2014-Jul/Aug - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

July/August 2014

  The Sierra Sacramento Valley Medical Society is dedicated to bringing together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.

  Unified Voice of All Physicians o Promote inclusiveness to members and prospective members o Collaborate across health systems and medical groups o Advance legislative advocacy for physician and physician-patient issues o Realign committees and councils with mission statement and strategic goals  Membership Retention and Growth o Effectively communicate value of membership to members and prospective members o Strive to meet the individual needs of all members o Promote members-only benefits and services  Promote and Protect Access to Care o Defeat trail-attorney threat to the Medical Injury Compensation and Reform Act (MICRA) o Develop and promote resources to enhance physician practice viability o Advance legislative advocacy for physicians and physician-patient issues  Enhance physical and mental health of our community o Expand physician volunteer opportunities through the Community Service, Education and Research Fund (CSERF) o Expand services provided to the region’s uninsured and medically indigent through the Sacramento Physicians Initiative to Reach out, Innovate and Teach (SPIRIT) program o Work collaboratively to address mental health needs of our community  (See the SSVMS President’s Message by José A. Arévalo, MD, on Page 3)

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

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Medicine 3

PRESIDENT’S MESSAGE Our Revitalized Strategic Plan for 2014–2018

The Deal Hasn’t Changed

Sean Deane, MD

José A. Arévalo, MD

BOOK REVIEW The Melba Notebooks

EDITOR’S MESSAGE Transitions of Care

Reviewed by Jack Ostrich, MD

Nathan Hitzeman, MD

SSVMS Alliance Review

EXECUTIVE DIRECTOR’S MESSAGE Increased Costs, Losing Doctors and Privacy

Kim Majetich, SSVMS Alliance President

BOOK REVIEW The Red Market

Aileen Wetzel, Executive Director

Reviewed by Nathan Hitzeman, MD

Fractals – the Geometry of the Natural World

A Posit on Medical Tourism

2014 Education Series

IN MEMORIAM Alton Gene Wills, MD

IN MEMORIAM Gail Mynard, MD

IN MEMORIAM Richard M. Ikeda, MD

Bob LaPerriere, MD

Who are the Uninsured Now?

Glennah Trochet, MD

New Ear

Thomas N. Atkins, MD

Dietary Sodium: Dogma, Doubt, Delusion

Ann Gerhardt, MD

SPIRIT 2014 and Beyond

Board Briefs

Kris Wallach, SPIRIT Program Director

Meet the Applicants

Classified Ads

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 Fractals are the geometry of the natural world which contains irregular surfaces, shapes, edges and corners that cannot be described by traditional (Euclidian) geometry. Their irregular repeating shapes are found in clouds, tree limbs, stalks of broccoli and mountain ranges − from beautiful symmetry to the chaotic. They are everywhere we look. With the aid of computers and specialized software, one can create beautiful images. Dr. Bob LaPerriere experimented with this lovely poppy image and created the fractal on our cover. Read more about his fun creations on page 8.

July/August 2014

Volume 65/Number 4 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

MEDICINE Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. 2014 Officers & Board of Directors José A. Arévalo, MD President Jason Bynum, MD, President-Elect David Herbert, MD, Immediate Past President District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Tom Ormiston, MD

District 1 Robert Kahle, MD District 2 Ann Gerhardt, MD Vijay Khatri, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD 2014 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Elisabeth Mathew, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Richard Gray, MD Karen Hopp, MD Maynard Johnston, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD

District 1 Jeffrey Cragun, MD District 2 Richard Pan, MD, Assemblyman District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large John Belko, MD Natasha Bir, MD Helen Biren, MD Gregory Blair, MD Kevin Elliott, MD Alan Ertle, MD Benjamin Franc, MD Karna Gocke, MD Thomas Kaniff, MD Vijay Khatri, MD Don Wreden, MD

CMA Trustees District 11 Barbara Arnold, MD

Douglas Brosnan, 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 John Paul Aboubechara, MS II John Belko, MD George Meyer, MD Sean Deane, MD John Ostrich, MD Ann Gerhardt, MD Gerald Rogan, MD Sandra Hand, MD Glennah Trochet, MD Albert Kahane, MD Lee Welter, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Adam Dougherty, MD Shahid Manzoor, MD Executive Director Managing Editor Webmaster Graphic Design

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Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2014 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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President’s Message

Our Revitalized Strategic Plan for 2014–2018 By José A. Arévalo, MD THE SIERRA SACRAMENTO Valley Medical Society (SSVMS) has worked for more than 154 years to address the challenges facing local physicians and their patients. SSVMS owes its success to setting and resetting goals relevant to the ever-changing healthcare environment, and to the many physicians throughout the years who have provided effective leadership. Earlier this year, the SSVMS Board of Directors initiated a revitalized strategic plan along with an extensive effort to solicit input from physicians practicing in El Dorado, Sacramento, and Yolo counties. At our March retreat, the SSVMS Board created a new mission, vision, and values of SSVMS, along with four key strategies. During the retreat, the Board worked in sub-groups to identify goals and actions for accomplishing the strategies. The resulting Strategic Plan, approved by the SSVMS Board on May 12, provides guidance to our work over the next three to five years. The plan focuses on how we will serve our membership and have the greatest positive impact on our community. The plan also lays out our priorities and aligns our activities so we can measure our success along the way. The top priorities are to be the unified voice of physicians and to promote inclusiveness of all physicians, to enhance membership retention and growth by communicating the value of membership to members and prospective members, to advocate for physicians and patients by protecting MICRA, to ensure practice viability and patient access to care, and to enhance the physical and mental health of our community. These priorities are evident in our new

mission statement: “The Sierra Sacramento Valley Medical Society is dedicated to bringing together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.” (See the full plan inside the front cover of this issue.) SSVMS is fortunate to benefit from dynamic physician participation and from collaborative opportunities with other organizations. I would like to personally thank our superb physician leaders and our outstanding staff for their contributions to our new Strategic Plan. We believe these efforts will be rewarded with a more cohesive and effective SSVMS. arevalJ@sutterhealth.org

Walk with a Doc is FREE to anyone who is interested in taking steps to improve their heart health.

Saturday, July 19, 2014 LOCATION: George Sim Park, To volunteer, or for more information, Sacramento contact Kris Wallach at 916 453‐0254 or kwallach@ssvms.org Saturday, August 2, 2014 LOCATION: South Natomas Community Park, Sacramento Sponsored by: Saturday, September 20, 2014 LOCATION: Foothill Community Park, Sacramento Supported by: For details, visit www.ssvms.org/events.aspx

July/August 2014

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

Transitions of Care 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.

ON MY RECENT RETURN FROM an annual medical trip to Nicaragua, I found myself stuck in Houston while flying the friendly skies. Over a 24-hour period, my wife and I changed gates about a dozen times, and the flight kept being delayed in 30-minute increments leading to chronic angst over when the real departure would be. None of the customer service staff seemed to know what was going on or what we were going through. I imagined all the moving parts of the airport and how things have evolved over the years. Medicine and the airline industry are often compared in the literature as they involve complex processes, and many lives are at stake. The good news is that, in many ways, flying and medicine have become safer over time. I remember sitting one aisle in front of the smoking section of the plane and asking my mom why smoke was coming into the nonsmoking section. Furthermore, better plane design and automation have led to fewer crashes. Medicine has become safer in the use of protocols and safety checks. Central line infections have decreased by more than 50 percent over the past decade, according to the CDC. We rarely saw off the wrong limb anymore and helpful pharmacy staff catch some of those pesky drug-drug interactions. Yet somewhere along the way, the personal touch seems to have suffered. I recall flying alone as a child and getting the special cockpit tour and the wings pinned on my shirt. I could ring my call button for just about any concern. I didn’t have to pay for a hot meal, let alone a cold one. Now there is a certain “roteness” and livestock feel to air travel. There is also liability paranoia to the extent that we have to be warned of “overhead contents” shifting. Similarly, medicine has evolved where people are moved in and out of the hospital

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as fast as possible and the staff changes over at lightning speed. Writer/surgeon, Atul Gawande, actually counted the number of staff (63) who cared for his mother during a brief hospitalization for a knee replacement. “The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience.” In a 2011 Health Affairs article titled, “Jiffy Boob,” Dr. Colleen Fogarty finds herself dizzied by the screening mammogram that turned into a diagnostic one. “I’m left with the feeling that I’d been through a ‘breast mill,’ passed among many staff members performing single tasks as they send me through the assembly line…I felt alone and isolated.” Duty hour restrictions for residents in training were supposed to make the hospital safer as well, but no studies to date have proven this, to my knowledge. These changes, along with patients rarely seeing their personal doctor at the bedside, have made medicine a series of patient handoffs. An article published last year in the Journal of General Internal Medicine found that interns spend about 40 percent of their time in front of the computer, but only 12 percent of their time doing direct hands-on patient care (down from about 20 percent the decade prior). Stanford physician, Abraham Verghese, writes about the “iPatient” or a virtual patient of data points, which has supplanted in importance real patients on rounds. Having a personal doula during childbirth has been shown to decrease Caesarian sections and increase patient satisfaction. Unfortunately, such a service is rarely covered by insurance, and I’m sure having a doula of sorts for any hospitalized patient would be scoffed at. Yet, many high-tech interventions of marginal benefit to patients are often embraced and reimbursed as cutting-edge medical care. continued on page 34

Executive Director’s Message

Increased Costs, Losing Doctors and Privacy That’s what happens when lawyers play doctor.

By Aileen Wetzel, Executive Director

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

YOU MAY HAVE HEARD THAT the trial lawyer-sponsored ballot measure that aims to undermine the protections of the Medical Injury Compensation Reform Act (MICRA) has officially qualified for the November ballot. On November 4, 2014, these trial lawyers will ask voters to weigh in on “The Troy and Alana Pack Patient Safety Act,” an initiative that was carelessly thrown together without any concern for taxpayer pocketbooks, privacy, patients or health care. If trial lawyers get their way, our state will be saddled with a costly threat to privacy that California simply cannot afford. If this measure is approved by voters, malpractice lawsuits and payouts will skyrocket, adding “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. Someone will have to pay, and that someone includes providers, taxpayers and consumers. SSVMS and CMA have joined a campaign coalition to oppose the measure. This group, “Patients and Providers to Protect Access and Contain Health Costs,” is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, familyplanning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals.

