Stephanie A. Jamison, MD; Christopher H. Kim, MD; Janet W. Lee, MD; Melissa L. Lichte, MD; Su Liu, MD; Pachida C. Lo, MD; Katie J. Long, MD; Ashley R. Lundgren, MD; Devna U. Magrola, MD; Kristen M. Marshall, MD; Lydia P. Mendoza, MD; Kiran Mudambi, MD; Alexander J. Nedopil, MD; Samantha J. Neureuther, MD; Rachelle L. Nicolai, MD; Alinea S. Noronha, MD; Amy K. Nuismer, MD; Devin A. Oller, MD; Caterina G. Palumbo, MD; Christine J. Park, MD; Katherine J. Park, MD; Andrew M. Perry, MD; Tamara S.V. Pleshakov, DO; Marisa E. Scofield, MD; Laura E. Sienas, MD; Meryl A. Simon, MD; Warrik M. Staines, MD; Daniel M. Strum, MD; Emily M. Tibbits, MD; Minh-Chi Tran, MD; Melissa A. Vanover, MD; Adriel M. Watts, MD; Julie M. Westberg, MD; Clara C. Yang, MD; Alexander B. Younts, MD; Michelle S. Yu, MD. For a Change in Membership Status from Student to Resident — Elizabeth Abdin, MD; Aleksandra N. Belova, MD; Jana Chtchetinin, MD; Irene Chen, MD; Dariush Garber, MD; Stephen S. Henrichon, MD; Jensine Lee, MD; Matthew J. Lopez, MD; Shiloh M. Martin, MD; Tricia M. Roberts, MD. For a Change in Membership Status from Resident to Active — Deborah S. Kim, MD. For Reinstatement to Membership — Carl C. Hsu, MD (Active); Robert J. Forster, MD (Retired). For Retired Membership — Michael H. Burman, MD; Bruce D. Miller, MD; Bahman Nazeri, MD. For Resignation — Andrew M. Park, MD (transferred to Orange County). Serving as the Board to the Community Service, Education and Research Fund (CSERF), the Society’s 501(c)(3) organization, the directors received an annual report regarding the SPIRIT Program from Jack Rozance, MD, Chair of
the SPIRIT Management Committee and Kris Wallach, Program Director. SPIRIT, Sacramento Physicians Initiative to Reach out, Innovate and Teach, was established in 1995 through a grant from the Robert Wood Johnson Foundation, the program engages volunteer physicians in the delivery of medical care to the uninsured. SPIRIT is funded by five partners, SSVMS, Sutter Health, Dignity, Kaiser and UC Davis, who annually contribute $15,000 to the program. BloodSource was a major donor to the program this past year with committed funding of SPIRIT through 2014. Other donations are received throughout the year. Since inception, the SPIRIT Program has treated 38,579 patients; performed 584 hernia surgeries, 70 cataract surgeries and 15 other out-patient surgeries. This year the SPIRIT Program will receive the CMA Foundation’s Robert D. Sparks, MD, Leadership Achievement Award for its outstanding concern for the health of communities and demonstrated efforts consistent with the mission of the Foundation.
September/October 2013
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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.
