2013-Nov/Dec - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

November/December 2013

savings of $ over 93,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s Trial Lawyers have launched an attack to undermine MICRA and its protections and we need your help. Membership has never been so valuable!

WAYS SSVMS/CMA IS WORKING FOR YOU! Physicians in El Dorado, Sacramento and Yolo Counties are saving an average of $93,748 this year.

Are you a SSVMS/CMA member? 2012 SIERRA SACRAMENTO VALLEY MEDICAL SOCIETY MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

El Dorado, Sacramento and Yolo counties $28,147

$7,976

$38,865

$24,996

Miami & Dade Counties, FL

$190,088

$46,372

$201,808

$146,089

Nassau & Suffolk Counties, NY

$127,233

$34,032

$204,684

$121,983

Wayne County, MI

$121,321

$35,139

$108,020

$88,160

FL-NY-MI Average

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$118,067

$30,538

$132,639

$93,748

(Non-Invasive)

Sierra Sacramento Valley Medical Society 5380 Elvas Ave, STE 101 Sacramento, CA 95819 Phone: (916)452-2671 Email: info@ssvms.org Join online today www.ssvms.org * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

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Medicine 3

PRESIDENT’S MESSAGE Reflections

A Primer on Dengue for Travelling Physicians

David Herbert, MD

George Meyer, MD

EDITOR’S MESSAGE The Scourge of Pre-Disease

Innovative Projects from the Med Tech Showcase

Nathan Hitzeman, MD

Bob LaPerriere, MD

EXECUTIVE DIRECTOR’S MESSAGE MICRA: The Current Threat

Cold Laser Therapy – An Investigative Report

Aileen Wetzel, Executive Director

Jack Ostrich, MD

The Final Countdown to a Covered California

Medical Reserve Corps Welcomes Volunteers

Adam Dougherty, MPH, MS IV

Lee O. Welter, MD, and Lynn Pesely

Say Uncle

Local Walk with a Doc is Going Strong

John Loofbourow, MD

Kristine Wallach, Program Director

2013 Education Series

Sacramento County Takes on Chlamydia

Is Gastroenterology Just a Designer Specialty?

Sandra Hand, MD

Michael Lawson, MD

Mobile Technology for a Mobile Homeless Clinic

A Posit on Lung Cancer Screening

Board Briefs

Meet the Applicants

Classified Ads

John Paul Aboubechara, MS I

“Guilt-Free” Recipes

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 Kinova USA, a Roseville company, is one of several local medical technology companies being featured in this issue for their innovative projects (pages 18–19). Our cover image features the unique JACO assistive robotic arm. JACO allows individuals with little or no use of their hands and arms to drink, eat, and perform a wide variety of tasks without assistance. With JACO, quadriplegics and those with Cerebral Palsy, Muscular Dystrophy, and any other disease or condition that limits upper extremity mobility can do for themselves tasks for which they currently rely on others. To see the robotic arm in action, go to http://youtu.be/1aMad40uiug.

November/December 2013

Volume 64/Number 6 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

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

CMA Imm. Past President Paul Phinney, 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

Reflections By David Herbert, MD OVER THE PAST TWO YEARS I’ve enjoyed sharing perspectives on a variety of topics that were, hopefully, of interest to at least a few of our SSVMS members. I was always pleasantly surprised when readers indicated that they had actually read some of them! Now I am writing my last column, which offers me the opportunity to reflect on some of what SSVMS has accomplished. I was most fortunate to become president following the very talented Dr. Alicia Abels, who had worked with our equally talented former CEO, Bill Sandberg, to further strengthen one of the best medical societies in the state. I started with our new CEO, Aileen Wetzel, who has proved to be a terrific asset for SSVMS. She is energetic, thorough, articulate, knowledgeable, and usually patient with the likes of me. Many things have happened during the last two years, not so much because of anything I have done, but because of the efforts of our many members and staff. Here are a few highlights: We have been extraordinarily successful in increasing our membership – up 29 percent, with resultant increases in our CMA House of Delegates representation. Mercy and Permanente have greatly increased their participation, UC Davis continues to support us, and our solo and small group members continue as a key constituency. We are hoping to welcome Sutter back into this group before too long. Our finances are very solid, and we have not had to raise our dues in 28 years! We have increased our involvement in the care of underserved members of our community, both through our own SPIRIT program, as

well as through collaboration with community clinics. Our journal has been one of the best of its kind under the leadership of editors Drs. Nate Hitzeman and Ann Gerhardt, and it is now sent to all community physicians, whether or not they are members. Our committees continue to do important work, as I outlined in a recent column. The SSVMS Alliance has raised funds for scholarships and community activities, and has sponsored some excellent important community meetings, most recently on bullying. Our increased membership has been important to CMA as it successfully fought off a number of misguided attempts to expand the unsupervised practice of non-physicians, and as it continues to work to preserve MICRA, among its many efforts on our behalf. Of course, our own Dr. Paul Phinney has led CMA as president this year. The future of SSVMS is quite bright! We are in excellent financial shape with a great CEO and staff, and our incoming president, Dr. Jose Arevalo, is not only capable, but innovative and articulate. I know that SSVMS will continue to make an important difference in the lives of our physicians as well as in the health of our communities. On a personal note, I’d like to thank all of you for allowing me the privilege of serving as your president. I’ve met many of you in your work with SSVMS, and I have learned a great deal from you. We have an amazingly talented group of physicians, and I am looking forward to seeing what we can do next! davidherbert166@gmail.com

November/December 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.

EDITOR’s Message

The Scourge of Pre-Disease By Nathan Hitzeman, MD

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

I RECENTLY RECEIVED AN in-service on using hierarchical condition category (HCC) codes as pertains to Medicare reimbursement for their managed care plan covered patients. This concept is not exactly new, as two years ago some hospitals in rural Northern California were busted for labeling over 1,000 admitted Medicare patients with “kwashiorkor” – which was considered a higher acuity condition and reimbursed more. None of us, I hope, are doing anything that egregious now, but the idea of maximizing profit by finessing diagnosis coding still doesn’t sit great with me. It’s a means of survival for hospitals and organizations already being pushed to the brink of leanness. Still, it got me thinking about all the ways we label our patients with “pre”-disease. I can take a 30-year-old new male patient who works long days and has three young kids at home who walks into my office on no meds, but perhaps carries some extra weight around his midsection, and fill up his electronic chart with a barrage of inflated diagnoses: obesity, prehypertension, family history of cardiovascular disease (grandfather died of a heart attack at age 60), family history of endocrine disorder (grandmother is on oral diabetes meds), low back pain (his back aches sometimes), cardiac murmur (was that a 1/6 systolic I heard?), irritable bowel syndrome (has irregular bowel movements at times), restless legs (sometimes moves his legs under the covers at night rather than staying still like a corpse), obstructive sleep apnea (wife heard him snore, sometimes feels tired during the day), and BPH (sometimes gets up twice to use the can at night).

I can then add to my diagnoses by casting out a net of lab work. And behold, the slightly elevated ALT followed by the ultrasound buys him fatty liver disease. Prediabetes is confirmed. HDL and vitamin D deficiencies are identified. (My God, how did he survive this long!) An ECHO of the heart for that slight murmur didn’t show valvular disease, but lo and behold, there is grade one diastolic dysfunction. I can add heart failure to his diagnoses and refer him to a cardiologist. The cardiologist orders a stress treadmill. The results are equivocal. A nuclear medicine scan is ordered and 1,000 chest X-rays’ worth of radiation exposure later, ischemic heart disease is ruled out. He still has diastolic dysfunction though. He thinks he can never have salt again. He gets depressed at night as he puts on his Darth Vader CPAP device, so I add depression to his diagnoses. For that IBS, he gets a colonoscopy which is benign and he is started on an expensive probiotic. Six months later, he’s gained 10 lbs., lost his job, and can’t afford any of the 10 medications he’s been started on in the interim. Do you get the point? We have enough disease in this country (see medical student John Paul Aboubechara’s article on the Willow Clinic), let alone the world (see Dr. George Meyer’s article on dengue and Dr. Mike Lawson’s article on Nicaragua). Let’s not go manufacturing more disease to keep us busy (see the discussion on the lung cancer screening Posit). We have all been guilty of this at some point, myself included. How can we change our culture? hitzemn@sutterhealth.org

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Executive Director’s Message

MICRA: The Current Threat If the initiative is successful, malpractice rates will skyrocket for physicians.

By Aileen Wetzel, Executive Director THE MEDICAL INJURY Compensation Reform Act (MICRA), California’s historic tort reform law, since 1975 has helped to keep malpractice premiums in check and to ensure that California’s patients have access to affordable health care. MICRA provides unlimited economic damages for past and future medical costs, unlimited damages for lost wages, lifetime earning potential or any other economic losses, and unlimited punitive damages. In addition, injured patients can recover up to $250,000 in non-economic damages, often referred to as “pain and suffering.” The $250,000 cap on non-economic damages has effectively limited meritless lawsuits and has kept health care costs in check. This past summer, California’s trial attorneys launched an all-out assault on MICRA by introducing a ballot initiative that would, among other things, quadruple the cap on non-economic (pain and suffering) damages from $250,000 to $1.1 million, plus a cost of living adjustment (COLA), retroactively adjusted for inflation going back the 38 years MICRA has been in place. In addition to raising the cap on non-economic damages, the ballot initiative, entitled “The Troy and Alana Pack Patient Safety Act of 2014,” requires mandatory drug and alcohol testing of physicians by hospitals, even if there has not been an adverse event. Failure to submit to testing within 12 hours after an adverse event will result in suspension

of a physician’s license. The requirement to test applies to any physician who has treated or prescribed medications to the patient within 24 hours of the adverse event. In other words, a physician is presumed negligent. Once the initiative is given title and summary by the State of California, the trial attorneys have 150 days to obtain 500,000 signatures to qualify for the 2014 ballot. If the initiative is successful, malpractice rates will skyrocket for physicians, force the closure of safety net clinics and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Your membership in organized medicine is more valuable now than ever. Because of MICRA, physicians practicing in El Dorado, Sacramento and Yolo counties are saving an average of $93,748 this year on medical liability rates.1 SSVMS/CMA and our coalition allies are working tirelessly to defend MICRA and to ensure that your ability to practice medicine is not threatened by this misguided effort. Physicians will be victorious in this fight, but in order to do so, we need your continued support. For more information about MICRA and what you can do to help in the fight, visit www.ssvms.org/Membership/MICRA.aspx or www. cmanet.org/micra. awetzel@ssvms.org Reference: 1 Medical Liability Monitor – Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

November/December 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.