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This measure would also have devastating effects on access to care for patients everywhere, but especially in rural and already underserved areas. Community health care clinics like Planned Parenthood and the Central Valley Health Network are already warning that this measure will cause specialists like OB/GYNs to reduce or eliminate services to their patients. This measure could also cause doctors to leave the state, meaning thousands of Californians could lose access to their trusted doctors. Over the next few months, you’ll hear a lot of rhetoric from the proponents of the measure – but really, this is another example of special interest politics trying to fool the voters into thinking this is something that it’s not. Authors purposely added doctor drug testing to disguise their real intent behind the ballot measure: to increase lawsuits against health care providers, which will increase our health care costs and reduce access to quality health care. According to the Los Angeles Times: “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support the measure. ‘It’s the ultimate sweetener,’ says Jamie Court, the head of Consumer Watchdog.” (December 10, 2013) This proposal also forces doctors and pharmacists to use a massive statewide database known as the Controlled Utilization Review and Evaluation System, or CURES, filled with Californians’ personal medical prescription information – a mandate our government will find impossible to implement, and a database

with no increased security standards to protect your personal prescription information from hacking and theft. Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands this ballot measure will place on it. This ballot measure will force the CURES database to respond to tens of millions of inquiries each year – something the database simply cannot do in its current form or functionality. A non-functioning database system will put physicians and pharmacists in the untenable position of having to break the law to treat their patients, or break their oath by refusing needed medications to patients. Most concerning, the massive ramp up of this database will significantly put patients’ private medical information at risk. The ballot measure contains no provisions and no funding to upgrade the database with increased security standards to protect personal prescription information from government intrusion, hacking, theft or improper access by non-medical professionals. The initiative is bad for patients, taxpayers and health care as a whole, and there has never been a greater need for physicians to band together and fight for our patients. As you can see, this initiative is fraught with problems and would prove detrimental to California’s health care system. SSVMS is asking each of you to join the effort to defeat this costly threat to our state, and in doing so, protecting access to care and preventing higher costs for all California. Together, I’m sure we will be victorious. As we forge ahead to Election Day, it is more important than ever to make sure we are speaking as a unified, coordinated voice. If you haven’t done so already, please visit CMA’s website at www.cmanet.org/micra for the latest information and handouts, and to sign up as a campaign coordinator in your area. Please also visit the campaign website at www.stophigherhealthcarecosts.com to sign up to become an official opponent of this badly flawed measure. From the website you can:

• Sign up to add your name to the growing list of individuals and groups opposed to the MICRA ballot measure. • Get important facts, downloads and information that will help you spread the word about this costly measure • Be part of our outreach team. If you have direct patient contact, become part of our outreach team. Visit CMA’s MICRA resource page to sign up as a campaign coordinator at www.cmanet.org/issues-and-advocacy/cmastop-issues/micra/join-the-fight/. • Participate in message/media training. The campaign is also looking for physicians interested in taking on a more public role, speaking to community groups about why this ballot measure should be defeated. Contact Molly Weedn at mweedn@cmanet. org for more information. awetzel@ssvms.org

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July/August 2014

Fractals – the Geometry of the Natural World By Bob LaPerriere, MD I BECAME AWARE OF FRACTALS only recently, when I acquired an app for my iPad entitled “FRAX.” It allows you to create, in a very “fun” and exciting way, fractal images from photographs. The visuals, such as the one on the cover of this issue, are only the “tip of the iceberg.” Despite reading numerous definitions of fractals (fractal geometry), the mathematical concepts are well beyond me. Fractals were not really defined until their introduction by Polish-born mathematician, Benoit Mandelbrot, in 1975, who pointed out that fractals could be an ideal tool in applied mathematics for modeling a variety of phenomena. However, some of the properties and concepts of, and foundations for, fractals

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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such as self-similarity and non-differentiability, were introduced in the early 1900s by mathematicians such as Felix Hausdorff, and other concepts as early as 1861 by Karl Weierstrauss. Some geometric equations have been defined as “sets,” such as the Julia set, the Fatou set and the Mandelbrot set which are visual demonstrations of complex equations. Fractals are the geometry of the natural

world which contains irregular surfaces, shapes, edges and corners that cannot be described by traditional (Euclidian) geometry. Their irregular repeating shapes are found in clouds, tree limbs, stalks of broccoli and mountain ranges — from beautiful symmetry to the chaotic. They are everywhere we look. This new system of geometry can, with the aid of computers, model and describe structures from seashells to galaxies. It has had significant impact on such diverse fields as physical chemistry, physiology, and fluid mechanics. One amazing characteristic of fractals is that they have infinite detail. Another is the property of self-similarity; any region of a fractal looks very similar to the entire fractal. All the information for a fractal is contained in its “parent” image.

Complex images of extraordinary beauty can arise out of fairly simple mathematical formulas. By modifying these formulas, one can create unique compositions previously unseen by the human eye. One very common shape or form found in both fractals and throughout nature is the spiral. Some have called fractals the “Thumbprint of God.” Unless you are a 21st century mathematician, don’t get challenged, frustrated and perplexed by the geometry and mathematics. Just enjoy the fractals we see in nature every day. And if you have even a little bit of creativity, experience this wonderful new art form and create your own fractals. The application “FRAX” can be as simple or complex to use as you wish. A separate version is available for the iPhone and the iPad.(Frax HD). A $6.99 upgrade offers the addition of many other adjustments with the ability to get a high definition image through their cloud processing.

References: http://fractalarts.com (a site in Seattle that produces fractal art with a nice “understandable” overview of what fractals are http://fract.al (the website for the iPad/ iPhone app “FRAX” with good background information) www-groups.dcs. st-and.ac.uk/history/ HistTopics/ fractals.html

drbob@winfirst.com

Several before and after photos show what fractals can produce from a “parent” image. Salvador Dali, eat your heart out!

July/August 2014

Who are the Uninsured Now? By Glennah Trochet, 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.

IF THE GOAL OF THE AFFORDABLE Care Act (ACA) was to reduce the number of uninsured Americans, by most reasonable measures, its implementation in California has been a success. As of March 31, 2014, Covered California reported that 1,395,929 people had enrolled in the exchanges and of those, 1,222,320 were eligible for subsidized premiums. An additional 1,900,000 people were enrolled in expanded Medi-Cal during the same period. All told, over 3,000,000 people in California obtained medical coverage as a result of the ACA. In Sacramento County, 43,796 people enrolled in the Covered California exchanges, and as of March 31, 2014 the Department of Health Care Services reported that there were 295,467 people enrolled in Geographic Managed Care Medi-Cal programs in this county. So who is left uninsured now? According to an April 22, 2014 report to the Board of Supervisors from the Sacramento County Departments of Health and Human Services and Human Assistance, between 2,000 and 5,000 people will continue to be eligible for county medically indigent services, either because they did not apply in a timely fashion for the exchanges, or because they newly become eligible. They project that the number will be at the lower end of the range. The same report states that, “Currently Sacramento County has a total of 42 people on CMISP.”1 In addition, undocumented immigrants are not eligible for either Medi-Cal or the exchanges. Since they usually do not have a Social Security number, it is unlikely that they can obtain health insurance through their

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employers, even if it is offered. There are also a variety of people who might be eligible for either Medi-Cal or the exchanges, but have not enrolled. Anecdotally I have heard of individuals who chose not to investigate the possibilities, either because they assumed that they would not be eligible or because they chose not to find out. Finally, some Californians will remain uninsured because they don’t qualify for a subsidy and can’t afford the premium for health insurance, whether offered through their employers or through the exchanges. Most Californians who remain uninsured are likely to have lower incomes, have limited English proficiency, and be Latino in origin. In addition, most of the uninsured are likely to reside in Southern California. According to those who conducted outreach for Covered California, there were significant barriers for enrollment. The list of insurance programs and benefits listed on the website were confusing and hard to understand. People needed more than one contact to understand what was required and what the benefits were for them. There are many families where some members are legal residents while others are not. These families are reluctant to enroll their qualified members for fear that the undocumented members will be found out and deported. The anecdotal evidence I have heard is that some adults in their late 20s and in their 30s, even with children, have not applied for insurance, opting for paying the penalty. Presumably, as the penalty increases in the future, they will be motivated to seek affordable options for health insurance.

So there you have it: those who remain uninsured are undocumented immigrants and their families, people whose income is too high for subsidies and too low to afford the premiums, and people who remain uninsured by choice. Unless we implement universal health care in this country, there will always be someone who chooses to remain uninsured, placing a burden on the rest of us when they suffer a catastrophic illness or accident. However, for those who would like to have health insurance but currently can’t obtain it, surely we can find ways to provide this. Right now there is a bill in the California legislature: SB 1005 entitled Health Care Coverage: Immigration Status. This bill would create the California Health Care Exchange Program for All Californians, as opposed to the California Health Care Exchange Program we have now. It would expand the insurance provided by the exchanges to all residents

regardless of legal immigration status. Subsidies would be provided with state funds rather than federal funds. Financial eligibility requirements would remain identical to those of the ACA. As we learn more about those who fall out of the subsidy and still cannot afford to pay for the premiums, the ACA requirements can be modified to help them, if Congress chooses to do so. Counties continue to be responsible for those who reside within their boundaries and don’t have health insurance. With only 42 CMISP eligible individuals in Sacramento, this is an opportunity for the county to use its significant resources to support and strengthen our community clinics by contracting out the care of these patients, saving a lot of money in administrative and overhead costs, and then investing the savings in medical care for everyone who lives here. trochetg@gmail.com References: Sacramento BOS meeting April 22, 2014 Agenda Item 73 Sacramento County Implementation Of The Affordable Care Act. Bibliography: California’s Remaining Uninsured http://itup.org/ delivery-systems/2014/02/04/californias-remaininguninsured/ Covered California Enrollment Statistics http://news. coveredca.com/2014/04/covered-californias-historicfirst-open.html Medi-Cal Managed Care Enrollment Report - March 2014 http://www.dhcs.ca.gov/dataandstats/reports/ Documents/MMCD_Enrollment_Reports/ MMCDEnrollRptMar2014.pdf

July/August 2014

A former employee sued me for wrongful termination.

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. SSVMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: A Helpline staffed by experienced employment defense attorneys. Any manager, ofﬁcer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

For more information on these important benefits, and the special SSVMS First-Time Buyers Program, please contact Mercer at: 800-842-3761 or email us at CMACounty.Insurance.service@mercer.com

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim. Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

Sponsored by:

EEO compliance training for managers/supervisors. An internetbased training program, compliant with California law, provides supervisors with sexual harassment training. Optional Wage and Hour Defense Coverage. (Subject to additional premium.) Ask about our First-Time Buyers Program.