Abbassi, Sam R., Ophthalmology, Rush Medial College 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Christiansen, Katie N., Internal Medicine, Eastern Virginia 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Abdin, Elizabeth, Internal Medicine, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Chtchetinin, Jana, Undecided, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Ali, Saba F., Internal Medicine, Fatima Jinnah Medical College, Pakistan 2011, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Cocciardi, Steven F., Internal Medicine, Jefferson Medical College 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Bahar, Runalia, Internal Medicine, University of Pittsburgh 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Cosentino, Mari L., Emergency Medicine, University of Arizona 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Belova, Aleksandra N., Pediatrics, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Davis, Amanda R., Family Medicine, Jefferson Medical College 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Brennan, Megan F., Emergency Medicine, Creighton University 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Canales, Myla J., Undecided, University of Texas, San Antonio 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Carlson, Anna G., Pediatrics, Geisel School of Medicine at Dartmouth 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Cepeda, Ashley M., Internal Medicine, Temple University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Chan, Derrick W., Family Medicine, SUNY-Buffalo 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Chase, Adrian L., Anesthesiology, University of Cincinnati 2012, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Chen, Irene, Emergency Medicine, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Chinn, Julie M., Pediatrics, Oregon Health Sciences University 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Chow, Alison M., Pediatric/Allergy/Immunology, University of Hawaii 2002, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800
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DeMartini, Jeremy M., Psychiatry, UC Los Angeles 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Dima, Jacob J., DO, Family Medicine, WUHS 2010, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5000 Early, Heather M., Vascular Surgery, Texas A&M 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Ekpo, Elizabeth I., Neurology, University of Oklahoma 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Elchico, Erick R., Anesthesiology, University of Toledo 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Erickson, Kyle N., DO, Internal Medicine, Midwestern-Arizona 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Fan, Jennifer J., Internal Medicine, SUNY-Buffalo 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Feng, Charles H., Allergy/Immunology, UC Los Angeles 2009, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Ferrari, Terri L., OB-GYN, University of Washington 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Sierra Sacramento Valley Medicine
Garber, Dariush, Emergency Medicine, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Garcia, Ronald T., Internal Medicine, East Tennessee 2009, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Gellineau, Victor M., III, Family Medicine, Howard University 1999, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Glass, Allison S., Urology, University of Missouri 2010, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Gomez, Nicole G., OB-GYN, UC San Francisco 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Grova, Monica M., General Surgery, UC San Francisco 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Harris, Brianna N., Otolaryngology, University of Southern California 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Harrison, Matthew W., Undecided, University of Texas Southwestern 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Henrichon, Stephen S., General Surgery, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Heyrani, Nasser, Orthopedic Surgery, UC Los Angeles 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Hinchcliff, Katharine M., General Surgery, SUNYUpstate 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Hood, Eve A., Internal Medicine, Michigan State University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Hopkins, Justin N., Orthopedic Surgery, UC Irvine 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Hylton, Jared R., Anesthesiology, UC Davis 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Jamison, Stephanie A., Family Medicine, University of Washington 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Lopez, Matthew J., General Surgery, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Park, Katherine J., Neurology, Loma Linda University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Lundgren, Ashley R., Internal Medicine, University of Washington 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Perry, Andrew M., General Surgery, University of Florida 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Mangrola, Devna U., Internal Medicine, Albert Einstein 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Petersen, Megan M., Gynecology Oncology, University of Colorado 2007, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Marshall, Kristen M., Internal Medicine, University of Nevada 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Pleshakov, Tamara SV, DO, Emergency Medicine, NY Institute of Tech 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Martin, Shiloh M., Pathology, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Qureshi, Ghayyur A., Pulmonary Critical Care/Sleep Medicine, Drexel University 1995, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333
Mendoza, Lydia P., Emergency Medicine, Medical College of Wisconsin 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Rao, Sriharsha M., Infectious Disease/Critical Care Medicine, JSS Medical College/Mysore University, India 2001, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-4821
Kimura, Robyn L., Pediatrics, Loma Linda University 1999, 900 Florin Rd #B, Sacramento 59831 (916) 421-8245