The Final Countdown to a Covered California By Adam Dougherty, MPH, MS IV THE CLOSING MONTHS OF 2013 bring a slew of activity in the implementation of the Affordable Care Act in California, and it is impressive to see just how far the state has come since the law was passed. While there have been some unfortunate delays announced from the feds, the main pillars of the law remain intact. Notable delays include the postponement of the annual and lifetime caps on out-of-pocket insurance costs to 2015, and deferral of the rule requiring large companies to provide comprehensive coverage to full-time employees.

The following are what’s happening with the big pillars, which go live beginning in 2014.

The Mandate The controversial individual mandate will go into effect on New Year’s Day, when most individuals will be required to have insurance coverage or will pay a penalty on their taxes that year if they don’t. In 2014, the penalty equals 1 percent of income or $95 (whichever is greater), and in 2016 phases up to 2.5 percent of income or $695. Groups exempt from this mandate include individuals who would have to pay more than 8 percent of their income for insurance, undocumented immigrants, and Native Americans.

The Exchange For those with incomes above 138 percent of the Federal Poverty Level (FPL), the state’s health insurance exchange called Covered California is expected to provide competitive insurance rates in a regulated market, while tax subsidies will help make coverage affordable for individuals and families up to 400 percent FPL. The exchange began pre-enrollment on October 1st, and will officially go live on the first of the year. The $80 million Covered California media blitz is in full swing, and Exchange officials hope to enroll over 70 percent of the 2.4 million Californians who are eligible for subsidies over the next year.

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Medi-Cal California is moving full steam ahead to expand Medi-Cal to every state resident under 138 percent FPL or roughly a salary of $16,000 per year for an individual and $27,000 for a family of three. This equates to 1.4 million newly eligible Californians, adding to the ranks of today’s 8 million Medi-Cal beneficiaries. Counties have been working feverishly to bring many of these individuals into the temporary Low Income Health Plans (LIHPs), commonly known as the “Bridge to Health Care Reform.” Over 615,000 Californians have already enrolled in county LIHP programs since 2011, and nearly all will transfer automatically to Medi-Cal on January 1st. Today, nearly 12,000 Sacramentans are benefitting from this program. It’s not all good news for Sacramento County, though, as the state plans to claw back $9 million next year from the County health budget since these traditionally countyfinanced, low-income individuals will transition to state-financed coverage (even though local expenditures will remain, as the county will still be responsible for care to those who remain uninsured). County officials are devising how best to streamline existing programs, as any cuts to benefits seem to be off the table. While the Medi-Cal expansion will have farreaching benefits for the health of the newly insured, coverage does not simply equate to access. California still has the lowest Medicaid spending per enrollee in the nation, and the second lowest share of physicians accepting new Medicaid patients at 57 percent. More so, the 10 percent Medi-Cal rate cut proposed in the Governor’s budget was indeed upheld in the courts and is now

actively being implemented. Nevertheless, 150 primary care services in Medi-Cal will still see a boost in payment to Medicare level in 2013-2014, thanks to the ACA, equating to a 136 percent increase in reimbursement on average. It is imperative that these services are taken full advantage of over the next year, and significant effort and political capital must be expended to extend them past 2014, in order to bolster primary care networks and adequately meet the pent-up need for the newly insured for years to come. While reimbursement is the most immediate priority, the state and committed, forwardthinking stakeholders must also buy in to more organized and integrated payment and delivery models in Medi-Cal that will improve efficiency while reducing barriers to care, or risk further provider network deterioration.

Public Awareness Much of the public continues to remain in the dark on most ACA implementation developments, and seems to become more skeptical when they actually do hear something

November/December 2013

about it. A recent Kaiser Family Foundation study conducted in August exemplifies this phenomenon, where individuals were asked who they would trust getting information from vs. actual exposure. The health care team tops the list of trusted sources, yet only one-fifth of individuals have received any information from a doctor or nurse. While the entire political spectrum is, indeed, represented in the medical profession, this peer-reviewed fact should be embraced: Insurance coverage reduces mortality, improves quality of life, and enhances productivity. The reality is that many eligible individuals will still lack coverage by the end of the decade because they can’t afford it, they can’t properly navigate the system, or they have encountered any number of barriers to outreach. Whatever our personal ideology, it would behoove all of our patients to benefit from these reforms, and

as stewards of health, we should be expected to guide them. Leading the way in this regard are the California Academy of Family Physicians, the California Chapter of the American College of Physicians, the California Academy of Physician Assistants and the Osteopathic Physicians and Surgeons of California, whose partnership was awarded an $865,000 grant from Covered California to develop educational programs for physicians and materials for patients in order to increase the number of Californians with health care coverage. A second coalition, made up of the CMA, the CMA Foundation, the Latino Physicians of California, the American Academy of Pediatrics and our very own SSVMS, was awarded $1.5 million from the same grant to educate providers. apdougherty@gmail.com

Say Uncle By John Loofbourow, MD Burned out houses, bombed out cities, poisoned children cold and dead make Us angry, here in heaven, where it’s love of hate we dread.

We’re all-loving, all-forgiving, ever old and ever new, but you must learn to always do what We say, not what We do.

With warnings and prohibitions, Our proclamations We made clear, yet you didn’t seem to care, and scarcely seemed to hear.

Do not think Us merely gods; We’re mankind’s greatest hope and State, the singular exception of all time, owners of all reason and all fate.

We can kill with fire and brimstone, from our far haven for the few, if just to make you fear Us, whether Sunni, Siha or Jew.

When We strike with fire and brimstone, from our far haven for the few, you will learn to love each other, Arab, Copt, Kurd, and Jew.

john@loofbourow.com

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What is it? This photograph of a stereoscopic card (circa 1910) shows a patient with a pustulo-crustosa form of syphilis. The card is part of a set, including a stereoscopic viewer, donated by Dr. Donald Lyman to the SSVMS Museum of Medical History.

November/December 2013

Sacramento County Takes on Chlamydia By Sandra Hand, MD, MPH CHLAMYDIA IS AN INFECTIOUS, sexually transmitted disease found in young people in their prime reproductive years. According to provisional 2012 data from the California Department of Communicable Diseases, women aged 15 to 25 account for the majority of new chlamydia cases in Sacramento County. There are more than twice as many cases in women than in men. Sacramento County ranks third among California counties (behind Kern and Fresno) for the highest chlamydia rates for the past five years, with an increase seen each year. Chlamydia can occur with no symptoms. The infection can result in pelvic inflammatory disease (PID) with subsequent scarring. Women who have had chlamydia may become infertile, have difficulty becoming pregnant, or have ectopic pregnancies. Babies born to infected At right is the home test kit called, “Don’t Think, Know.”

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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mothers can also be affected. Chlamydia trachomatis is the causative agent of trachoma, one of most common causes of blindness worldwide. Chlamydia is relatively easy and inexpensive to treat if the infection is diagnosed. The CDC recommends that sexually active women aged 25 and under be screened annually, especially if they have multiple partners, a partner who has multiple partners or they change partners. In 2009, Los Angeles County initiated a chlamydia and gonorrhea home test kit program for young women called, “Don’t Think, Know.” Women can order kits online or by phone from the County health department and receive them in the mail. Once the self-administered vaginal swab specimens are collected, they are mailed in a postage-paid envelope to the Public Health

Lab for processing. Confidential test results and referrals for treatment can be viewed securely online. Vaginal self-testing has been shown by various studies to be both effective and acceptable to young women. In August 2013, Sacramento County Public Health launched “I Know Sacramento,” a local version of LA County’s chlamydia and gonorrhea home test kit project that is funded, in large part, by the California Department of Public Health STD Control Branch. As in Los Angeles, Sacramento County women aged 25 and under can order a test kit, access their test results, and obtain treatment referrals at www. dontthinkknow.org or by calling (916) 875-KNOW (5669). San Diego and Alameda counties have also launched similar programs. Dr. Miriam Shipp, the STD controller for Sacramento County, says, “‘I Know Sacramento’ is a great program that connects young women to discreet testing for diseases and gives them the information they need to obtain treatment, if necessary. It also gives them the opportunity to learn more about protecting themselves from STDs, whether they test positive or not.” Information about the Division of Public Health and other available public health programs and activities can be obtained by visiting www.scph. com. Thanks are due to Dr. Miriam Shipp, STD Controller, Stacy Syass and Dominic Mori of the Sacramento County STD Control Unit for corrections and edits, and to Dr. Olivia Kasirye, Sacramento County Public Health Officer, for pictures of the kits and posters. smh9142@comcast.net

November/December 2013

Mobile Technology for a Mobile Homeless Clinic By John Paul Aboubechara, MS I A 67-YEAR-OLD VIETNAM WAR veteran returned to clinic with complaints that the numbness in his fingers had intensified. He had been previously diagnosed with Type II diabetes mellitus, and was prescribed metformin. That his symptoms continued to worsen made us think that he might be non-compliant. I could not understand why patients would not follow simple prescriptions. Discussion with my preceptor made me realize that many of our patients do not adequately understand the diseases with which they are diagnosed. As such, they may not understand the importance of following their medical treatment. To address this issue, we started the Willow Educational Resources Program (WERP) that aims to educate our patients about important health topics. Rather than simply telling my