Mercer Health & Beneﬁts Insurance Services LLC • CA Ins. Lic. #0G39709 • 800-842-3761 12

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New Ear By Thomas N. Atkins, MD

We are up at 4:30 It’s dark, not to eat or to drink – NPO and so we go. Into the lobby, Fluorescence white like the complexion of the receptionist, Doesn’t work in sun light. All the questions, date of birth, allergies, meds and the rest; the Qs, Sign this and sign that, Your card please? Copay $250, And then we sat. Called to my gurney, Handed a pack – A gown, some sox and a very thin hat. To a restroom to change – No bench, just a sink And an elevated toilet seat, Put your sox on, your gown and your hat, With nowhere to sit, It is quite a feat. “You ok in there?” The nurse quite concerned, About throughput I think, not so much for me Or what I had learned. My clothes in a sack back to gurney 6, Warm blankets, BP the Qs and a stick. The IV is running, The sleep man arrives, The Qs after hand shake plus more about past, “Anyone in your family die when they passed them the gas?”

The surgeon stops in, Explains the procedure with a grin, Answers my questions, patient to win… my confidence in him. Signs the right side, no wrong side for me or for him. The OR nurse is next on the scene, The Qs once again, she is all dressed in green. Efficient, competent, all business and care, Older, experienced, a confident air. The ride to the OR, the ceiling fluorescence, As in “ER,” “St. Elsewhere,” and “Dr. Kildare,” The very dramatic experience of care. In the OR, then back out, “Head first for this one” The room seems to shout. The surgeon sits in the corner, Preparing his notes? Smiles again and then it’s quickly lights out. The sleep man injects, I notice the tiles, The next thing I know I am back in a stall; Wondering if really, this really is all? “Time to go” says the nurse as she slides on my pants And transfers me slowly to a large wheel chair. Through it all was my wife, my love, my support – Guiding all who would touch me with her hand and protection – Now driving me home for day of reflection Augmented by soup, Vicodin and dreams. So that’s what it’s like to get a new ear, What everyone has done so that I may hear. (Plus insurance she says) I encourage all to support your patients who are considering a cochlear implant, it is life changing!! atkinst@sutterhealth.org

July/August 2014

Dietary Sodium: Dogma, Doubt, Delusion By Ann Gerhardt, MD THE 2013 INSTITUTE OF MEDICINE (IOM) report concerning dietary sodium recommendations was the subject of a major symposium at the April 2014 American Society of Clinical Nutrition (ASCN) scientific meeting. The Centers for Disease Control (CDC), recognizing new evidence that severe sodium reduction might harm health, had commissioned the IOM to update recommendations about dietary sodium intake. The IOM concluded that 1) there is a risk of more cardiovascular disease with high sodium intake; 2) studies are inconclusive about the health effect on the general population when dietary sodium falls below 2300 mg/day; 3) there is evidence that sodium restriction below 2300 mg/day is harmful for patients with heart failure; and 4) there is limited evidence for harm or benefit of sodium restriction below 2300 mg/day in high risk subgroups. The ASCN symposium presenters agreed with the harm of extreme sodium restriction in heart failure patients, but felt that the IOM’s conclusions did not go far enough.

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.

Dogma A substantial body of evidence, mostly from Westernized societies, links excessive dietary sodium to hypertension, stroke and cardiovascular disease. These studies assumed, but did not have data verifying, a linear relationship down to zero intake. Aggregating results from studies in hypertensives yields an average systolic blood pressure drop of 3 to 5 points and a diastolic pressure dip of 0.8 to 2 points when sodium is restricted. People eating huge amounts of sodium

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respond the best, especially if they are obese. In 2010 the Department of Health and Human Services and the Department of Agriculture responded to the general acceptance of the need for sodium reduction and updated the Dietary Guidelines for Americans (DGA). They set a goal of reducing dietary sodium intake to less than 2300 mg/day for the general population. They recommended a more stringent goal of 1500 mg/day for high-risk individuals, including African Americans, those older than 50 years and anyone who already has hypertension, diabetes or chronic kidney disease. Dietary sodium currently averages 3400 mg/ day in U.S. adults (range 2000-5000). This is down 500 mg/day from 10 years ago, but failure to meet DGA guidelines continues to cause consternation in many public health officers. Doubt Should these guidelines really apply to everyone? Data linking dietary sodium intake to blood pressure repeatedly show that there are salt-responders and salt-nonresponders. Only a few people with normal blood pressure show a response to dietary sodium reduction. Salt responsiveness may change over an individual’s lifespan – for example, salt sensitivity in some obese, hypertensive teens dissipates with weight loss. African-Americans as a group have slower urinary salt excretion after a salty meal than do Caucasians, but among both groups, blood pressure response to sodium is highly hereditary. Salt sensitivity is related to at least a dozen genes, not all of which have an obvious connection to known regulatory systems.

In the DASH (Dietary Approaches to Stop Hypertension) trial, a fruit- and vegetable-rich prudent diet slashed hypertensives’ average systolic pressure by 11 points and the diastolic pressure by 5 points. Unlike the sodium data, the DASH diet lowered blood pressure in all categories of people. A study that added salt restriction to some subjects’ DASH diet achieved no further blood pressure reduction. Diets high in potassium and calcium foster lower blood pressure. Salt decreases potassium and calcium levels by increasing urinary losses. Could this be part of the reason that sodium raises blood pressure? Should we be focusing more on increasing dietary potassium and calcium and less on reducing sodium? Other data suggest that chloride, rather than sodium, may be the problem. In animals, non-chloride sodium compounds such as sodium glutamate, bicarbonate, ascorbate and phosphate, do not raise blood pressure. And then there’s the little problem of increased mortality with very low sodium intake and activation of the renin-angiotensinaldosterone system (RAAS). Delusion Data from worldwide studies strongly support a J-shaped curve for the association between sodium intake and health outcomes including, but not limited to, hypertension. There is a steeply-increased health risk at sodium levels below 2300 mg/day, a relatively flat nadir through about 3500 mg/day, a mild incline through 5000 mg/day and then a moderately steep rise after that. In spite of these data (available since the 1990s), the American Heart Association recommends less than 1500 mg/day for everyone, based mostly on blood pressure studies. The World Health Organization sets goals of less than 2000 mg/day, but couples that with a recommendation to eat at least 3510 mg of potassium per day. Sodium is essential for cellular and organ function, energy generation via Na, K-ATPase, blood pressure support, neuromuscular function and maintenance of a renal gradient that allows

proper water and electrolyte homeostasis. Even mild hyponatremia can cause weakness and mild cognitive impairment, especially in the elderly. Excessive sodium restriction has a good reason to backfire, especially in heart failure patients. Very low sodium intake activates the renin-angiotensin-aldosterone system (RAAS), which tightly controls sodium levels. It senses sodium intake below 1500 mg/day and kicks in to raise blood pressure. This is the level that causes circulatory collapse in Addison disease patients, who have no aldosterone. RAAS is great as a fail-safe mechanism to prevent damaging hypotension, but persistently high angiotensin and aldosterone levels contribute to adverse cardiac and renal remodeling. That’s the opposite of what we should want for our heart failure patients, or anyone else, for that matter. As further proof of this concept, hypertensives with the lowest urine sodium, reflecting high RAAS activity, have the highest heart disease risk. The aldosterone inhibitors aldactone and eplenerone both have irrefutable benefits in most patients with heart failure. So why is it a good idea to seriously restrict sodium in these patients, when it further stimulates the RAAS system to raise aldosterone? Very low sodium intake also increases sympathetic nervous system activity, raising heart rate and blood pressure. It increases insulin resistance, accelerating the journey to overt diabetes. Until now, the general science community rejected the J-shaped curve and unhealthy effects of draconian sodium restriction as “improbable.” Critics emphasize the studies’ methodological problems, without acknowledging the same problems with the lower-sodium-is-better studies. Desirable In 2005, the IOM accepted the J-shaped curve and set an “adequate intake” (not requirement) recommendation of more than 1500 mg/day. The 2013 guidelines go a step further, stating that very low dietary sodium is unhealthy for patients with heart failure, and there is not enough evidence to recommend reduction

July/August 2014

below 2300 mg for high-risk populations. In spite of the J-shaped sodium-health curve and the IOM recommendations, government policy and physician recommendations have not changed concerning very low intakes. The eminent nutrition scientists at the ASCN symposium suggested that 2300-4945 mg/day is OK in most people, depending on genetics and other lifestyle factors. That range happens to coincide with usual intake by the majority of societies across the globe – both Westernized nations suffering from an epidemic of cardiovascular disease and subsistence societies virtually free of that scourge. The ASCN presenters basically castigated policymakers continuing the lower-is-better view. They also felt that a population-wide effort to restrict sodium intake to 2300 mg/ day 1) is not supported by the data; 2) is a misplaced use of effort and resources; and 3) potentially increases harm when the elderly with minimal sodium intake become weak and fall from hyponatremia, or zero-sodium zealots

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develop unwanted cardiovascular effects of an activated RAAS. Cardiologists fear that deemphasizing salt restriction will keep people from reducing it at all. That’s a valid concern, especially for patients whose idea of a low-sodium diet is to eat only half the bag of chips. But limiting dietary advice to sodium is to ignore the more compelling DASH and potassium data and benefit. A recommendation to eat minimallyprocessed food diets (processed food generally has a lot of sodium) full of vegetables, whole grains, fruits, low-fat dairy and lean animal products focuses on all the good things, not just salt. Since the taste for salt is the only taste sensation that turns on and off according to the body’s need, a person consuming such a diet who craves salt should eat some. And policymakers should heed the advice of the IOM and the implications of all the scientific data, not just the parts that drive their policy. algerhardt@sbcglobal.net