Mohammed, Jamal M., Sleep Medicine, DR.B.R. Ambedkar, India 2006, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Ritchie, Emily Z., Radiology, Louisiana State University 2008, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Koo, Benjamin J., Neurology, Loma Linda University 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Mudambi, Kiran, Pediatrics, UC Los Angeles 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Roberts, Tricia M., Psychiatry, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Latif, Syed R., Cardiology, Brown University 2008, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Nedopil, Alexander J., Orthopedic Surgery, Tech University, Germany 2008, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Romanowski, Kathleen S., Surgery/Burn, University of Chicago 2006, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Neureuther, Samantha J., General Surgery, Albert Einstein 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Scofield, Marisa E., Emergency Medicine, Ohio State University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Nicolai, Rachelle L., Emergency Medicine, Oregon Health Science University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Sienas, Laura E., OB-GYN, Creighton University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Jones, James H., Anesthesiology, Albany Medical College 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Julie, Ian M., Emergency Medicine, Washington University 2009, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Kann, Gregory S., Emergency Medicine, Ross University 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Kim, Christopher H., Pediatrics, Emory University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Kim, Deborah S., Emergency Medicine, University of Illinois 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106
Lee, Janet W., Otolaryngology, Duke University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Lee, Jensine, Internal Medicine, UC Davis 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Li, David, Anesthesiology, University of Miami 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Simon, Meryl A., General Surgery, Drexel University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Libet, Lev A., Emergency Medicine, Albert Einstein 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106
Noronha, Alinea S., Family Medicine, SUNYDownstate 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Lichte, Melissa L., Family Medicine, Tufts University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Nuismer, Amy K., Psychiatry, St. Louis University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Liu, Su, Internal Medicine, Michigan State University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Oller, Devin A., Internal Medicine, Temple University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Staines, Warrik M., Emergency Medicine, Eastern Virginia 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Palumbo, Caterina G., Undecided, University of Toledo 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Strum, Daniel M., Internal Medicine, University of Washington 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Park, Christine J., Psychiatry, New York Medical College 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Sun, David H., Hematology/Oncology, Robert Wood Johnson 2009, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Lo, Pachida C., Psychiatry, Oregon Health & Science University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Loh, Cindy, Family Medicine, Ross University 2007 Long, Katie J., Pediatrics, Creighton University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Singh, Jaspreet, Gastroenterology, Dayanand Medical College, India 2004, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
continued on next page
September/October 2013
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Applicants continued from page 33 Tibbits, Emily M., General Surgery, Wright State University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Tran, Minh-Chi, Internal Medicine, UC San Francisco 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Tun, Zin M., Anesthesiology, SUNY-Upstate 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Vanover, Melissa A., General Surgery, University of Texas, San Antonio 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
34
Vien, Terry, DO, Anesthesiology, WUHS, Pomona 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Watts, Adriel M., Emergency Medicine, University of North Carolina 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Westberg, Julie M., OB-GYN, Albany Medical College 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Yang, Clara C., Undecided, Temple University 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Sierra Sacramento Valley Medicine
Yonts, Alexandra B., Pediatrics, University of Nebraska 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Yu, Kimberly P., Physical Medicine & Rehabilitation, UC Davis 2012, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member) Yu, Michelle S., Internal Medicine, University of Southern California 2013, UCDMC, 2315 Stockton Blvd, Sacramento 95817 (916) 734-2011 (Resident Member)
Saturday, September 7, 2013
Walk With A Doc is a FREE program for anyone interested in taking steps to improve their health.
LOCATION: Foothill Community Park 5510 Diablo Drive, Sacramento
Saturday, October 19, 2013
LOCATION: North Laguna Creek Park 6400 Jacinto Ave, Sacramento
Sponsored by:
WHO CAN ATTEND: ANYONE. Tell your patients! Bring a friend! Bring your kids!
r Lease pace fo 0 SF S e c ffi al O 7,55 ” Medic ampus • ±760 to ± Class “A an C s n Ju
Check our website for start times and directions.
Supported by:
http://www.ssvms.org/Events.aspx www.ssvms.org/Programs/ WalkWithADoc.aspx
e ate ur practic e Lease R Competitiv on the needs of yo on site ted based Imaging, and Labs s construc Floor plan Cafe, Full Service Pharmacy,
Mercy Sa
Susan Nelson Kim Collins
Lic. #01413052 916.367.6352 Lic. #00829067 916.367.6340
PLANET
E L LY
DESIGN / MARKETING
Kelly K elly Rackham Rackha m [916] 616 6270 planetkelly@me.com www.planetkelly.com
Full time Physician needed for MED7 Urgent Care Center. We have urgent care clinics located in Carmichael, Roseville, Folsom and Sacramento. MED7 has been providing urgent care services in the greater Sacramento area since 1987. Visit our website for more information about MED7 at www.med7.com. Attractive compensation package. Call Merl O’Brien, MD at 916-483-5400 ext. 111 or e-mail CV to sherry@med7atwork.com
Visit SSVMS online at www.ssvms.org
September/October 2013
35
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