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patient that he has to take his metformin, I can teach him what exactly diabetes is, and how taking his medication regularly can manage his blood glucose. Moreover, we realize that many of the patients we see at our clinic suffer from preventable diseases. So, if we can educate them about prevention, we can reduce their risk of disease. Initially, we feared that putting together a program with such a broad focus would prove to be time- and resource-consuming. After all, our clinic has a small budget. The Willow Clinic is a free, student-run, health care clinic supervised by Dr. Jaesu Han and supported by the UC Davis School of Medicine. Our clinic serves the homeless community of Sacramento. We operate out of the Salvation Army homeless shelter, which is close to Loaves and Fishes, Friendship Park, and other shelters. As a free clinic with humble funding, we have had to run as a makeshift mobile clinic. All of our infrastructure and supplies are stored in a small shed. Each Saturday morning, we borrow a few rooms from the Salvation Army in which the premeds set up the entire clinic from scratch in about 30 minutes. The cubicle walls for the patientsâ&#x20AC;&#x2122; rooms are rolled in, examination tables are unpacked, intake stations are set up, and the preceptorsâ&#x20AC;&#x2122; discussion room is established with several laptop computers. We even have our own WiFi to power our newly-adapted electronic medical record system (Practice Fusion). With such mobility,

we have even taken our supplies with us as we hold special clinics all over Sacramento. With the nature of our clinic in mind, one can see that WERP had to be flexible. We initially thought we would need a seating area and a display on which to give our multimedia presentations. But, the Salvation Army did not have any more space to spare, let alone a projector. So we began to make use of any space that was available. Some Saturdays we used the kitchen, other Saturdays the backyard patio, and yet on other days, we roamed down North B Street to give short talks to the homeless community who gathered there. For a display, a projector or TV would not work, so we resorted to using a tablet computer. Our presentations included many figures, images, and an occasional video. The tablet gave us

the flexibility to give our presentations in any venue, while using high-quality multimedia. We have given talks to hundreds of patients on topics ranging from hypertension to back pain. Having a flexible means of presentation has allowed us to give talks that better suit each venue. We gave formal presentations when we had a large turnout, discussion-based when with only a few people, and one-on-one talks when dealing with a patientâ&#x20AC;&#x2122;s sensitive issue. It is too early to know if our efforts are making an impact. In the case of my 67-year-old patient, his symptoms are now under control. If you are interested in volunteering at Willow, feel free to contact me. jjaboube@gmail.com

November/December 2013

Having a flexible means of presentation and a laptop computer has allowed clinic personnel to give health talks that better suit the patients.

“Guilt-Free” Recipes OCCASIONALLY AT SSVMS committee meetings, our members digress to discussing recipes for healthy living. When challenged to share them, a few doctors did submit their favorite concoctions. While a few physician members light-heartedly questioned the “healthy” endorsement, pretty much everyone nodded in agreement to “guilt-free.” Below are a few contributions.

Vegetarian Moroccan Lentil Stew with Raisins

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 exotically-flavored stew, a favorite of Drs. Andrew Klonecke and George Meyer, can be stretched to feed a crowd when ladled over rice or potatoes. It’s also good for people with gluten sensitivity, but not for those with milk allergy. Ingredient List – Serves 6 l Tbs. olive oil 1 cup chopped onion 3 cloves garlic, minced (1 Tbs.) 1 28-oz. can crushed tomatoes 2 18.2-oz. cartons prepared lentil soup, such as Dr. McDougall’s 1 15-oz. can chickpeas, rinsed and drained 1/2 cup raisins or dried currants 2 tsp. ground cinnamon, or to taste 1 1/2 tsp. ground cumin 1/4 tsp. red pepper flakes, or to taste 6 Tbs. plain nonfat Greek yogurt or soy yogurt, optional Directions 1. Heat oil in medium saucepan or Dutch oven over medium heat. Add onion, and sauté 3 minutes, or until softened and translucent. Add garlic, and cook 1 minute, or until garlic is soflened, but not browned, stirring constantly. 2. Stir in tomatoes, soup, chickpeas, raisins, cinnamon, cumin, and red pepper flakes. Season with salt and pepper, if desired. Bring stew to a simmer over medium-high heat, stir-

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ring occasionally. 3. Reduce heat to medium-low, and simmer, uncovered, 20 minutes, or until mixture is reduced and sauce has thickened, stirring often from bottom to prevent sticking. Garnish each serving with 1 Tbs. of yogurt, if using. Nutritional Information Per 1-cup serving: Calories: 263, Protein: 11 g, Total fat: 4g, Saturated fat: <1 g, Carbs: 49g, Cholesterol: mg, Sodium: 642mg, Fiber: 13g, Sugars: 11g

Dr. Bob’s “Guilt-Free” Oatmeal Pancakes (Double Batch) A favorite breakfast recipe from Dr. Bob LaPerriere. Ingredient List - Makes approximately 32 four-inch pancakes 3 cups “quick” rolled oats 1 quart lowfat buttermilk (1% butterfat) 1 cup Eggbeaters egg substitute 1 cup White Whole Wheat Flour or White Whole Wheat Pastry Flour* 5 heaping Tbs. Splenda (Splenda in the big bag for baking, not the small packets) 2 tsps. baking soda 1 tsp. kosher salt 1/2 cup ground flax seed 1 cup Kellogg’s All Bran Bran Buds (may use “original” if buds not available) Preparation 1. Put Bran Buds into bowl, add 2 cups hot water and let soak until soft. 2. Mix flour, Splenda, baking soda, salt and flax seed together. Combine oats and buttermilk, add Eggbeaters and the Kellogg’s All Bran Bran Buds with the water they are soaking in. They should have absorbed most of the water. Then stir in the flour mixture. Mix gently, do not beat. Batter will be thick as will the pancakes. 3. Heat a griddle to 400F degrees and coat with a little oil or shortening (I use spray). Cook pancakes on griddle. Turn over when the

bottom is nicely browned. They are done when the top of the pancake, when lightly touched, “bounces back.” Cool on rack. These freeze very well and heat well direct from freezer in a microwave. Do not over-microwave them, though. These are great with blueberries added. Also, you could add walnuts and/or cinnamon. If I use frozen blueberries, I thaw them in water, then drain them well. Nutritional Information Approximate per pancake: Calories 75, Fat 2 gm, Fiber 2 gm *White Whole Wheat Flour is available at Whole Foods and often at Trader Joes. White Whole Wheat Flour is 100% whole wheat, but comes from white wheat rather than red wheat. It is much lighter in color and taste than red wheat flour, which is what most flour is made from. The pastry flour tends to make a more tender product, as pastry flour is lower in gluten than regular (hard wheat) flour, but both seem to work equally well in this recipe. All-purpose flour is a mixture of pastry (soft wheat) and regular (hard wheat) flours.

Banana Oatmeal Cookies Another favorite from Dr. Bob LaPerriere. Does well as a double batch also, which makes about 7 dozen. Preparation 1. Mix ingredients below together well using mixer: 3 black ripe bananas* 1/3 cup canola oil 2 tsps. vanilla 2 oz. Eggbeaters 2. Add and Mix: 1 cup raisins (soak in hot water until soft and drain) 1/2 cup chopped walnuts (optional) 3. Combine items below and mix into above until blended and all moist. (May need a bit more flour if bananas were large. Dough should still be a bit “shiny,” but should hold together in a “clump.”) 2 cups quick cooking oatmeal 1 cup soft (pastry) whole wheat flour**

1/2 tsp. salt 1/2 rounded tsp. baking powder 3/4 cup Splenda (the large bag variety, not the small packets, which are more concentrated) 4. Drop onto parchment paper-covered baking sheet, bake at 325F degrees in a convection oven for about 10-12 minutes (depends on size). Baked cookies are 1½ to 2 inches in diameter. Do not overbake. They will still be light in color. Move parchment onto slotted rack to cool. I freeze cookies as soon as they cool. They will keep much better, stay fresher and do great after thawing a few in a microwave when you need them. *I often freeze extra bananas too – no need to bag or wrap them – when they are getting “old.” When thawed (in microwave, approximate setting 1# on defrost), you can then squeeze out the banana like toothpaste or they peel easily. One banana = approximately ½ cup. **Available at Whole Foods. You can use regular white whole wheat flour if you cannot find the pastry flour, but pastry flour makes a more tender cookie as it contains less gluten. White whole wheat (as opposed to most flour that comes from red wheat) produces a lighter colored and better textured product than red wheat flours. Bob’s Red Mill is one example of white wheat pastry flour.

Cauliflower Pizza Dr. Sandra Hand recommends this dish. Directions 1. Preheat oven to 450F. Cover baking sheet with parchment or prepare with cooking spray. Assemble the following: 1 cup cooked and riced cauliflower (see notes) 1 egg 1 cup low moisture mozzarella cheese, shredded 1/2 tsp. fennel 1/2 tsp. oregano 1 tbsp. parsley Pizza toppings and sauce of choice 2. Mix together the first 6 ingredients into a dough. continued on page 30

November/December 2013

A Primer on Dengue for Travelling Physicians By George Meyer, MD

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to e.LetterSSV Medicine@gmail. com.