SPIRIT 2014 and Beyond By Kris Wallach, SPIRIT Program Director AS THE DUST JUST BEGINS to settle from the implementation of the ACA, the Sacramento Physicians’ Initiative to Reach out, Innovate, and Teach (SPIRIT) Program is looking at what’s next. For nearly 20 years, SPIRIT has successfully recruited and placed volunteer physicians in county and community clinics serving the unand under-insured. In addition, our program has provided case management and care coordination services for patients needing specialty or surgical services. In the past, the majority of the physician volunteers placed by the SPIRIT program have been within county clinics, and the majority of referrals received have come from those same county clinics. With the implementation of the ACA, and more specifically the expansion of Medi-Cal, many patients who might otherwise be eligible for services through SPIRIT are now newly eligible for Medi-Cal or for subsidized insurance through Covered California. While we continue to coordinate care for the region’s uninsured, the SPIRIT program is looking ahead to expand services to other populations, specifically the undocumented. Here’s how you can help! SPIRIT has a need for physicians to volunteer one four-hour session per month in one or more local clinics in the following specialties: dermatology, neurology, office GYN, orthopedics, and primary care. For this volunteer opportunity, the clinic will work with you to set a regular schedule, provide you with support staff, and cover your medical liability while in their clinic. We are also seeking volunteers willing to donate evaluation and/or out-patient surgery, either within your practice, surgi-center or in local hospitals. Specific areas of need are endocrinology, general surgery, radiological services, and urology. SPIRIT will provide case management and care coordination services,

working as liaison between your office, the referring clinic, and the patient. SPIRIT can help you find a volunteer placement that meets your needs and interest, whether that be within your own office, in a local clinic, serving as a preceptor at a Student-Run Clinic, providing peer review (administrative), or in a state-of-the-art mobile medical vehicle. Let us help you find a rewarding and satisfying volunteer opportunity right here in your own back yard! Call (916) 453-0254 or email us. kwallach@ssvms.org

Outstanding Volunteers of the Year On April 8, 2014 the Sacramento County Board of Supervisors recognized and honored SPIRIT volunteer physicians who donate time and expertise at the Primary Care Center. “Whereas, the SPIRIT Program Volunteers, Dr. Alan F. Moritz, Dr. JaNahn C. Scalapino, Dr. Lawrence J. Bass, and Dr. (John) Curtis Zingheim, have tremendously improved the quality of life for many residents of Sacramento, especially the most frail and vulnerable members of our community. These dedicated volunteers have a valuable impact on the level of services provided at the Primary Care Center.” (Left to right) Supervisor Jimmie Yee; Sherri Heller, PhD, Director DHHS; Supervisor Don Nottoli; Supervisor Susan Peters; SPIRIT volunteer (John) Curtis Zingheim, MD; Supervisor Roberta MacGlashan; Susmita Mishra, MD, Medical Director, DHHS Primary Health Division; Supervisor Phil Serna, and Kristine Wallach, SPIRIT Program Director.

July/August 2014

The Deal Hasn’t Changed By Sean Deane, 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.

“THE DEAL HAS CHANGED.” That was the message about the Affordable Care Act (ACA) to a large gathering of physicians I attended recently. We heard about patient satisfaction scores, and how the insurance companies would drop us if our fish tank and office furniture didn’t dazzle in the reviews. We heard about money, and how any “savings” the public expected would likely come directly from our dinner tables. We heard about patient expectations of access, how our spouses and children needed to sacrifice more of their time with us, and how we should expect to receive no payment for our after-hours work. We heard about how the expectations we started with about life in our profession needed to be cast by the wayside. “Get over it,” the speaker said. “The deal has changed.” The recent developments in health care have made me reflect on why I pursued a career in medicine in the first place. It had little to do with things that are quantifiable or that I can rate on a scale. I think back to my teenage days, translating for my family during doctors’ visits. I was nervous and ashamed. What teen wouldn’t be? Translating intimate details about my Hungarian grandmother’s body aches and bowel movements was bad enough, but now to have to admit that my family didn’t have any money? It wasn’t fair. By today’s standards, it wasn’t fair, but insurance-sponsored phone translators and care managers were a long way off yet. I said the words. She couldn’t afford her medicine, I told him, and he silently disappeared. He came back and handed her a brown paper bag full of samples. Clapping his hands in hers with a cry, she turned to me and said, “Mondd meg hogy fogok sütni neki egy torta.” ”Tell him I’m going to bake him a cake.” He just looked

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surprised by the response. It probably wasn’t the pivotal moment that led to my donning a white coat many years later. There were others. However, my grandmother’s doctor was part of most of them, though he never realized it. A few decades on, I’ve found myself in the position of occasionally handing out those paper bags to my needy patients. Sunshine Act or no, I accept those samples when I can. I know what they can mean. I’m not surprised when I see the response to that part of “the deal,” because I’ve been on the other end. Other parts of why I went into medicine, I sometimes forget. Until I’m reminded. Sometimes the deal involves matters I, perhaps foolishly, thought pedestrian – like the phone call I received from a woman who said, “you know that thing you did with the two nasal sprays? That was magical.” We were talking about rhinitis, after all, not Nobel research. To her, it mattered. My training in a few guidelines had removed a thorn she had carried in her side every day, a thorn that impacted every one of her activities. That training, even in the mundane, relieved suffering that was impactful in ways I didn’t fully appreciate at the time. Sometimes, the deal involves more shock and awe. A man showed up in my practice a few months ago, asking my harried front desk clerk to interrupt me as I scampered about on a particularly busy clinic day. Ripping open his shirt as I took him aside in an exam room, he proudly displayed the scar of his CABG, and thanked me for it. The EKG I ordered for the “allergies” he assumed were making him short of breath led to the CABG that he felt changed his life. I didn’t order it thinking I would change his life. I didn’t order it because I was a miracle worker. I ordered it because I’d been trained in guidelines that said it was necessary. “Glad I could be of help,” was about all I could muster.

Sometimes the deal doesn’t involve patients at all. Sometimes it doesn’t involve us being magically skilled, or super heroes, or even more than average at mentoring. In the midst of ICU rounds as a senior resident, I was desperately confused as I tried to listen to one of my medical students rattling off vitals and vent settings in no particular order. Stopping her mid-sentence, I discussed the appropriate order – “pulse relates to blood pressure, inspiratory pressure relates to CO2, PEEP relates to saturation,” and so on. Her eyes spat venom as she slowly and icily enunciated the remainder of her presentation. I tossed and turned every night for the next month, knowing that the morning’s student presentations would be delivered with thinlyveiled daggers, wondering if I could have handled it better. A few years later, at an institution 500 miles away, we were together again. This time, we were mutual consultants. In a moment of candor she said, “remember that time you told me how to do ICU vitals? I hated you for that. But now I teach it to all of my medical students.” We both laughed, but inwardly, I felt humbled. And surprised. Did my grandmother’s doctor realize what the brown bag meant, all those years ago? Probably not – at least not at the time. Half my lifetime later, I had the unexpected opportunity to tell him about it as he walked into a committee we were serendipitously chosen to serve on together. He walked over and introduced himself with an extended hand, saying his name, thinking I was just another colleague to welcome. Taking his hand, I stood up and said, “I know who you are. We met a long time ago. You’re the reason I’m here.” Surprise again – the years hadn’t changed the look I remembered so well. A few months before, a hand was extended to me by another

physician who came to interview for a training program I was representing. We shook hands. We sat down. “So,” I said, “... how’d you wind up here interviewing to become an allergist?” I was shocked by the response. “I’m here because of you. I worked with you a few years ago, and decided this is what I wanted to do with my career.” It was a former student, one I’d met only briefly. I cleared my throat a few times, hoping the lump I felt in it wasn’t too obvious. I never expected that part of the deal. I don’t think my grandmother’s doctor did, either. There are few professions amongst human endeavors in which the mundane is equivalent to the sublime. Medicine is one. We perform a small act of kindness, and the course of a life is altered. We show up at work and follow a few standard guidelines, and a life is saved. We click a few buttons, or scribble a few words, and suffering is relieved. We say a few offhand words, and they become maxims for our successors to live by. The Affordable Care Act may change things for all of us – patients, caregivers, teachers, students, and researchers. The dust hasn’t settled, and none of us really knows what will happen. Some of us may leave our research careers for the clinic; others among us might do the reverse. Some of us may change from large groups to private practice. Some of us might change from private practice to large groups. Some of us might do more primary care; some of us might do less. We might make less money. We might make more. Were any of us thinking about any of that when we walked, wide-eyed, into our first day of medical school? I don’t think so. We were thinking about the promise of the deal. And the deal hasn’t changed.

”Tell him I’m going to bake him a cake.”

sdeane@mountainsideallergy.com

July/August 2014

Book Review

The Melba Notebooks Author John Loofbourow, MD, ISBN-13: 978-0615863054, JAYEL Publisher, 2014, 177 pages

Reviewed 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.

VERY EARLY IN THE TWENTIETH century, Melba Colm and Bob Loofbourow were born, she to John and Minnie Colm, he to Leon and Anna Loofbourow. Melba and Bob were married in 1931. One of their four children, Dr. John Colm Loofbourow, has written a book about them called, “The Melba Notebooks,” which chronicles his parents’ declining years as depicted in diaries kept by several caregivers who lovingly labored to allow Bob and Melba to remain in their home in spite of multiple infirmities. The author relies on diary entries from 1995 to 2002, and the story flows from year to year, gently edited and interspersed with occasional filial comments that help fill in personal or medical historical gaps, or are directed at the larger issue of the “Aging of America” and the medical, political and sociological problems that surround that evermore important societal phenomenon. Dr. Loofbourow begins: “Five well-worn notebooks are filled with the handwritten entries of caregivers as they communicate with one another during Bob and Melba’s final years of life. I am grateful to you all; without your original dialogue much would be lost to time.” And he is thankful, as well, for “...the tolerant and supportive environment in the town of Ferndale, Washington, where people from all walks of life personally contributed to the conditions that made it possible for Melba and Bob to stay in their home until Melba’s death.” Bob was a Stanford-trained mining engineer. Melba, like her mother and mother-in-law, were rarities for their generations − college graduates. She attended Chico State Teachers’ College (now California State University, Chico) and

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Stanford as an English major. She rarely taught professionally, but she did a great deal of writing, and she shared a love of literature and poetry with Bob. Bob’s profession took him and the family to mining sites in Mexico and the Philippines, and around the western USA. In 1935, when he expressed support for a miners’ strike in Tayabas, Philippines, he was fired and subsequently blackballed, and for the next 10 years could find work only as a miner himself. Son, author and editor, John, fondly recalls that gypsy life, the many travels of the peripatetic miner and his family: “I remember each and every mining town, and have revisited many. For a young boy, those little remote towns were mostly fun, freedom, and fancy (and) like Bob and Melba, (I became) a lover of...languages, peoples and cultures, (and) I became an incurable xenophile.” Bob and Melba were, therefore, necessarily frugal. Later in their lives, that frugality manifested itself in occasional grimly humorous ways. Bob had become incontinent following surgery for prostate cancer. At first, he used washcloths to soak up the urine, but his doctor and caregivers insisted he use “Depends” instead. He rebelled at the cost and unnecessary waste, so he would dry and re-use the Depends. He air-dried them, usually outdoors, if the weather was clement. A diary entry dated 9-161995 by his daughter, Sophie, records her mother’s dismay: “6:00 PM. Mom went to the toilet and became outraged by the odor in the bathroom from soiled Depends on the windowsill. I removed them.”