I RECENTLY RETURNED FROM Nicaragua and Costa Rica where dengue is a common problem in both countries. It seems to be the worst it has ever been this year in Costa Rica, with both the capital city, San Jose, and the beach areas in Guanacaste province the worst hit. Since dengue has been an increasing problem in South and Central America, and there are many Sacramento residents travelling to areas where dengue is prominent, including the Deep South in the United States, I thought it would be helpful to SSVMS physicians to get a little primer on dengue. Dengue fever, an arthropod-borne RNA viral disease (mostly Aedes aegypti), can be a devastating disease to children and seems to be more severe in younger adults than older ones, with women thought to be more susceptible than men. Around 80 percent of those infected by the mosquito have asymptomatic disease. The incubation period is three to ten days and usually presents with fever and vomiting with retro-orbital pain and then generalized muscle and joint pain (breakbone fever), often with petechiae. The WBC is usually low. The fever can be quite high for several days, but usually lasts no more than seven days. Days four to six of the illness are usually when patients may develop hemorrhage and/ or shock. Once past this period, they begin to improve. After the fever has been gone for 72 hours, the patient is no longer considered to be contagious. Hospitalized patients with dengue are in beds with mosquito nets. After 72 hours of being afebrile, the mosquito nets are removed. The liver is often affected by dengue, and

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patients may have abnormal AST/ALT levels. Every patient diagnosed with dengue in the hospital in Nicaragua receives one liver ultrasound (U/S); if the liver is greater than two centimeters enlarged by U/S, this is considered a warning sign of severe disease. Dengue shock syndrome may also be anticipated by the finding of pericardial fluid on ultrasound. Probably the most worrisome finding is the low platelet count that seems to nadir on the last day of fever. (I saw two patients whose nadir was 40,000 platelets). The platelet count slowly recovers after the fever breaks. This can be a cause for hemorrhage, especially in children. There are four different strains of dengue. Talking to a few Peace Corps volunteers in Nicaragua, most have had dengue once. Post infection immunity is gained only for the infecting strain. If a patient acquires another strain, the disease is often more severe. PEARL: A patient who returns from a dengue area who develops fever more than 14 days after returning DOES NOT have dengue. geowmeyer1@earthlink.net

HealtHcare

reForM

Health care reform is in full-swing with the heftiest legislation set for 2014 — when health insurance will become available to millions of Americans who were previously uninsured.

tHe Basics For inDiviDuals

DiD you know? Beginning January 1, 2014, new regulations provide most Americans access to affordable health insurance that covers essential care. The regulations that facilitate this include: • Individual Mandate—Most individuals are required to have and maintain health insurance effective January 1, 2014. There are exceptions for certain individuals. • Penalty—If you elect not to purchase coverage, you are required to pay a penalty – in 2014: the greater of $95/individual (3 per family), or 1% of income – In 2015: the greater of $325/individual (3 per family), or 2% of income – In 2016: the greater of $695/individual (3 per family), or 2.5% of income • Guaranteed issue—Insurance companies must sell coverage to everyone, regardless of pre-existing conditions, and can’t charge more based on health or gender. • Health Insurance Exchange—Individuals without access to affordable, employer-sponsored plans that provide qualifying coverage can enroll in plans offered either through the individual insurance market or through Covered California with coverage beginning January 1, 2014. Open enrollment commences on October 1, 2013. If individuals don’t enroll with the exchange during the initial open enrollment period, they will have to wait until next year’s open enrollment period to obtain coverage. • Subsidies—Individuals and families may qualify for federal tax credits and benefit subsidies only through the exchange. Tax credits are available to those who meet certain income requirements and do not have access to affordable health insurance that meets minimum coverage standards offered through their employer or another government program. Eligibility for tax credits is based on family income and size. • Premiums—Premiums can only vary by age, geography and family composition. They may not vary by gender or health conditions. • Annual or lifetime limits—Individual and group plans may not impose limits on essential benefits. • Out of Pocket expenses—Limits out-of-pocket expenses for co-pays, co-insurance, deductibles, etc. to $6,350 per individual to a maximum of $12,700/family annually.

Sponsored by:

Starting in 2014, most Americans must have qualifying health coverage or pay a tax penalty. Options for coverage include insurance purchased through the individual market, a public exchange, a government program or an employer-sponsored program.

MiniMuM essential BeneFits incluDe: • Ambulatory services • Emergency services • Hospitalization • Maternity and newborn care • Mental health/substance abuse treatments • Prescription drugs • Rehabilitative services • Laboratory services • Preventive/wellness services • Pediatric services

learn More Stay tuned for more healthcare reform communication. In the meantime, please call Marsh/Seabury & Smith Insurance Program Management at 800-842-3761 for more information.

for more information, call a marsh client advisor at 800-842-3761. Marsh and the Society do not provide tax or legal advice. Please consult with your own advisors to determine how the law’s changes and your decisions impact your personal situation.

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 • d/b/a in CA Seabury & Smith Insurance Program Management 60979 (10/13) ©Seabury & Smith, Inc. 2013 • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com

Innovative Projects from the Med Tech Showcase By Bob LaPerriere, MD

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to e.LetterSSV Medicine@gmail. com.

SARTA, the Sacramento Regional Technology Alliance, is a non-profit organization founded to stimulate high-tech growth and attract investment capital to the greater Sacramento region. MedStart, started in 2008, is one of its programs with a focus on medical technology. In 2008, there were 73 medical technology companies. Today, 126 are located in the Greater Sacramento Area, supporting 5,000 jobs. Eighteen of these companies are new in the past year. SARTA produces an annual Med Tech Showcase that I recently attended. A few highlights of the conference include: The IBM artificial intelligence computer, Watson, was the winner on Jeopardy in 2011. Its predecessor, Deep Blue, beat the world chess champion in 1997. Watson is now trying to transform healthcare. Partnering with Memorial Sloan Kettering and WellPoint, Watson is now helping to fight cancer with evidence-based diagnosis and treatment suggestions. The student science team from Mira Loma High School, coached by teacher James Hill, was introduced. They recently won the 23rd Annual National Science Bowl. They also won it in 2009 and 2011. Five local companies participated in a panel, representing the following types of projects being developed in our area: Applied Science is a designer and manufacturer of next generation, integrated blood collection monitors and mixers for the global whole blood collection industry. Their products integrate the collection process and data management in an innovative and comprehensive manner. Care Innovations, an Intel/GE company, is

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focused on technology-based solutions to aid independent living in a unified way, while still meeting the unique needs of each person. HealthLinkNow is a fully-integrated online clinic integrating telemedicine, scheduling, practice management and electronic health records. It was recently awarded a $7.7 million CMS Innovation GrantÂ to provide telepsychiatry to patients in Montana and Wyoming where there is a severe shortage of psychiatrists and other mental health providers. Stratovan Corporation provides 3D surgical planning and diagnostic software with a recent addition that improves solid tumor evaluation. This same technology is being leveraged for detecting explosives in checked luggage. Wijit, Inc. (which recently sold to Rosevillebased Kinova USA) is the manufacturer and distributor of the revolutionary Wijit leverdrive and braking system for wheelchairs. Created by Brian Watwood, an incomplete quadriplegic who could not operate a push-

rim wheelchair, the Wijit eliminates the hand, wrist and shoulder injuries that are endemic with push-rim wheelchair use. It is faster (with a 1:2 leverage ratio) and out-maneuvers push-rim wheelchairs, and allows for far more effective cardiovascular workouts than any other wheelchair system. In addition to the Wijit, Kinova USA is also the national distributor for the Kinova JACO assistive robotic arm. JACO allows individuals with little or no use of their hands and arms to drink, eat, and perform a wide variety of tasks without assistance. With JACO, quadriplegics and those with Cerebral Palsy, Muscular Dystrophy, and any other disease or condition that limits upper extremity mobility can do for themselves tasks for which they currently rely on others. Eric Silfen, MD, VP and Chief Medical

Officer of Philips Healthcare, was the Keynote speaker during the dinner banquet. His talk was, “Innovation in the Medical Device Industry: Will the Phoenix Rise from the Ashes?“ The 2013 Claire Pomeroy Award for Innovation in Medical Technology was awarded to William Bargar, MD – Inventor of ROBODOC® a robotic surgical system for total knee and hip replacements.

At far left is the Kinova JACO robotic arm. Above is the Wijit wheelchair that features a lever drive and braking system. This allows for leveraged propulsion in forward and reverse, precise steering and powerful braking.

ssvmsmus@winfirst.com Further information: www.sarta.org/medstart/ www.sarta.org/William-Bargar-2013-award-winner.html www-03.ibm.com/innovation/us/watson/ www.sacbee.com/2013/04/29/5379267/mira-loma-seeks-thirdnational.html www.bizjournals.com/sacramento/news/2013/07/23/kinova-usaprepares-to-mass-produce.html www.sarta.org/brian-watwood-2012-award-winner.html

November/December 2013

Cold Laser Therapy – An Investigative Report By Jack Ostrich, 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.

LAST AUGUST 14, I VISITED a chiropractor to see what he might be able to do about my painful right knee. I do not have any pain in either knee, but I have been lately impressed by a proliferation of chiropractic advertisements aimed at people suffering, not just with neck and back pain, but also with common peripheral joint arthritic pain, as well as diabetes, thyroid disease, sleep disorders, irritable bowel symptoms, vertigo and even cardiac disorders. No longer, it seems, are some chiropractors limiting their practices to spinal disorders, and some are clearly claiming expertise in general medical practice. So it came to pass that I called Dr. Smith (not his real name) to request an appointment regarding my chronic right medial knee pain. The lady who took my call asked if I had a history of trauma (no) or if I had had any scans or X-rays (no), and she said that was not a problem because “the doctor can do a scan himself right here in the office” and that there was no additional charge for that (good deal). The cost for the consultation would be $35, just as the ad in the newspaper had promised, and that was a bargain since the customary fee for a first visit was $250 (really good deal!). She advised me that the consultation would take about 45 minutes and my significant other was also invited to be present (she declined). I was booked to see the doctor a week after my call, and I arrived 20 minutes early in order to fill out some paperwork and a questionnaire. The office is in a pleasant modern shopping mall in South Sacramento. Dr. Smith’s name is prominently on the door and a menu of his