Overall, Bob is less of a burden to the caregivers than Melba who has had an emergency cholecystectomy and has suffered falls resulting in pelvic and hip fractures with subsequent surgery. His hearing is very poor, and he often refuses to use amplification. His practical and frugal engineer’s mind leads him to urinate in the sink because it saves water and is more convenient for him. He leaves leftover food in the oven rather than the refrigerator so less power is needed to re-heat it. In the winter he turns down the heat to save power and money until the caregivers, teeth chattering, surreptitiously turn it back up. Most of the diary entries are mundane, and are used by the caregivers to communicate with each other regarding what happened in the morning or evening, what needs to be done, or what has been taken care of and what can safely be ignored. Years go by and there are only a few untoward events. The author succinctly and poetically refers to those years as “the ankylosis of elder-time.” Melba becomes less mobile and occasionally soils herself as she cannot get to the toilet in time. “3/26/99 8 AM. Mom not dressed yet. Trail to bathroom as she waited too long again. Got her cleaned up...helped her get dressed, wiped up floor.” Bob continues to exercise almost daily. His hearing worsens, and he becomes more ornery and is occasionally a bit combative. Melba suffers with a painful hip beset with avascular necrosis. Her mental status deteriorates more than Bob’s. An attempt to alleviate her pain by the use of a fentanyl patch provokes a crisis. “4/2/00 10 AM. Melba very weak, gray in color, unable to speak, sweaty. Called doc and she called 911. Paramedics came, took mom to

hospital. They kept her 5 hours then sent her home. It was apparently a side effect of the new pain patch. It only cost taxpayers $15,000.” The episode leads the caregivers to agree to a compact that reads: “This is the time to talk seriously among ourselves and with the doctor about end-of-life care; to work together; to avoid calling 911 because to do so is true elder abuse.” Bob occasionally sleeps all night head down on the kitchen table. In front of TV, both usually fall asleep. Soon Bob develops edema in his lower legs, his recorded weight rapidly goes from 155 to 191 pounds, and he becomes orthopneic and has to sleep upright in an adjustable recliner. Lasix is started with modest benefit.

July/August 2014

Bob Loofbourow always wanted an electric train as a child. He finally got one.

Melba Loofbourow did a great deal of writing and shared her love of literature with her husband.

“8/20/00 7 AM. Both still sleeping. 8 AM same thing. 8:50 Melba awake. Changed clothes in bed, wants to nap a little longer before getting into chair. 10 AM Melba in bed resting. 11 AM Bob still in bed. 5 PM going to feed Melba some dinner. Melba asked where Bob was? So we went into the bedroom. Bob opened his eyes and said “Hi!”. It was cute... Melba ate 100 percent of her dinner.” At this point, Melba is still using the fentanyl patches with good effect and no major side effects. There are no diary entries to indicate a precipitous change in her overall health, and she dies quietly at home on September 26, 2000, age 92, married 69 years.

By December, 2000, Bob is doing better. He enjoys going out for rides in the car and brief walks, although his shortness of breath severely limits his walking. He has few complaints of pain. His appetite is good and he is less ornery. It is not always clear that he is aware of Melba’s death and he probably is not. He moves to an assisted living facility where he has his own room that is filled with familiar furniture and pictures as well as an electric train purchased at the local Goodwill store. He had always wanted an electric train as a child and had never had one. He seems to enjoy watching the train and “sleep-watches” television. He still uses the sink as a urinal. His heart failure worsens in 2002 and he collapses on September 14, 2002. No one calls 911. As previously noted, the vast majority of the diary entries are humdrum and workaday as they outline the last few years of life for a couple who would never make headlines. The author/editor/son sums up: “...for Bob and Melba to stay in their home and for Melba to die there, is something that society might well disapprove of, were they aware of the details; the three-story home, the risks of falling, of fire, of germs. Unaware of, or unsympathetic to the preferences of an old couple who have always been independent, selfreliant and rational to a fault, an “authority” might consider the conditions of their old age living to amount to neglect, and those who allow it, abusive. But neglectful and abusive of what? Not of life, not of old age, not of family.” jmost119@aol.com The print edition of the book is available through www.Amazon.com or www.createspace.com, and the ebook is available on Kindle.

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SSVMS Alliance Review By Kim Majetich, SSVMS Alliance President and Celeste Chin, SSVMS Alliance Immediate Past President THE ALLIANCE, A 501(C)(3) non-profit organization, is dedicated to improving the quality of health in our community through education, community health project funding and granting scholarships to those seeking careers in the medical field. This past year we had the privilege of giving over $43,000 back to our local community as follows: Community grants ($34,110); Nursing Scholarships ($3,750), and the SSVMS William E. Dochterman Medical Student Scholarship Fund ($5,250).

Art of Medicine Dinner/Auction This sold-out event, held April 26, 2014, at the Del Paso Country Club, raised over $67,000 for the SSVMS Alliance Community Endowment Fund. “The evening was remarkable for the high quality art, great auction items, and the opportunity to reconnect with physicians from all modes of practice – and all for a good cause,” said Dr. David Herbert, SSVMS Immediate Past President. We want to give special thanks to this year’s major sponsors: Peju Provence Winery, Dignity Health, Infinity of Elk Grove, Dr. Richard Hauch and Kim Pacini-Hauch and Sutter Medical Group. We also want to thank Gabriella Neubuerger and Susan Brownridge, co-chairs of the event, and their team for their hard work in creating an evening of camaraderie for the physician community while raising a record amount for the organization.

Holiday Sharing Card Featuring the beautiful art of Dr. Barbara Arnold, this past year’s Holiday Sharing Card raised over $20,000 to benefit the SSVMSA Community Endowment Fund and the SSVMS William E. Dochterman Medical Student Scholarship Fund.

Community Health Day Community Health Day, “Sticks, Stones, Tweets, Hashtags – Bullying in the Lives of Our Children,” was held on September 21, 2013. It focused on the rise of bullying in our children’s culture and the need for awareness within our community. A special thanks go to Kaiser Permanente, California Medical Association Alliance Foundation, Sutter Health Center for Psychiatry, Costco, Tony and Ilham Saca for their financial support, and the San Juan Unified School District, Jason Bynum, MD, and SSVMS for their contributions.

2014 Community Grants Announced The Alliance awarded grants to the following non-profit organizations: Children’s Receiving Home of Sacramento — 2 exam tables and 6 EpiPens for residential dormitories; Cordova Community Council — 1,000 bike helmets; Kiwanis Family House — Rent and meal subsidies for families with loved ones at UCDMC and Shriners Hospital for Children; Oak Park Preschool, Inc.— Healthy Eating/ Active Living Seminars, Oak Park Walking Club and Preschool spring/summer garden; People Reaching Out — “My Smyle” project involving peer mentoring of adolescent girls against alcohol and drug abuse; Sacramento Food Bank and Family Services — Support to distribute fresh and seasonal crops, nutrition seminars, education materials and consumable goods; Society for the Blind — 24 low-vision simulator goggles and educational materials for 120 outreach/education programs. We are looking forward to another year of promoting health in our community. If you would like to join our membership, we invite you to visit our website: www.ssvmsa.org. Our membership is open to physicians, spouses/partners, medical students, and friends of medicine. July/August 2014

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.

Book Review

The Red Market On the Trail of the World’s Organ Brokers, Bone Thieves, Blood Farmers, and Child Traffickers. Author Scott Carney, ISBN-13: 978-0061936463, William Morrow Publisher, 2011, 272 pages

Reviewed by Nate 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.

THE COVER ALONE OF A SKELETON with a price tag intrigued me to read this 254-page investigative report on the lawful, and often unlawful, procurement of blood, tissue, organs, oocytes, stem cells, surrogates, adopted children, and even shorn human hair from around the world. After obtaining a graduate degree in anthropology, the author, Scott Carney, supervised American students who studied abroad in India, and he had to deal with the unexpected death of one his female students. The ordeal of fending off reporters, dealing with corrupt police, trying to keep the body preserved, overseeing the autopsy, and preventing theft of the student’s remains prompted him to research the shadowy world of the “red market,” or really a black market of human parts. Most of the research is done in India – ground zero of rampant corruption and social class divisions, but he also ventures into other parts of Asia and even the innocuous island of Cyprus. His writing comes across as frank, thoughtful, and persuasive that the current donor-recipient process is fatally flawed. He has reported for NPR, the BBC, and National Geographic. Most of us have heard stories of body snatchers in Victorian times procuring cadavers and skeletons for medical schools in England. When the public in Europe and the U.S. had had enough of this desecration, the market for skeletons turned to India, Britain’s colony, which served as nearly the sole source of skeletons for medical education for nearly 150 years. The Indian government outlawed the practice in 1985. As one could imagine, the market survived and stayed underground after this, but

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many skeletons did not. Much of the policy on blood and tissue donation in the U.S. draws from the discovery of blood types in 1901, the increased need for blood during the World Wars, and the exponential growth of surgical procedures in the mid to late 1900s. Over time, it became clear that paying people for their blood was infusing our supply with HIV and hepatitis C. In 1984, then U.S. Senator Al Gore led the charge for the National Organ Transplant Act that banned paying people for their blood or organs. What it didn’t ban was payment for the process of obtaining the blood and organs and then using them in recipients. Hence, donors got nothing, and numerous middle men and the hospitals continued to reap profits. I found Chapter 3, “Kidney Prospecting,” to be one of the more disturbing chapters. It profiles the town of Tsunami Nagar, an Indian slum created from relocated survivors of the 2004 tsunami. The town is nicknamed “Kidneyville,” and the poor people are preyed upon by “brokers” to donate a kidney for what, to them, seems like a fortune: $800. Mr. Carney talks with the women who have undergone the procedure, only to find that their hopes for a better life were shattered when butcher-type surgeries left them with chronic disability and no follow-up care. It’s a heartbreaking “seller beware” story, and the picture of a woman showing her huge scar says it all. Chapter 4, “Meet the Parents,” exposes the human trafficking that fuels at least part of the adoption industry. Much of the red market is based on anonymity. Closed adoption is a classic example of this. Disguised as a well-