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offered services is neatly printed on a window to the left of the door. They include “Functional Neurology,” “Functional Medicine,” “Detox and Anti-Aging Program,” and “DRX 9000 Non-Surgical Spinal Decompression,” among several (and I do mean several) others. I filled out a questionnaire and identified myself as a retired family practitioner. Nowhere in the questionnaire was there a request for past medical or surgical history, or which OTC or prescribed medications I might be taking. I mentioned my concerns to the receptionist and she said that Dr. Smith would cover those items when he interviewed me. The office was cheery and bright, and the staff was cheery and bright, as well. A portly middle-aged man sat next to me in the waiting room and asked me if it was my first visit. Having found out that it was, he then inquired what complaint had led me to Dr. Smith. He asked me if I had ever tried Tai Chi, as he had found it quite therapeutic for his own aches and pains, in addition to Dr. Smith’s ministrations, of course. He then recited his version of the origins and the philosophical and physiological underpinnings of Tai Chi. He rose from his chair and demonstrated a few Tai Chi-sy moves, as well. He was quite nimble. And he was still going at it when Dr. Smith emerged from the rear of the office complex, introduced himself and shook my hand. I mumbled some thanks to the Tai Chi master and followed Dr. Smith to his office. We chatted for a while, and I related my own medical educational history and my own experience in medical practice. I told him that

my right knee pain was always medial and it particularly bothered me when I played golf. I reported that my knee never became swollen. I said that I had been attracted by his newspaper advertisement regarding his use of cold laser and that I was interested in that treatment modality, as it certainly seemed safe, and I had tried long-term glucosamine without benefit and I did not want to use NSAIDs regularly, although I did find them helpful. He told me about his own background, and displayed his diplomas that included an MD from the American University of Antigua Medical School, his chiropractic degree, and a certificate of expertise in thermography from a chiropractic college in South Carolina. He also announced that he had a PhD in genetics from University of the Pacific, but had no diploma to show me for that course of study. When I returned to my home, I could find no doctoral program in genetics on the UOP website, although, of course, there might have been one in the past, and Dr. Smith’s own website makes no mention of his medical or genetics degrees. His office and exam room is open to the main hallway. There is no door, and a clear glass floor-to-ceiling partition, about a third of the way across the long axis of the room, separated the rather busy hallway from me as I sat facing him behind his desk. The glass partition, I suppose, made our conversation somewhat more private, but then he did not ask for any intimate personal or medical information other than some cursory questions about my knee pain. Unsolicited, I told him about the drugs I take for hypertension and elevated cholesterol. His only comment was that I should take supplementary Coenzyme Q-10 to help reduce the risk of “statin toxicity.” He wrote no notes regarding any of this. Maybe I was being recorded, but I doubt it. He next asked me to stand and roll up my pant legs to above my knees. He did not examine my knees except visually. He rolled out a machine that vaguely resembled the Disney cartoon character “Wall-E” from the 2008 movie of the same name. It was a thermographic

scanner, he explained, and he wanted to get the scan done to see how bad my knee degenerative disease, indeed, was. Behind Wall-E and in front of Dr. Smith and me was mounted a large video screen that displayed real-time thermograms generated by Wall-E. Sure enough, there appeared to be a bit more warmth along my medial right knee compared to the left. And “bit” is the operative word. Anyway, the difference was spectacular enough for Dr. Smith to announce that there was significant inflammation present and that it would be a worthy target for his cold laser. I then sat down and he told me that he wanted to do a neurological exam, necessary, he said, to discover if some subtle “brain or spinal nerve imbalance” might be causing undue stress on the right side of my body and secondarily on my poor right knee. The exam was fairly thorough, although he missed spinal nerves 1, 2, 5, 9, 10 and 12. He did not bother testing number 2, I suppose,

November/December 2013

since I had driven to his office, filled out some forms and followed him to his office without crashing into anything. He judged that I had a mild deficiency of light touch and two-point discrimination on my right side, and my rapid alternating hand movement test was a bit clumsier on the left (I am right-handed). My balance and general coordination, however, were quite excellent for a septuagenarian, he announced. (“In spite of all that cheap gin I drink,” I thought to myself.) Then we sat down to discuss his therapeutic recommendations. I rolled down my pant legs. He reached into a drawer and produced several bottles that he displayed on his desktop. He described each, and most were herbal mixtures. A couple were standard vitamin and mineral mixtures, and one was straight Coenzyme Q-10. He was confident that if I took all these pills and powders regularly – for how long? – I would achieve “detoxification” and my immune system would be greatly strengthened. He strongly urged me to take the products at least for as long as the cold laser treatments lasted, as doing that would most definitely improve the efficacy of the laser regimen. He was not at all concerned about any interaction with my prescribed medications, but offered that opinion only after I asked him if he, in fact, had any concerns.

EDITOR’S NOTE: A little online research describes Cold Laser Therapy or Low Level Laser Therapy (LLLT) as a treatment that utilizes specific wavelengths of light to interact with tissue and is thought to help accelerate the healing process. Cold lasers are handheld devices used by the clinician, often the size of a flashlight. The laser is placed directly over the injured area for 30 seconds to several minutes, depending on the size of the area being treated and the dose provided by the cold laser unit. During this time, the non-thermal photons of light that are emitted from the laser pass through the skin’s layers (the dermis, epidermis, and the subcutaneous tissue or tissue fat under the skin). This light has the ability to penetrate two to five centimeters below the skin at 90mw and 830 nm.

He charted out a course of laser encounters starting with three times a week for four weeks, then two times a week for four weeks, then once a week for four weeks, then wait and see. He said many people got better before the 12 weeks were up, and there would be a pro-rated refund if such a salubrious effect were to occur. But, on the other hand, many patients have had flares of pain even after complete relief and had to return for “tune-up” laser applications. The total cost was to be $3,000, in advance, and that included the vitamins and supplements for three months. Dr. Smith then politely escorted me back towards the waiting room area. En route, we stopped to admire his DRX 9000 spinal decompression machine. No one was in its grip as we passed. It looked big enough to accommodate Shaquille O’Neal. Adjacent to the DRX 9000 room was a room with seven or eight people all lying either supine or prone on contoured recliner chaises, some wearing what appeared to be small parachute packs on their lower backs or necks or anterior abdomens. They all looked happy and relaxed. A very old lady walked by as we stood looking at the happy relaxed people on the chaises. A younger woman was with her, but not touching her as she walked haltingly. She was almost audibly creaky. The younger woman said to me, “When my mother first came in here three months ago, it took two of us to get her from the car to the treatment room, and now she’s able to be back in her own home.” We got back to the waiting room and the Tai Chi master was no longer there. The room was empty except for Dr. Smith, myself, and the perky receptionist. Dr. Smith shook my hand, repeated his therapeutic advice and said to call for an appointment if I chose to pursue the laser schedule. He stood near the receptionist as she handed me a receipt for my $35 payment. We all said goodbye, but before I stepped out into the bright midday sun, I put on my sunglasses so as not to shock my rods and cones and my so far perfectly good pair of second cranial nerves. jmost119@aol.com

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SAVE THE DATE! Thursday, January 16, 2014 SSVMS & Alliance Annual Installation and Awards Dinner Hyatt Regency Hotel, 1209 L Street, Sacramento 6:00 pm Social; 6:45 pm Dinner; 7:30 pm Program

Installations Jose A. Arevalo, MD, President 2014 2014 SSVMS Officers and Board of Directors Award Presentations Golden Stethoscope Award • Medical Honor Award Medical Community Service Award • Dorothy Dozier Helping Hands Entertainment To Be Announced

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November/December 2013

Medical Reserve Corps Welcomes Volunteers By Lee O. Welter, MD, and Lynn Pesely, Coordinator, Sacramento Medical Reserve Corps

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.

CONSEQUENT TO THE SEPTEMBER 11, 2001 terrorist attacks, our government sought, by organizing and training volunteers, to improve future recovery and mitigation of similar events. The Sacramento Regional Medical Reserve Corps (SRMRC), the 42nd Medical Reserve Corps to be recognized nationally, was then organized and sponsored by Executive Sponsor Sacramento County Sheriff. An early member, the late Dr. Kenneth Ozawa, recruited physicians and other new members. The mission of the Medical Reserve Corps (MRC) is to improve the health and safety of communities across the country by organizing and utilizing public health, medical and other volunteers. One telling example of the value of organization and training for volunteers was an early wildfire in San Diego. Of the thousands of spontaneous volunteers who gathered at Qualcomm Stadium, it was mainly the military personnel – suitably trained, organized and equipped – who offered significant value. Another instructive example was the volunteer rescue of over 600 survivors of a large Mexico City earthquake in 1985. Sadly, lacking suitable training, equipment, and organization, 100 of those volunteers died in the effort. One wonders how much more successful the efforts would have been with better organization and preparedness. MRCs make a difference in disaster response and have a track record of doing so across the nation in times of flood, fire, hurricane and acts of terrorism. Most recently in Boston, MRC units were staffing medical treatment areas for the marathon. After the bombing incident, 200 volunteer MRC members turned their focus to

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disaster response and helped save lives. MRC members were active in the response effort after Hurricane Sandy in 2012. In response to fires in Southern California, San Diego’s MRC performed triage at area shelters. Trained MRC members, both medical professionals and support volunteers, contribute to response efforts and support public health throughout the year. The mission of the SRMRC is to engage volunteers to support public health, emergency response and community resiliency. The program has five focus areas: 1) To assist first responders with field triage in a large scale disaster; 2) To provide support to public health; 3) To provide triage and assistance to hospitals in a surge; 4) To provide medically-related support to shelters; and 5) To offer community support. Initially organized and managed by Sacramento Sheriff’s Lieutenant Paul Tassone as Sacramento Regional Medical Reserve Corps, the local group has undergone some organizational changes, including a change of name and of executive sponsor. Sacramento Office of Emergency Services is the new Executive Sponsor of Sacramento Medical Reserve Corps. Nearby counties of Yolo, El Dorado, and Placer now have separate, but still affiliated, chapters. The Sacramento Medical Reserve Corps (SMRC) membership of volunteer medical professionals (doctors, nurses, paramedics, EMTs and support members) has recently supported Sacramento County Division of Public Health with annual flu clinics and was active in H1N1 response efforts in 2009. The program recently supported the Sacramento Metropolitan Fire

District and the Sacramento County Sheriff’s Department by staffing medical treatment areas and by providing equipment and supplies for the response effort for “Rafting Gone Wild” on the American River. The program also supported the City of Sacramento by staffing cooling centers in response to the heat wave over the 4th of July holiday week. SMRC supports the community by providing first aid at public events, such as the recent California Capitol City Air Show and the annual Kid’s Day event at Hagan Park in Rancho Cordova. SMRC supports exercises for the City of Sacramento Police Department and the California Highway Patrol, and provides health screening services for at-risk populations. The SMRC is currently recruiting MDs, other medical professionals and support volunteers to join the program. Consider joining MRC! This is what some of our physician members have to say about their experience with the SMRC: “I’m volunteering because I am a New Orleans native and lived on the Mississippi Gulf Coast and wanted to help after Katrina.” –George Meyer, MD. “I joined as it is an opportunity to serve the community. As a retired physician, it is nice to be involved in medical support.” –Retired USN Admiral Bonnie Potter, MD. “The Medical Reserve Corps really needs all components of the medical field. I don’t think there is any doubt that the best patient care would be delivered by a coordinated medical care team led by the person with the most in-depth training in the field of medical care.” –Harold Renollet, MD. If, or more likely when, disaster threatens our community, medical professionals feel compelled to help with prevention, rescue and recovery. However, our familiar workplace site and team may not be accessible. Though unaffiliated volunteers may have value, those who have learned to work with an organized volunteer team typically are much more useful. SMRC offers education and training, along with team exercises, key equipment and supplies

which may be needed. Their work with regional Public Health departments leverages their knowledge and management, helping to meet their occasional need for large numbers of workers. Besides this serious preparation, MRC volunteers are well motivated, friendly, fun people with whom to work. With Sacramento at very high risk of major flooding, with auxiliary electrical generators below the likely flood level, and with hospitals largely useless without electrical power, those hospitals’ staff (if they are able to travel to where needed) would largely be useful in triage and evacuating patients. To be useful at a different institution, or in field operations, those same medical professionals would do best if they had joined an MRC. Membership in SMRC is readily available, with qualifications including a background check and willingness to complete valuable training such as basic life support (BLS/AED) and Incident Command System (ICS). SMRC membership meetings, usually held at 6:30 pm the third Tuesday of each month at Shriners Hospital for Children, welcome guests. Your attendance and participation help maintain and improve the health and safety of our community. For more information, go to www.srmrc.org.

The SMRC is currently recruiting MDs, other medical professionals and support volunteers to join the

lwelter916@att.net peselyl@sacoes.org

program.

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November/December 2013

Local Walk with a Doc is Going Strong By Kristine Wallach, Program Director

Walkers at the May 11, 2013 walk gather in McKinley Park. Doc leader, Richard Pan, MD, is to the right of banner.

ENTERING OUR SECOND FULL YEAR of the project, the SSVMS Walk with a Doc (WWAD) program is changing our focus and renewing our commitment. Created in 2005 by Dr. David Sabgir, a board-certified cardiologist at Mount Carmel St. Ann’s in Ohio, Walk with a Doc is currently in 26 states and four countries. The program seeks to encourage healthy physical activity in people of all ages, and to reverse the consequences of a sedentary lifestyle in order to improve the health and well-being of the country. Each WWAD event starts at 8:30 am on a Saturday with registration. At 8:45, the Doc leader talks for 10–15 minutes about a health issue of his or her choosing (usually

corresponding with their specialty and how exercise impacts it). At 9:00, the group walks for approximately 30 minutes. In May of 2012, the California Medical Association Foundation spearheaded a pilot project with a small grant from Anthem Blue Cross to bring Walk with a Doc to California by rolling it out to three county Medical Societies – Sierra Sacramento Valley, Fresno-Madera, and Humboldt-Del Norte. The statewide kickoff walk was held at the Capitol on September 29, 2012. In the fall of 2012, SSVMS produced three WWAD events in Sacramento parks and one at the UC Davis Arboretum. In 2013, SSVMS scheduled 16 WWAD events around Sacramento County (13 completed to date with a total attendance so far of 282), and has received sponsorship from the SSVMS Alliance. In 2014, SSVMS has plans to schedule one walk per month, linking our walks to the Sierra Health Foundation Healthy Communities Coalition Communities of Focus. The Healthy Sacramento Coalition (www.sierrahealth.org/healthy sacramento) is a group effort that includes more than 40 organizations working to reduce chronic disease and to improve health for all Sacramento County residents. The Healthy Sacramento Coalition is funded by a Community Transformation Grant provided by the Centers for Disease continued on page 28

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Is Gastroenterology Just a Designer Specialty? The Nicaraguan Experience

By Michael Lawson, MD AS I DO MY 10TH COLONOSCOPY for the day, I ponder the questions raised by the New York Times and the Washington Post, “Am I the cause for the rising cost of Healthcare? But aren’t I saving lives?” You have a three percent chance of dying from colon cancer and I am reducing that risk to 1.5 percent. Studies show you can do the same with exercise and aspirin, but the public believes indoctrinated celebrities, not scientists. As atonement for my sins I published an article titled, “The Cecal Stampede: The Headlong Rush to Colonoscopy,”1 questioning the impact of colonoscopy on overall survival rates. Still feeling guilty, I pondered whether I could be of more use to mankind. Gastroenterologists have other skills that the general public doesn’t appreciate. We do have the ability to endoscopically remove polyps, but we can also remove common bile duct stones and place stents across benign and malignant luminal strictures. I was fortunate to be included in the Nicaraguan Medicos Program established by Vice Dean Michael Wilkes, MD, of UC Davis. During the first two years of my mentorship, beginning in 2008, I offered my services as a general internist seeing urgent care type problems in steamy outpatient clinics and teaching the UCD students about the woes of patients, usually women, trapped in a third world country ravaged by a tragic civil war and rampant domestic abuse. The mental scars resulted in some of the worst functional and somatic complaints I have ever seen. I did my best, but felt I could do more.

By some strange luck, I met the Nicaraguan general surgeons working within the free government system in Leon. They asked me to help with a difficult endoscopy. They were having trouble canulating a patient’s strictured common bile duct. They were using antiquated fiber optic endoscopy equipment with unreliable fluoroscopy. They handed me the scope and a bent-over used needle knife – no glucagon here to stop the duodenum from spasming! By shear blind luck, I punctured the CBD and obtained a cholangiogram. From then on they treated me like a rock star, unaware of my reliance on complete serendipity. However, our alliance was forged and the relationship transcended language barriers. Gall stone disease has reached epidemic proportions in Central America, and I have become part of the crusade against it. I have even removed an impacted cholesterol common bile duct stone in an 11-year-old girl. I was able to acquire recently-donated endoscopes and an array of accessories to support a high profile endoscopic biliary service to give Nicaraguans across the country access to a free, sometime life-saving technique. Phillips donated a decent fluoroscopic C Arm. Each year since, I have travelled with endoscopy donations to Leon, and alongside a colleague from Spain, Miguel Simon, we have taught these dedicated surgeons the best techniques we can. Each year I have seen great improvements in confidence and skill. The common bile duct cannulation rates and stone retrieval rates have gone from 50 percent to a respectable 80 November/December 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.

percent. The extent of the sphincterotomies has gone from a tentative 5 mm to an aggressive 1.5 cm. We churn through 20 to 30 cases a week. I now receive emails boasting weekly solo numbers of cases around a respectable five to seven patients a week. Every time I leave Nicaragua now, I feel that I have left behind equipment and expertise that have advanced the medical care of a poor population in need of an expert specialist service. In return, UC Davis medical students are welcomed into the OR. They see the challenges that we face and the aggressive risks, despite limited resources, we need to take to meet these challenges. The U.S. public and U.S. government

need to look beyond a test like colonoscopy that has been oversold, to other skills that gastroenterologists provide. In turn, the American Gastroenterology Association and American College of Gastroenterology should promote and advertise these skills and offer teaching of these techniques in underdeveloped countries. The need is there, and many lives can be saved. Michael.J.Lawson@kp.org Reference: 1 Dig Dis Sci 2008;53(4):871-4

Walk with a Doc continued from page 26

Walk leaders at the August 18, 2013 walk at Howe Park were Steve Polansky, MD, Larry Saltzman, MD, and Larry Lieb, MD.

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Control and Prevention to support state and local groups that are trying to reduce chronic disease. An analysis of both primary and secondary data revealed that there are 15 zip codes in Sacramento County experiencing a high burden of disease, and having consistently high rates of poor health outcomes (above county, state and Healthy People 2020 benchmarks) related to chronic disease and mental health. These zip codes are:Â 95660, 95673, 95815, 95821, 95838, 95841, 95817, 95820, 95822, 95823, 95824, 95828, 95832, 95811, and 95814. We are working with Parks and Recreation departments in these zip codes to locate parks to host Walk with a Doc events in 2014. Linking with the Communities of Focus offers the opportunity to collaborate with existing community coalitions and stakeholders to increase publicity and participation. If you are interested in leading a walk in 2014, please contact Kris Wallach at (916) 453-0254 or kwallach@ssvms.org.

A Posit on Lung Cancer Screening “Low-dose CT scan screening of patients for lung cancer is just another high-tech, high-cost, low-return boondoggle.”