meaning privacy law, orphanages need to do these studies, and the outsourced third parties little more than provide children to adoption like Covance who oversee the study design agencies, regardless of how the children came to and execution, will have you questioning the be at the orphanages. In particular, he chronicles validity and ethics of many of the studies upon the abduction of an Indian boy who ended up which we base our prescribing practices. in Malaysian Social Services, an orphanage that Mr. Carney estimates, based on WHO data, has supplied children to many well-known that 10 percent or more of organ procurement is adoption agencies in the U.S. The dots are hard done illegally worldwide. Billions of dollars are to connect, and documents can easily be forged. changing hands. He concludes the following: International trials and investigations move at a “After almost four years studying the breadth snail’s pace and cannot address the volume of of red markets, I am no longer shocked by the the abuse. gory details of an autopsy or the depth to which My wife and I are avid Oprah fans, but a criminal will sink to harvest human materials. after reading Chapter 6, “Cash on Delivery,” Rather, I am only surprised at how normal it we couldn’t help but feel disappointed that is to simply shrug our shoulders and take the Oprah had misdirected praise to the infertility supply chain for granted.” He doesn’t offer easy clinic in Anand, India, where childless middle solutions to the problems, but after reading The class couples around the world can get in-vitro Red Market, you will never see human remains services and have a surrogate mother hired and organ transplants in the same light again. who will live in a supervised compound for nine months until their scheduled C-section. hitzemn@sutterhealth.org With the promise of a $5-6,000 payout, very poor women who may not make that kind of money in their lifetime will leave their existing families for almost a year to undergo this INC. process which is not without risk. A REGISTRY & PLACEMENT FIRM Similar stories play out elsewhere in India and on the island of Cyprus in the Mediterranean, where lax laws encourage affordable infertility care using imported Eastern European Nurse Practitioners ~ Physician Assistants oocytes and surrogates. Also chilling are the accounts of blood farms in India where kidnapped people are bled to near death, too weak to escape. The rest of the book is somewhat lighter fair and speaks to stem cell procurement, and how shorn hair from a religious Locum Tenens ~ Permanent Placement pilgrimage is turned into celebrity hair in Hollywood and New York. Perhaps most entertaining is a chapter on V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 human clinical trials where the author FA X : 8 0 5 - 6 4 1 - 9 1 4 3 volunteered to take large amounts of Levitra in a Bayer Pharmaceuticals tzweig@tracyzweig.com study. His characterization of some w w w. t r a c y z w e i g . c o m of the professional “volunteers” in

Tracy Zweig Associates Physicians

July/August 2014

A Posit on Medical Tourism “Physicians and patients in the U.S. should consider medical procedures outside the country, where they are becoming far less expensive, with comparable outcomes.”

Background: Due to a variety of factors, having surgical procedures done in the United States has become costly, and sometimes prohibitively so for patients with an increasingly higher share of cost. Dr. Elizabeth Rosenthal has written several national articles on this topic. Also recently in Forbes magazines, columnist Dr. Robert Pearl writes about a state-of-the-art heart surgery center that has opened up in the Cayman Islands, some surgeries costing “two percent” of what it would in the United States. 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 – 15/Disagree. Commentary follows:

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 agree. The failure to control costs and document superior outcomes may well doom certain procedures in the U.S. —Gary Roach, MD I agree, however, if they choose to do so, they should return to where ever they had their surgery for any follow up or post-operative issues/complications/concerns. You should not expect to have it both ways. —Jonathan Wardell, MD I disagree. Within a month, I had two patients with failed kidney transplants from China. There was no ability to have follow-up or access to records. — Daniel Yuen, MD I disagree. The U.S. system is still based on need, and these patients are coming back with complications that would need treatment under different standards in the US. —Mohammad Kabbesh, MD I disagree, only from the view of follow up.

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As we surgeons know, there is no surgery that is minor surgery. Complications always happen. Some major – some minor. Who is going to do the follow up? Overseas centers should tie up with large groups in this country, then only the post-op care can be provided. —Satya Chatterjee MD I agree. Of course, some surgeries can never be outsourced, like an emergency appendectomy; however, if I want to get a buttlift, a tummy-tuck, or some other things tidied up, why not pay less and make a vacation of it! —Nathan Hitzeman, MD I agree. Clearly, these can be done with comparable quality to that done here, but at far less cost. It’s “medical provincialism” and arrogance for us to think that “no one” else can provide quality comparable to ours. Many of these physicians are U.S.-trained. That said, the difficulty remains in being able to identify the remaining lower quality centers, so that they can be avoided. —James Sehr, MD I disagree. By directing our patients out of the country for medical procedures, it indirectly gives undue credibility to physicians and medical systems which we know little about, have little reference to their quality standards, and which we have no way of regulating. I feel it is my responsibility to direct a patient to a physician or medical group in which I can feel confident they are going to receive highquality care, or at the very least, I know the standards at which that physician or group is held to. Also, when complications arise (as they inevitably will), who will have to manage those complications? The answer is us – our primary physicians, our emergency physicians, and our surgeons. —Kevin Jones, DO

I agree. Including access to drugs and other devices (from reliable sources), another source of differential healthcare price. —Alicia ParisPombo, MD I agree. Why NOT? But, take an “ombudsman.” —Nancy Gilbert, MD I agree. The key point, though, is “comparable outcomes.” For good or ill, many procedures have become commodities and market forces cannot be ignored. —Gerald Bishop, MD I disagree. Often times, the procedures are not done according to Standard of Care in the U.S., and patients may have an increased risk of complications that would normally have been minimized if the procedure had been done in this country. Cheaper, yes – but at what cost? —Horacio Chiong-Rivero, MS III I agree. Free country still, but must be prepared for additional costs as complications do occur. —John Young, MD I agree. A question that arises is this:

Would an offshore medical center recruit patients? How? Hospitals and subspecialists seem an unlikely source of referrals, but might become interested in providing follow-up for a price. Insurers, including government, could seek significant savings offshore, and be able to require verifiable and high-level performance due to their purchasing power. Direct advertising seems likely. And referring primary care docs could become the darling of offshore centers with the attention and perks that suggests. But most significant of all is that the patient would benefit because there is no free market for medical care in the U.S. today. Ours is a “Gotcha” medical system. —John Loofbourow, MD Patients maybe; not physicians. Maybe we should seek modification of our pricing for certain procedures before admitting that our care isn’t worth what we are charging. —Albert Kahane, MD

July/August 2014

All webinars are free for SSVMS/CMA members and their staff. Nonmember price is $99. For more information or to register, visit www.cmanet.org/events or call CMA’s Member Help Center at (800) 786‐4262.

July 16: Recipe for Financial Success: Key Steps to Increasing Your Net Income 12:15 – 1:15 p.m. Physicians and office managers need business management skills, particularly in the financial area. This webinar will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms. 1.00 CME CREDIT. July 30: What to Expect from a Medi‐Cal Audit 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the role of utilization oversight and claims monitoring, increase understanding of the audit process and possible outcomes, and understand common problems and methods to improve documentation. 1.00 CME CREDIT. July 31: HIPAA Breach Notification and California Requirements 12:15 – 1:15 p.m. Every medical practice in California has obligations to report breaches of unsecured patient information, in some cases within 5 days to California authorities, and promptly for HIPAA compliance. This webinar will review and simplify these requirements. 1.00 CME CREDIT. September 10: HIPAA Update: Are You Compliant with the Final Omnibus Rule? 12:15 – 1:15 p.m. With so many changes to HIPAA, this rule is referred to as an "Omnibus Rule." Many changes have a profound impact on medical practice workflow and are also relevant if you use an electronic health record. This webinar provides an overview of the HIPAA changes and key steps medical practices can take to comply with HIPAA. HIPAA enforcement penalties can be severe for medical practices who are not compliant! 1.00 CME CREDIT.

September 17: Managing Difficult Employees and Reducing Conflict in the Practice 12:15 – 1:15 p.m. This information‐packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set practice values; and reduce conflict in the practice. 1.00 CME CREDIT October 1: Family Medicine, Frontline of Care 12:15 – 1:15 p.m. This webinar will review strategies to help the provider take a pro‐active approach to dealing with external pressures, as well as review basics in documentation, prescribing, referring, and practice management. 1.00 CME CREDIT. October 8: Protect and Preserve Your Patient Relationships 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/patient relationship. 1.00 CME CREDIT October 29: Managing Up! For Managers 12:15 – 1:15 p.m. Managers, Administrators and CEOs in medical practice need to successfully learn to supervise staff or manage down but also achieve results by influencing their physician bosses by managing up. Learn techniques from Debra Phairas, President Practice and Liability Consultants who has worked with over 1700 practices and recruited over 100 Medical Practice Administrators. 1.00 CME CREDIT

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

In Memoriam

Alton Gene Wills, MD 1939–2014

AT HIS HOME on March 16, 2014 with his family and friends with him, Dr. Alton Wills left us. He leaves behind not only his family, friends and colleagues, but a legacy of concern for humanity in keeping with the highest traditions of medicine. Alton was born July 8, 1939 in Corpus Christi, Texas, to Alton Gus and Vivian Josephine Wills. His parents were sharecrop farmers and owners of Corpus Christi Butane Company. They lived in Robstown where Alton was educated. He graduated from Robstown High School in 1957 and matriculated at Texas A and I, now known as Texas A and M-Kingsville. At the insistence of his father, Alton joined the Army ROTC program. He excelled both academically and in the ROTC rising to the position of Commander of the Drill Team. The story of Alton’s college career is that he had a lot of fun, but managed to do well enough to be admitted to the University of Texas Medical School in an accelerated three-year program. Alton was admitted to the Army Senior Student Program during his last year of medical school, and went to Tripler Army Medical Center in Honolulu for an internship. After the internship, he was assigned as a Battalion Surgeon with the 25th Infantry Division in Vietnam. Following a year tour there, he was assigned to Ft. Bliss, Texas, as the Director of Outpatient Services. He was honorably discharged in 1968, and he accepted a position with Kaiser Permanente in Sacramento. Throughout his life, Alton maintained a deep respect for the military. Whenever he came across a military person in uniform, he would stop and thank the

person for their service. In October 1968, Alton opened his own family practice in Fair Oaks. From the beginning, he was actively involved in the medical staff of Mercy San Juan Hospital. He served as Chief of Family Medicine, and during his eight years on the executive committee, he was elected Chief of Staff, serving a two-year term. In 1993, he left private practice and went to work at McClellan Air Force Base. Within two years, he was promoted to Chief of Occupational Medicine for the Base as a GS-15. During the time at McClellan, he completed a Master of Public Health degree in Occupational Medicine and became board certified by the American Alton Gene Wills, MD Board of Preventative Medicine. Alton also was deeply involved in organized medicine. He was a member of our medical society for 45 years. In 1980 he was elected to the Board of Directors, and on January 1, 1985, he began his term as the 111th President. He was an alternate-delegate and delegate to the California Medical Association for 25 years. He also served as an alternate-delegate to the American Medical Association. Throughout his career in family medicine, he practiced “old school medicine” making house calls and attending significant events in his patients’ lives. Many of his patients became friends for life. Alton is survived by the love of his life, Debbie, and his 3 children and 8 grandchildren. — John M. Whitelaw, MD