Background: On July 30, 2013, the U.S. Preventative Services Task Force released its preliminary recommendation that physicians screen high-risk, 55-79-year-old adults for lung cancer on an annual basis using low-dose CT scans. (High risk means 30 “pack-years” of smoking.) In the National Lung Screening Trial (NLST), almost 25 percent of screening tests were positive, but 96 percent of these were false positives, leading to worry, further scans, possible biopsy. On the benefits’ side, the Number Needed to Screen (NNS) to prevent a death from lung cancer over 6.5 years of screening is 320. For mammography in one’s 50s, breast cancer and sigmoidoscopy/colon cancer, the NNS is 1339 and 817, respectively. 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: 25/Agree – 16/Disagree. Commentary follows: This seems like another expensive and potentially risky test, recommended by nationally-anointed experts, that will provide minimal public health benefit. In addition, the responsibility to recommend it will fall mainly on primary care docs, and failing to recommend it will, no doubt, increase their malpractice risk. Unnecessary risks for patients will include radiation exposure, the anxiety over abnormal and possibly false positive findings, and biopsy procedures that can, of course, produce their own constellation of untoward events. –John Ostrich, MD

Lung cancer is the leading cause of cancer deaths in the U.S. CT screening in targeted patients who are at high risk for lung cancer can reduce mortality from lung cancer. –Seth Rosenthal, MD I strongly disagree with the posit. Screening, in accordance with the NLST inclusion criteria, clearly has its benefits, comparing rather favorably to national breast and colon cancer screening guidelines. But here is the real question: Who should pay for it? High-risk smokers? In other words, not me, and not society at large. Another tax on cigarettes might do the trick. Another challenge will be leadership to encourage compliance with screening criteria. Perhaps we will see a “PI-RADS” (Pulmonary Imaging Reporting and Data System) someday. –Don Udall, MD I believe the test has merit; however, it may be that both the definition of “high risk,” as well as the decision algorithm that follows a “positive” screening test, require further modification to minimize the risk of death from the screening process (i.e. positive screen leads to invasive and potentially lethal invasive diagnostic test). –Matthew Sena, MD Is the high false-positive rate better than a coin flip? Seriously, there are better methods on the horizon. Genetic testing of lung cancer has shown there are some 60 types of lung cancer, a few of which now have specific effective treatment for those individuals with that type of lung cancer. Inexpensive mass nanotechnology blood testing will become available in the near future (at your neighborhood Walgreen’s). Identification and detection of cancer specific or November/December 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. 29

…here is the real question: Who should pay for it?

susceptible blood-borne proteins and genes will avoid false positives and give earlier diagnosis of lung and other cancers. These innovations will require adaptation by our profession, as well as help our patients. –Richard Park, MD Unlike breast and colon cancer, there are no good treatments for advanced stages of lung cancer. While the value of screening in these cancers is widely accepted, contemporary success treating all stages of these cancers dilutes the effectiveness of the screen. This is not the case for lung cancer, where survival is quite good if surgically resectable, and quite bad if it is not. As the meta-analysis shows, in this situation it pays to screen. –Michael Chow, MD With an NNS that bests other commonlyaccepted practices such as breast cancer and colon cancer screening, the question should turn from whether we should offer this screening to how can we offer this screening in a cost-effective and coordinated fashion in the community that follows the inclusion and exclusion criteria of the study? In addition, we should be asking and hoping that further research will help us flesh out the gray areas that this creates. For example, will three annual screenings at ages 55, 56, and 57 truly impact cancer risk at age 72, or will further scans be necessary? Further, will it be possible to match a high-sensitivity test with a high-specificity test to help us reduce the falsepositive rate? –Seth Robinson, MD Lung cancer is deadly, and the experts at the USPSTF are no dummies. But the collateral

damage from this screening will be severe. In their recent September 5th NEJM study, McWilliams, et al, looked at data from Canada where 12,029 nodules were detected by low-dose CT screening among 2,961 patients. Only 144 out of the 12,029 nodules proved to be cancer (about five percent of patients with nodules). The rest of the patients had unnecessary scans and biopsies. One could argue that a lung biopsy is more risky than a breast or colon polyp biopsy. –Nathan Hitzeman, MD The USPSTF holds screening tests to rigorous standards, and they reject many as “not recommended” or “insufficient evidence,” and they get a lot of flack for that. So when they actually endorse a screening test, I think we should listen. –Howard Slyter, Jr., MD I disagree. As one who was a very heavy smoker for 40+ years, I want every survival opportunity available, even at my advanced age. –Albert Kahane, MD Pitiful scientific analysis with statistical manipulation. –Roland DeMarco, MD I think it is a useful adjunct to helping decide on screening for lung cancer. –Ghayyur Qureshi, MD I disagree with the posit. I think if imaging reduces lung cancer mortality, we should do it. –Ann Richardson, MD I am happy that there is “truth” being reported about failed ideas. Is anyone paying attention to this? –Elisabeth Mathew, MD

Guilt-Free Recipes continued from page 15 3. Press thinly and evenly onto prepared baking sheet. One recipe will make about a 10-inch pie. 4. Bake at 450F for 8-10 minutes. 5. Remove from heat and add alfredo, pesto or tomato-based sauce. Add toppings. Meat must not be raw. 6. Return to 450F oven for 8-10 minutes or until cheese is melted and edges are slightly brown. 7. Slice and remove to serving plate while still 30

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slightly warm. Each pizza crust provides 405 calories before topping. Notes: This makes a thin crust pizza. Prepare cauliflower by grating or pulsing in a food processor until the size of rice or meal. Personal experience suggests parchment paper is superior to cooking spray for reducing likelihood of crust sticking. Leftover cauliflower can be used as rice. I add a teaspoon of toasted sesame oil to increase nutty flavor.

Board Briefs September 9, 2013 The Board: Received an update from Dustin Corcoran, CEO, California Medical Association, regarding the trial lawyers ballot initiative to overturn MICRA, the Medical Injury Compensation Reform Act. Received an update from the following county public health officers: Olivia Kasirye, MD, Sacramento; Alicia Paris-Pombo, MD, El Dorado; Connie Caldwell, MD, Yolo. Approved the 2013 Second Quarter Financial Statements and Investment Reports. It was noted that SSVMS membership is at a historic high of 2,915, and for the 7 months ending July 2013, SSVMS has exceeded its annual budget for dues-related income. Approved the SSVMS endorsement of Dr. Jason Bynum’s CMA Resolution, “Services for Mentally Ill Students,” scheduled to be considered at the 2013 CMA House of Delegates. Approved the Membership Report: For Active Membership — Nova R. Aguila, MD; Shannon H. Beal, MD; Jens Bjeregaard, MD; Erin A. Boyd, MD; Asad A. Chaudhary, MD; Kenneth H. Cheung, MD; Julie M. Chinn, MD; Jason K. Deitchman, MD; Jacob J. Dima, DO; Huy T. Duong, MD; Christine A. Griger, MD; Saman Hayatdavoudi, MD; Ed J. Hendricks, MD; Dylan B. Hickey, DO; Julie L. Ingwerson, MD; Juliet LaMers, MD; Daniel P. Lavery, MD; Reza Pirsaheli, MD; Javier R. Rangel, Jr., MD; Usha K. Rao, MD; Deanne M. Roberts, MD; Ashish Sharma, MD; Charles Shieh, MD; Baljit S. Sivia, MD; Nell V. Suby, MD; You S. Tay, MD; Marie L. Truong, DO; Walter D. Hyuen, DO. For Reinstatement to Active Membership – Dawei (David) Zheng, MD. For Resident Membership — Elizabeth I. Ekpo, MD; Erik R. Elchico, MD; Charles H. Feng, MD; Ronald T. Garcia; Michelle Y. Hamline, MD; Matthew W. Harrison, MD; Jared R. Hylton, MD; James H. Jones, MD; Ian M. Julie, MD; Benjamin J. Koo, MD; Syed R. Latif, MD: Shelena

D. Laws, MD; Daivd Li, MD; Jamal M. Mohammed, MD; Megan M. Petersen, MD; Emily Z. Ritchie, MD; Kathleen S. Romanowski, MD; Jaspreet Singh, MD; David H. Sun, MD; Zin M. Tun, MD; Terry Vien, DO; Kimberly P. Yu, MD. For Resignation — Nathaniel G. Lane, MD (transferred to Orange County); Mark D. Levine, MD (transferred to San Francisco); Henry J. Schwartz, MD (transferred to Sonoma). Approved revisions to the following SSVMS Policies: SSVMS Statement of Investment Policy and Board Review of SSVMS Financial and Investment Performance. It was noted that revisions to these policies are in response to a recommendation from the Auditor that the accounting policies for the Community Service, Education and Research Fund, a 501(c)(3) organization and its William E. Dochterman Medical Student Scholarship Fund be established separate from the SSVMS accounting policies. Serving as the Board of Directors for the Community Service, Education and Research Fund (CSERF), the Board: Approved the following Community Service, Education and Research Fund (CSERF) Policies: CSERF Statement of Investment Policy, Board Review of CSERF Financial and Investment Performance Policy. Also approved was the CSERF Policy, William E. Dochterman Medical Student Scholarship Fund, establishing the scholarship fund as a component of CSERF. Approved the recommendation from the Scholarship and Awards Committee to award 2013 William E. Dochterman Medical Student Scholarship to the following applicants: Oluyemi A. Ajirotutu, 4th year student at Charles Drew University/UCLA Medical Education Program; Brnadon J. Cortez, 2nd year student at UC San Diego School of Medicine; Yangfan Luo, 1st year student at Keck School of Medicine/University of Southern California; Andrea L. Nos, 4th year student at Loyola University Stritch School of Medicine; Akhilesh S. Pathipati, 1st year student at Stanford University School of Medicine.

November/December 2013

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. â&#x20AC;&#x201D; Jason P. Bynum, MD, Secretary.

Aguila, Nova R., Family/Geriatric Medicine, University of Santo Tomas, Philippines 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Das, Anne, Transfusion Medicine/Blood Banking, Maharashtra University, India 2004, BloodSource, 10536 Peter A McCuen Blvd., Mather 95655 (916) 456-1500

Beal, Shannon H., Vascular Surgery, University of Tennessee 2005, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Deitchman, Jason K., Family Medicine, UC Davis 2010, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Bewley, Abigail M., Pediatrics, Columbia University 2009, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-6800

Dima, Jacob J., DO, Family Medicine, Western University Health Sciences 2010, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 973-5000

Kuo, Wen En, Dermatology, Medical College of Georgia 2009, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 631-3010

Dumani, Donny A., Transfusion Medicine, UC San Diego 2008, BloodSource, 10536 Peter A McCuen Blvd., Mather 95655 (916) 456-1500

Kurlinkus, Charles E., Emergency Medicine, UC Davis 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6600

Duong, Huy T., Neurosurgery/Neurosurgical Oncology/Skull Base Surgery, UC Davis 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490

La Mers, Juliet, Emergency/Family Medicine, Tulane University 1989, Emergency Physicians Medical Group/Marshall Medical Center, 1100 Marshall Wy, Placerville 95667 (530) 626-2717

Eduljee, Arish Y., Neurology, Govt Med College/ South Gujarat Univ, India 1996, Woodland Clinic Medical Group, 515 Fairchild Ct, Woodland 95695 (530) 668-2600

Lavery, Daniel P., Neurology, Ohio State University 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5175

Bir, Natasha D., General Surgery, UC Davis 2004, Woodland Clinic Medical Group, 1321 Cottonwood St, 2nd Fl, Woodland 95695 (530) 668-2600 Bjerregaard, Jens, Anesthesiology, St. Louis University 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Boskovitz, Abraham, Neurosurgery, University of De Lausanne, Switzerland 1998, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5490 Boyd, Erin A., Internal Medicine/Hospitalist, University of Michigan 2008, Mercy Medical Group/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5000 Brayley, Jason D., Family/Sports Medicine, Loma Linda University 2001, The Permanente Medical Group, 10305 Promenade Parkway, Elk Grove 95757 (916) 544-6300 Bromfield, Christian S., Orthopedic/Orthopedic Trauma Surgery, University of Southern California 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2030 Carroll (Stott), Catherine V., Internal Medicine, UC Davis 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Chaudhary, Asad A., Neurology/Vascular Neurology, University of Punjab, Pakistan 2002, Mercy Medical Group, 8220 Wymark Dr, #200, Elk Grove 95757 (916) 667-0600 Cheung, Kenneth H., Neurology, UC Davis 2009, Mercy Medical Group, 8220 Wymark Dr, #200, Elk Grove 95757 (916) 667-0600 Chinn, Julie M., Pediatrics, Oregon Health Sciences University 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Cotton, Dale M., Emergency Medicine, Cornell University 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Griger, Christine A., Pediatric/Administrative Medicine, Jefferson Medical College 1974, Sutter Medical Group, 2800 L St, 7th Floor, Sacramento 95816 (916) 454-6634 Haider, Khursheed, Critical Care Medicine, Hamdard College of Medicine, Pakistan 2000, Mercy Medical Group, 6501 Coyle Ave, Carmichael 95608 (916) 536-3079 Hamline, Michelle Y., Pediatrics, University of Minnesota 2013, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Hayatdavoudi, Saman, Pulmonary/Critical Care Medicine, Ross University 2005, Pulmonary Medicine Associates, 1485 River Park Dr #200, Sacramento 95815 (916) 325-1040 Hendricks, Ed J., Obesity/Bariatric Medicine/ Pathology, Columbia University 1961, 2621 Capitol Ave #B, Sacramento 95816 (916) 551-1999 Hickey, Dylan B., DO, Family Medicine, Touro University 2010, Mercy Medical Group/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5000 Hughes, Jonathan A., Transfusion Medicine, Wayne State University 2007, BloodSource, 1056 Peter A McCuen Blvd., Mather 95655 (916) 456-1500 Ingwerson, Julie L., Physical Medicine & Rehabilitation/Sports Medicine, Creighton University 2008, The Permanente Medical Group, 10305 Promenade Pkwy, Elk Grove 95757 (916) 544-6300

Sierra Sacramento Valley Medicine

Kellenbeck, Erica S., Emergency Medicine, University of Washington 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Koshy, Maria T., Psychiatry, Rush Medical College 2009, The Permanente Medical Group, 7300 Wyndham Dr, Sacramento 95823 (916) 525-6100

Laws, Shelena D., Emergency Medicine, UC Irvine 2011, UCDMC, 2315 Stockton Blvd., PSSB#2100, Sacramento 95817 (916) 734-2011 (Resident Member) Lee, Samuel H., Ophthalmology, Loma Linda University 2008, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4015 Lemos, Bianca C., Dermatology/Mohs Surgery, University of Pittsburgh 2005, The Permanente Medical Group, 10725 International Dr, Rancho Cordova 95670 (916) 631-3010 Lupa, Michael D., Otolaryngology/Rhinology/Allergy/ Skull Base Surgery, Case Western Reserve 2006, The Permanente Medical Group, 1600 Eureka Rd, Roseville 95661 (916) 784-5880 Lurvey, Robert B., Urology, University of Illinois 2011, UCDMC, 4860 Y St #2200, Sacramento 95817 (916) 734-2222 (Resident Member) Manglik, Shruti, Internal Medicine, University of Iowa 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Manzoor, Shahid, Family Medicine/Hospitalist, University of Karachi, Pakistan 2002, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Mendoza, Amelia D.M., Family Medicine, University of Santo Tomas, Philippines 2007, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3540

Meredith, Dennis S., Orthopedic/Spine Surgery, Harvard University 2007, Woodland Clinic Medical Group, 632 W. Gibson Rd, Woodland 95695 (530) 668-2630

Rao, Usha K., Internal Medicine/Hospitalist, Texas Tech University 2010, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Nandan, Yogesh, Internal Medicine/Hospitalist, Ross University 2004, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Reichert, Sonia E., Hematology/Oncology, Our Lady of Fatima University, Philippines 2004, Woodland Clinic Medical Group, 515 Fairchild Ct, Woodland 95695 (530) 688-2600

Naqvi, Ali, Emergency Medicine, SUNY-Buffalo 2012, UCDMC, 2315 Stockton Blvd., Sacramento 95817 (916) 734-2011 (Resident Member) Neumann, Anne M., DO, Family Medicine, Touro University 2010, Woodland Clinic Medical Group, 1207 Fairchild Ct, Woodland 95695 (530) 666-1631 Nonis, Pradeepa S., Internal Medicine, University of Peradeniya, Sri Lanka 2007, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Notash, Mark A., Emergency Medicine, Northeastern University 2006, CEP/Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5000 Pirsaheli, Reza, Neurology/Stroke, Azad Medical School, Tehran 2001, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Rafii, Flora I., Pediatrics, UC Davis 2008, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4060 Rangel, Javier R., Dermatology/Dermatopathology, UC San Francisco 2007, The Permanente Medical Group, 2345 Fair Oaks Blvd., Sacramento 95825 (916) 631-3010

Roberts, Deanne M., Otolaryngology, Vanderbilt University 2008, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3560 Rose, Natalie C., OB-GYN, UC San Diego 2009, The Permanente Medical Group, 1650 Response Rd, Sacramento 95815 (916) 614-4055 Scharf, John E., Hospice/Palliative Medicine, Virginia Commonwealth 1986, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 977-3095 Sharma, Ashish, Gastroenterology, Osmania Medical College, India 1990, The Permanente Medical Group, 2025 Morse Ave, Sacramento 9585 (916) 973-5000 Shieh, Charles, Cardiothoracic Surgery, Vanderbilt University 2002, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Singh, Gurpreet, Gastroenterology, SUNYDownstate 2007, Woodland Clinic Medical Group, 1321 Cottonwood St, Woodland 95695 (530) 688-2618

Sonik-Spielvogel, Sonia, Internal Medicine, UC Davis 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Sood, Sunita T., Gastroenterology, Ross University 2005, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Suby, Nell V., Gynecologic Oncology, University of North Dakota 2006, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000 Tay, You S., Endocrinology, University of Nevada 2008, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-6200 Truong, Marie L., DO, Psychiatry/Child & Adolescent Psychiatry, Western University School of Health Sciences 2008, The Permanente Medical Group, 2008 Morse Ave, Sacramento 95825 (916) 973-5300 Waechter, Neal R., Internal Medicine/Hospitalist, University of Michigan 1998, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2000 Wu, Peggy S., Radiology, Boston University 2007, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2029 Yuen, Walter D., DO, Internal Medicine, Western University Health Sciences, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Yuen, Wing-Yan (Cindy), Family Medicine, Ross University 2010, Mercy Medical Group, 1264 Hawks Flight Ct, El Dorado Hills 95762 (916) 939-9773

Sivia, Baljit S., Internal Medicine, Ross University 2010, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

November/December 2013

Classified Advertising

Office Space

Doctor-Mentors Needed

Medical Office. Like new. 1,200 sf, 3 exam rooms, large waiting room, 1355 Florin at Freeport, (916) 730-4494.

Are you a physician willing to donate a few hours of your time to mentor eager new medical students? The Willow Clinic, an affiliated UC Davis School of Medicine program, needs doctors like you. We’re recruiting friendly people with a desire to teach the next generation of physicians and to help the community. The clinic serves Sacramento’s homeless and is open every Saturday from 9 a.m. to 1 p.m. Volunteer physicians are welcome on a one-time only or rotating basis. For further information, contact: eabrezinski@ucdavis.edu.

Office Space to Share: 7600 Hospital Dr. next to Methodist Hosp. of Sacramento. 2400sqft, 6 exam/procedure rooms. Ideal for FP or OB/GYN. Contact K.A. Overton MD by email kaomdinc@netzero.net or (916) 681-4434.

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Subscription Services, Inc. 1.800.289.6247 / www.buymags.com/cma

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1.800.253.7880 / www.medicalert.org/cma

Medical School Debt Management Members-only coupon required: www.cmanet.org/membership-benefits Practice Financing Reduced Loan Administration Fees

Members-only coupon code is required 1.800.786.4262 / www.cmanet.org/benefits

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Contact CMA at 888.401.5911 or email economicservices@cmanet.org

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All SSVMS Members $100,000 Automatic Policy http://www.ssvms.org/Membership/ BenefitsandServices.aspx

Sierra Sacramento Valley Medicine

Saturday, November 16, 2013 LOCATION: Tahoe Park 3501 59th Street, Sacramento Saturday, December 7, 2013 LOCATION: Southside Park 2115 6th Street, Sacramento

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