July/August 2014

In Memoriam

Gail Mynard, MD 1946–2014

Gail Mynard, MD

GAIL MYNARD WAS BORN IN Chicago. She grew up in a large family, with four sisters and a brother. She went to college in Seattle, majoring in philosophy, and to medical school at Marquette. Upon graduation in 1972 she and fellow medical student, Jim Mynard, were married. They lived in San Francisco where Gail worked at the Oakland Naval Hospital. They moved to Davis where Jim worked at Kaiser on Morse Avenue, and Gail at Woodland Memorial Hospital. They adopted Craig, then Peter, and had Anne. Since 1984 when Gail also joined Kaiser, they have lived in Sacramento. Gail was a lifelong adventurer, took her children trekking in Europe and Asia; she climbed Mount Kilimanjaro when she was fifty; she made many trips to South America. She liked walking tours in England, hiking, and skiing; she rode horses, even after hip, knee and shoulder replacements, and pelvic fracture repair. She was an arts enthusiast, loved live theatre and opera, read incessantly. She loved to cook, to eat, to drink, and to entertain. She valued friendship, and sharing good times with good friends. I miss her very much and never expect to meet anyone like her again. — Gail Pirie, MD

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Invictus A Poem for Gail Mynard 1946–2014 Throw on her roses, roses But never one that’s white The only speed she knows is The color-filled speed of light. Her life was running, running Through a maze of heat and sound seeking a fount of meaning That no one else had found. Her restless, ruthless spirit Dragged her flesh along behind And when her body failed her She cauterized it with her mind. We hear the echoes, echoes, From the drumbeat of her life. They roll along the shoreline Of the frightened sea of time. — John Loofbourow, MD

In Memoriam

Richard M. Ikeda, MD 1932–2014

Doctor I, Samurai NEITHER THE RAMSHACKLE building nor the address are visible from Florin Road. But inside on the afternoon of March 27, 2014, more than a hundred people from all walks of life gathered to talk about an 82-year-old man. Richard Ikeda was, among many other things, a former UCD Med Center Staff Pathologist and Chief of Autopsy Service, who enjoyed teaching, and discovered about 33 years ago that he wanted to devote the rest of his life to what might be the Private Practice of Community Medicine. He called it, “Health for All.” In typical Ikeda fashion, he simply “did it all.” He focused both on medical matters and on societal conditions like education, motivation, and opportunity. He refused to paternalistically “empower,” choosing to engage and inspire on a personal level. That is the hallmark of his life’s work, clearly expressed in the faces and comments of people at the memorial. He is fondly remembered for his unfailing energy, his outrageous sense of humor, and most significantly, being a social and medical warrior who only briefly suspended his activities to die. Unwilling to completely surrender, he continues to teach at UCD as a volunteer cadaver. Richard Manabu Ikeda was born in Hawaii, studied at Punahou School, recalled fishing in Pearl Harbor, and watching events from afar on December 7, 1941. He attended Harvard University and obtained his MD degree in Vienna, where he and Jaqueline Recaut were married. In 1964, they moved to Sacramento and Richard began a Pathology residency at the Sacramento Medical Center. In 1981, he founded “Health For All.”

Ikeda and I knew each other, were the same age, and did similar things in neighboring counties; yet I burned out after only 10 years, while he continued for more than 30. Throughout, Dr. Ikeda remained tirelessly devoted to the people who motivated him. Browsing online for “Health For All” will bring up a list of clinics, with two in Sacramento. The public record is substantial, well known, and easily available; therefore, it will not be copied here. Even the brochure from his memorial required 200 words to simply list his medical activities and organizational associations. Behind all that documentation remains this unique individual. Below are some comments from people who best knew Richard M. Ikeda, MD Dr. I: “He used to say if you are going to be a samurai, chop off the whole head.” “He’d give you the shirt off his back. Somebody else’s too.” “Dr. I was totally organized disorder.” “He often said, ‘You are the people who went before you.’” “He was fearless. After being carjacked at gunpoint, he escaped with bullet holes in his car, which he drove around defiantly for years.” “He always tried to inspire people to challenge themselves.” “His energy, sense of humor, optimism, and outrage never failed him.” To quote Shakespeare’s Antony, “When comes such another!” — John Loofbourow, MD

July/August 2014

Board Briefs May 12, 2014 The Board: Received an annual report from Peter Hull, MD, Chair of the Emergency Care Committee highlighting the past successes of the committee and summarizing issues being addressed. He noted that the growing number of psychiatric patients seen in the emergency rooms, and waiting sometimes days and weeks for placement in 5150 designated facilities, continues to be a significant problem. Received the resignation of Lorenzo Rossaro, MD as Secretary and Director due to his acceptance of a position as Global Senior Director of Medical Affairs at Gilead Pharmaceutical and relocation to Foster City, California. Elected Vijay Khatri, MD, a surgical oncologist with UCD Medical Center, to the Board of Directors representing District 2, Office 2, to fill the vacancy created by the resignation from the Board of Lorenzo Rossaro, MD. Elected Tom Ormiston, MD, Director District 6, to fill the vacancy in the office of Secretary and to serve for the remainder of the unexpired term. Approved the SSVMS Strategic Plan 20142018 developed at the March 9, 2014 Board Retreat. The plan identifies priorities for SSVMS over the next 3-5 years. They are: 1) To be a unified voice of all physicians and to promote inclusiveness of all physicians; 2) To enhance membership growth and retention by communicating the value of membership to members and prospective members; 3) To advocate for physicians and patients, with a focus on preserving MICRA and protecting practice viability; 4) To enhance the physical and mental health of our community. Approved a one-time bridge funding of $1,000 to the California Public Protection and Physician Health (CPPPH). CPPPH is a 501(c) (3) organization formed by the California

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Medical Association, the California Hospital Association and others in 2009 when the Medical Board closed its Diversion Program in 2008. Approved the 2014 Nominating Committee members as follows: Chair, David Herbert, MD, Immediate Past President; District 1, Ruth Haskins, MD; District 2, Patricia Samuelson, MD; District 3, Barbara Arnold, MD; District 4, Ulrich Hacker, MD; District 5, Paul Akins, MD; District 6, Marcia Gollober, MD; At-Large Member, Richard Jones, MD; At-Large Member, Katherine Gillogley, MD. The Nominating Committee is charged with nominating members to fill vacancies on the Board of Directors and the Delegation to the California Medical Association. Received an update from Dr. Chris Serdahl, Chair of the Solo and Small Group Practice ad hoc Committee which is charged with the task of identifying the key challenges to practice viability for physicians in solo and small group practice and to report back to the Board with recommendations on how SSVMS can assist members with addressing the identified challenges. The committee will be meeting in June to further discuss their suggestions and form recommendations to the Board. Reviewed the recommendations from CMAâ&#x20AC;&#x2122;s Governance Technical Advisory Committee regarding restructuring the composition of the CMA Board of Trustees proposed redistricting. The recommendations will be considered at the 2014 House of Delegates and CMA is requesting feedback from the county medical societies and delegations. Approved the following nominations to CMA 2015 Councils and Committees: Council on Legislation: Patricia Samuelson, MD, At-Large Member; Mary Jess Wilson, MD, representing the Government Employed Forum; Committee on Medical Services: Barbara Arnold

MD and Samrina Marshall, MD; Council on Ethical Affairs: Marcia Gollober, MD; Council on Information Technology: Ben Franc, MD. Final appointments will be made by the CMA Board of Trustees serving as the Nominating Committee pending approval by the 2014 House of Delegates. Reviewed proposed appointments to the Mental Health Task Force which will hold its first organizational meeting in June. The task force is charged with recommending to the Board of Directors specific mental health issues within our region that SSVMS can raise awareness, educate and take action to resolve. Approved the Membership Report: For Active Membership — James K. Abshire, MD; Jacob A. Bair, DO; Yener A. Balan, MD; Leslie R. Barger, MD; Nathan S. Beckerman, MD; Margaret E. Bojanowski, MD; T. Breit, MD; James F. Brennan, MD; Thanh-Tuyen C. Bui, MD; Marian L. Butcher, MD; Hannah C. Chang, MD; Tammy L. Chen, MD; Steven M. Cherry, MD; Lisa D. Chodak, MD; James H. Clingan, MD; Gregrey Cohen, MD; Danielle M. Collins, MD; Costanzo A. Diperna, MD; Hadi A. Firoz, MD; Jennifer L. Gullo, MD; Chetan Goud, MD; Jason K. Gritti, MD; Rafieh Hajiani, MD; Yusheng (Sean) Han, MD; Jennifer S. Jennings, MD; Bruce W. Jensen, MD; Monica R. Kasrazadeh, MD; Joy Kay, MD; Nathan Kuppermann, MD; Mark J. LaBriola, MD; Rebekah Latham, DO; Lily K. Lin, MD; John R. Loudermilk, MD; Lucien M. Maidan, MD; Theresa D. Marsh, MD; Mark A. Marshall, DO; Jasminder S. Momi, MD; Jeffrey G. Moore, MD; Dan Nadler, MD; Zack M. Nakao, DO; Rowena D. Pantig-Astorga, MD; Daniel Park, MD; Zakwan Quwatli, MD; Vinay M. Reddy, MD; Laura M. Robinson, MD; David Siegel, MD; Jennifer U. Spiegel, MD; Charles E. Stewart, MD; E. Bradley Strong, MD; Christianna M. Stuber, MD; Robert M. Suskind, MD; Mia S. Tanaka, DO; Grace Tarng, MD; Mark A. Taylor, MD; Tet Toe, MD; Helen M. Weinrit, MD; Richard H. White, MD. For Change in Membership from Resident to Active — Kevin M. Jones, DO; Christina S. Ortega, MD.

For Resident Membership — Arash Calafi, MD; George K. Gallardo, MD; Garin G. Hecht, MD; Swati Rao, MD; Ryan M. Spielvogel, MD; Tonantzin E. Rodriguez, MD; Stephanie A. Wood, MD. For Reinstatement to Active Membership — John T. Cornelius, MD; Stanley Henjum, MD; Kai-Ting Hu, MD; John Keltner, MD; Thomas Pound, MD; Mark W. Redor, MD; John J. Tiedeken, MD. For Change in Membership Status from Active to Active 65/20 — Carl S. Hsu, MD. For Renewal of a Leave of Absence — Jeffrey P. Clayton, MD. For Retired Membership — Jesse W. Adams, MD; Mervin B. O’Neil, Jr., MD. For Resignation — Frank Apgar, MD; William Gilbert, MD; Mark A. Notash, MD (transferred to Alameda); Voltaire Sambajon, MD; Bryan D. Smith, MD (moved to Washington); Marc Walter, MD; Patricia L. Wiggins, MD. Ratified the April 1, 2014 Termination of Membership for Nonpayment of Dues for the Following — Jimmark Abenojar, MD; Samir G. Artoul, MD; Christopher Balwanz, MD; Vipin Bansal, MD; Bruce Barnett, MD; Carol Berry, MD; Nicole Carob, MD; Garrick Chang, MD; John R. Claiche, MD; William Conard, MD; Frederic Conte, MD; Stephen Cox, MD; John de la Vega, MD; Richard Detwiler, MD; Thuy Duc, DO; Robert Duncan, DO; Lewis Dudley, MD; Sharon Dutton, MD; Georg Emlein, MD; Gilmer C. Ewing, MD; James Flanigan, MD; Erin Forest, MD; Scott Foster, MD; Brian Golden, MD; Brian Goldsmith, MD; Deepika Goshike, MD; Lofti Hacein-Bey, MD; Glenn Hakanson, MD; Glenn Hofer, MD; Christopher Hoffman, MD; Nancy Inforzato, MD; Ron James, MD; Christopher Jones, MD; Ajay Joshi, MD; Darcy Ketchum, MD; Nidal Khalili, MD; Nancy King, MD; Randy Knutzon, MD; Monika Kraft, MD; Christopher Laing, MD; Juliet La Mers, MD; Mark Leibenhaut, MD; Ralph Libet, MD; Hank Lin, MD; David Linstadt, MD; Raquel Livoni, MD; Eleanor Fung-Yee Lo, MD; Mark Logsdon, MD; Yuriy Lyubanskyy, MD; Vartan Malian, MD; Sapoora Manshaii, MD; Jeremy Martinez,

July/August 2014

MD; Alexander Massey, MD; John McCarthy, MD; Connie Mitchell, MD; Govind Mukundan, MD; Richard Myers, MD; Michael Niedermeier, MD; Michael Norton, MD; Masaru Oshita, MD; Karen Pantazis, MD; Tommy Poirier, MD; Norman Poppen, MD; Sarah Preiss-Farzanegan, MD; Anthony Pu, MD; Kathleen Puglia, MD; Narasimhachar Raghavan, MD; Eugene Reames, MD; Janice Ryu, MD; A. Brandt Schraner, MD;

David Seidenwurm, MD; John Shrum, MD; Chris Simopoulos, MD; James Steidler, MD; Gina Tobalina, MD; Katharina Truelove, MD; Wesley Tsai, MD; Bahram Varjavand, MD; Patrick Vogel, MD; Calvin Wang, MD; Laurel Waters, MD; Jason Wiesner, MD; David Winfield, MD; Dylan Witt, MD; David Wolfman, MD; Julie Wong, MD; Dawei Zheng, MD.

Transitions of Care continued from page 4 In this issue, Dr. Sean Deane describes a New Deal in medicine. We must ask ourselves if the deal has changed or not, and find a way to hold onto the core principles of the patientphysician and teacher-learner interaction. At perhaps no other time in our profession are we so challenged to remind ourselves of why we

IPFA/BCA Global Symposium on

The Future for Blood and

Plasma Donations

sacramento Developed by internationally recognized experts, this inaugural symposium will address key topics including the increased demand for plasma-derived therapies.

23-24 september 2014

Sheraton Grand Sacramento, CA, USA Register today: www.ipfa.nl

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chose this profession and how we would want our own family members to be treated when they seek care. We need to simplify. hitzemn@sutterhealth.org

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; Thomas W. Ormiston, MD, Secretary.

Abshire, James K., Internal Medicine, University of Texas Southwestern 1990, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Balan, Yener A., Psychiatry, Albany Medical College 2005, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Barger, Leslie R., Pulmonary/Critical Care Medicine, University of Nevada 1982, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Bojanowski, Margaret E., Family Medicine, The Chicago Medical School 1984, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Brennan, James F., Urology, Mt. Sinai 1983, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Bui, Thanh-Tuyen C., Family Medicine, University of Lausanne, Switzerland 2003, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Butcher, Marian L., Pathology, Louisiana State University 2007, Diagnostic Pathology Medical Group, 3301 C St #200E, Sacramento 95816 (916) 446-0424 Calafi, Arash, Orthopedic Surgery, UC San Diego 2013, UCDMC, 4860 Y St #3800, Sacramento 95817 (916) 734-5885 (Resident Member) Chodak, Lisa D., OB-GYN, Virginia Commonwealth 1995, Mercy Medical Group, 8120 Timberlake Way #102, Sacramento 95823 (916) 681-6102 Clingan, James H., Family Medicine, New York Medical College 1981, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333 Cohen, Gregrey S., Pediatrics, University of Arizona 1987, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3540 Collins, Danielle M., OB-GYN, UC Davis 2010, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Diperna, Costanzo A., Thoracic Surgery, Mt. Sinai 1998, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 229-8543 Firoz, Hadi A., Internal Medicine, SUNY Downstate 1997, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3620 Gritti, Jason K., Internal Medicine, St. Georgeâ&#x20AC;&#x2122;s University 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106

Hajiani, Rafieh, Hospitalist/Internal Medicine, Shiraz University, Iran 1994, Mercy Medical Group-Mercy San Juan Hospital, 6501 Coyle Ave, Carmichael 95608 (916) 537-5079

Quwatli, Zakwan, Pulmonary/Critical Care Medicine, University of Aleppo, Syria 2002, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Han, Yusheng (Sean), Pathology, Southeastern University, China 1988, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5000

Reddy, Vinay M., Physical Medicine/ Rehabilitation, University of Nevada 1996, Spine & Nerve Diagnostic Center, 4420 Duckhorn Dr #200, Sacramento 95834 (916) 419-9900

Hecht, Garin G., Orthopedic Surgery, University of Michigan 2012, UCDMC, 2315 Stockton Blvd., #3800, Sacramento 95817 (916) 734-2011 (Resident Member)

Rodriguez, Tonantzin E., Family Medicine, UC Davis 2014, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Jensen, Bruce W., Family Medicine, University of Nebraska 1971, Mercy Medical Group, 8001 Madison Ave, Citrus Heights 95610 (916) 962-0660

Siegel, David, Infectious Disease/Internal Medicine, Albert Einstein 1973, UCDMC, 4150 V St #3200, Sacramento 95817, (916) 734-2812/Mather Hospital, 10535 Hospital Way, Mather 95655

Kasrazadeh, Monica R., OB-GYN, University of Missouri 1993, Mercy Medical Group, 1730 Prairie City Rd #120, Folsom 95630 (916) 351-4800 Kuppermann, Nathan, Pediatric Emergency Medicine, UC San Francisco 1985, UCDMC, 4150 V St #2100, Sacramento 95817 (916) 734-5010 LaBriola, Mark J., Hospitalist/Internal Medicine, St. Louis University 1985, Mercy Medical Group-Mercy General Hospital, 4001 J St, Sacramento 95819 (916) 453-4545 Maidan, Lucian M., Neurology/Neuroradiology/ Vascular Neurology, Carol Davila School, Romania 1992, Mercy Medical Group, 6555 Coyle Ave, Carmichael 95608 (916) 536-3540 Matani, Satyen H., Hospitalist/Internal Medicine, R. Gandhi University 1997, India, Mercy Medical Group-Mercy Methodist Hospital, 7500 Hospital Dr, Sacramento 95823 (916) 423-3000 Momi, Jasminder S., Nephrology, Ross University 2001, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3333

Stewart, Charles E., Otolaryngology, Loma Linda University 2000, The Permanente Medical Group, 2025 Morse Ave, Sacramento 95825 (916) 973-5322 Stuber, Christianna M., Ophthalmology, University of Pittsburgh 2007, Mercy Medical Group, 3000 Q St, Sacramento 95816 (916) 733-3311 Toe, Tet, Hospitalist/Internal Medicine, Institute of Medicine I Rangoon, Myanmar 2001, Mercy Med Group-Mercy Folsom Hospital, 1650 Creekside Dr, Folsom 95630 (916) 986-4426 Weinrit, Helen M., Occupational Medicine/ Anesthesiology, Tel Aviv University, Israel 1989, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 White, Richard H., Rheumatology, Washington University 1973, UCDMC, 4150 V St #0400, Sacramento 95817 (916) 734-2737 Wood, Stephanie A., Family Medicine, UC Irvine 2012, Sutter Health Family Medicine Residency Program, 1201 Alhambra Blvd., #340, Sacramento 95816 (916) 731-7866 (Resident Member)

Moore, Jeffrey G., Pathology/Cytopathology, Loyola University 1990, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2300 Ortega, Christina S., Internal Medicine, University of Texas 2011, The Permanente Medical Group, 6600 Bruceville Rd, Sacramento 95823 (916) 688-2106 Pantig-Astorga, Rowena D., Family Medicine, Angeles University, Philippines 1996, Mercy Medical Group, 8220 Wymark Dr #200, Elk Grove 95757 (916) 667-0600

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July/August 2014

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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.

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Membership Has Its Benefits!

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

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

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Sierra Sacramento Valley Medicine

savings of $ over 81,000 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 $81,752 this year.

Are you an ssVMs/CMA member? 2013 sIERRA sACRAMEnTo VALLEy MEDICAL soCIETy MICRA sAVIngs ChART general surgery

Internal Medicine

oB/gyn

Average

(non-Invasive)

El Dorado, sacramento & yolo Counties

$28,147

$7,976

$36,865

$24,329

Connecticut

$92,782

$34,700

$170,389

$99,290

District of Columbia

$73,018

$24,010

$147,595

$81,541

new york

$148,454

$35,883

$227,899

$137,412

CT-DC-ny Average

$104,751

$31,531

$181,961

$106,081

MICRA Savings

$76,604

$23,555

$145,096

$81,752

sierra sacramento Valley Medical society 5380 Elvas Ave., ste 101, sacramento, CA 95819 Phone: (916) 452-2671 fax: (916) 452-2690 Join online today www.ssvms.org * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 38, No. 10, October 2013. Annual rates with limits of $1 million/$3 million.

P R O u d tO b e e N d O R s e d b Y t h e s i e R R A s A C R A M e N tO VA L L e Y M e d i C A L s O C i e t Y.

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

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